the following is a medical media production from 

WR AMC Tv.

The angiography of them with emphasis on 

inflammatory disease.

Now,

the if you look at the literature,

especially in the older,

older,

I mean about five or six years ago later you'll 

find that there are repeated statements saying that 

you cannot differentiate 

abscesses from high performer that there's no 

way to differentiate them.

The I felt exactly the same way.

A matter of fact.

One of the statement comes from paper which I vote.

And a couple of years ago,

about three or four years ago We had a course in Las 

Vegas which dealt with 

renal masses and 

these courses.

I don't have self film if you have been in them and 

it's not a plug for the course they're doing very well there is no 

place really on them.

But what happened is that you're showing 

cases and everyone of faculty 

happened to have 

page one or two of these cases an 

abscess which were the case which no one was supposed to pick 

up.

And as the third or fourth day came up,

the participant would just instantly pick it 

up,

make a diagnosis.

And when you ask them,

how did you make diagnosis So that it's easy 

because DR sansa showed us an identical case.

So we got the faculty together and put all the 

cases on view boxes and suddenly we had about 25 

of these cases and sure enough,

if you look at them as a goal,

there are patterns which make a 

diagnosis quite possible.

The thing is that none of us,

even with long experience sees 

more than two or three of these cases and 

therefore Came up with the diagnosis that you really 

cannot differentiate them from 11 collisions.

Now recently these kids have become much 

more common than they used to be.

And that's mainly because the drug addiction,

injection,

intravenous of Helen and 

feta means with dirty needles 

and therefore they are no 

longer as well as there used 

to be.

And I think you should be aware of them.

I'd like to start with saying that 

you cannot make a diagnosis without correlating 

with clinical finding.

But it's part of,

I'll go into the clinical,

I'll show you the clinical science.

It has to be tied together the 

symptoms of patient and the and geographic findings.

But if you do,

you can make a diagnosis and diagnosis is important because 

if the kidneys still function,

it shouldn't be removed.

It should be treated with antibiotics rather than 

taken out and then found out that snap says,

when we start with the first slide back,

want me to show you what the University of Utah looks like.

As you can see,

it's quite nice.

We didn't have that much snow this year.

But that's what normally you would look like.

Okay,

let's start with some of these cases and what 

at the beginning,

I'd like to go to some variants of the normal,

not inflammatory disease,

but these are masses,

which can be confused with neo 

plasm and for instance,

you can see here the kellys is a little bit 

stretched.

It's not doesn't look particularly bad up some soils 

and you do an angiogram and you can 

see the small mess here and that's just a column of 

Bertin which is all of you have seen 

is a normal variant.

Should not be confused with an angiogram.

Here is only oblique view.

You see how these arteries are stretched slightly 

around 

and there was again,

it's called of Bettina,

what is it?

It is basically a renal 

medulla which is in virgin.

Ating into the I'm sorry cortex in 

virgin into medulla and it is completely normal 

tissue.

And if you remove that you'll find this normal family with 

nothing,

nothing is seen lately.

We are quite aware of these findings,

but a lot of kidneys have been 

removed because of columns of built in and tell people 

became more acquainted with these findings.

Another thing which will worry you occasionally are 

if you get my VP and you see indentations like that.

Now,

these are generally vascular indentations.

They could be aneurysms.

Most of the time they're just the arteries.

And if the patient is asymptomatic.

And if you are just doing this study for let's say 

hypertension,

hypertension would not be a good idea for 

infection usually will not pursue it.

But if you look what happens if you hear these 

these out here that artery and that aren't relying 

right on these callouses and they're pushing them out.

Now,

what you could do if you compress these,

your toe and get a little bit more context into 

the currency.

So if you infuse a little bit diabetic 

or even just double your dose,

the callouses will become more the standard,

these indentations will disappear.

So you really don't need to do an angiogram to 

detect these.

Here's some other indentations.

Now,

you could say most of the time you don't worry about this too much.

But if you have a patient with the material,

you have to worry about them because the material,

it could be a small transitional cell carcinoma,

which you have to pick up.

So you have to see if that is real.

If that's real lesion,

that kidney will probably have to be removed.

So you have to prove that that is not is not just 

a vascular indentation.

And but you can see the auto is don't show 

anything when you get into the venus phase.

You can see there's very lightly,

you can see here the renal vein coming.

The other innovation coming 

now,

I will say that most of the time with little experience,

you recognize that you know where they go and you don't do 

angiograms to do this.

These are mainly done.

These are old cases which were done most 

when we learn.

And also to show these illustrations 

a little bit more disturbing is when you have an indentation like 

that.

And again,

unless you can fill that by using more contrast medium,

you're not sure is an extrinsic mass because after 

all,

you most certainly should be aware when you see something like that,

that could be a mess.

It's not invading,

It's nice and smooth,

but it could be in the kidney yet there is nothing more than 

the normal kidney.

You don't see very much in the arterial phase,

but when you come to the venus face,

see that's that part of the kidney which is 

kind of folding in right in the 

high alum.

And that gives us an invitation here on a collecting 

system.

There is a probably easier to interpret that is a 

spleen giving you that straight line and dr 

Felson Ortiz article about humps and bumps and 

something else I don't remember of kidneys 

and uh it can it can see it 

could look like like a legion and we're going to go 

over some cases afternoon about an 

extra term.

And you'll see that actually the very large masses 

are very difficult to at least to 

decide where they come from.

I'm sure you can see a mass.

But to see that liver is kidney.

To do,

we know it's not as easy as it sounds 

and all these vectors are very nice 

when they work,

but they don't always work and when messes get huge.

They don't work in this case.

It's just a normal invitation caused by the 

spleen,

you can see it a little bit better.

Yeah,

straightening of that line.

I think the important thing is to see that that is definitely extra 

in regard to whatever it is because you get this 

nice calm cavity.

Okay,

okay.

Now,

what about these Catholics here?

Here's a woman which had some 

hypertension.

It looks like there might be a small lesion 

pushing on here.

And you can see you inject contrast medium and it 

looks like there's something maybe sitting in this kidney.

Well,

that's a kidney which had some inflammation and 

uh,

that's a scar.

Associate probably there was a stone in this article,

the seal system many years ago.

And you can get these peculiar appearances,

uh,

with an indentation here because 

of palenque in which was pulled in by the 

skull.

You can also see that the cortex is nicely here.

But then it's not seen well on this area and in this 

area.

So you have some hints that this kidney was infected.

I'm showing you all these cases to make you aware 

that not everything we're seeing is really seriously 

abnormal or is abnormal.

And it's very 

important to pick up so that you don't do 

unnecessary angiography.

Now,

here's again,

an older person who is very bizarre looking kidneys.

Well,

it was a little experience,

you'd know that that's public pelvic like 

comatose is a disease which is appearing in the 

older,

It's not a disease.

It's a variant of the normal,

preparing all the people were renal 

renal pelvis gets a lot of fat.

And you can show that by doing the photography where you can 

see the loose and see now with cT scanning would be very easy to 

show that the fat density and we most certainly will not do an 

angiogram.

But frequently you'll do your VP because the patient has the 

material and then you are stuck with 

situation.

Do you want to pass it or are you going and assume that there's 

nothing there?

It's just fat Or can you be sure of it?

Well,

here's what the angiogram looks like.

The arteries are a little bit splayed and the 

article faces difficult to 

see but to see anything abnormal.

But then the infographic faces much 

clear.

You can see that a lot of loose NC.

And if you have a CT scanner and use cancel that,

you'll find all that is nothing but fair.

That's normal finding in older people.

The other side just looks the same.

You have a little blunting of these Catholics which is unrelated to the 

entity.

It is just you can see 

nicely how this fat surrounds all these kelly sees.

Okay,

now,

let's start looking about real masses 

and there's a beep and if you always,

if you wait an IVP be sure to try to outline the 

kidneys.

A frequent mistake.

People look only at the kelly sees and if you are 

how you don't you don't see the whole 

kidney.

And quite often 

terms were not 

change the kelly sees,

but will will just appear as a mass if it's 

going in the going in the low paul's point of 

the upper pole here.

You can see that mass outline the errors.

You can see a little bit better on a mammogram because,

yeah,

kidney goes all looks like there.

You can see your kidney.

It's just the same thing.

Closer view.

And here during arteriogram,

you see,

of course,

the point how much burn you can see there's really a bulge here.

That is quite a common finding if you have access or in 

lotteries,

it is kind of an attempt duplication of 

the kidney.

We do have a kidney on this side.

If that kidney would have been on that side.

You talk about the cost topic,

kid nick.

And when you do your diagram,

you'll find his extra artery leading there.

But that's not always the case.

And he's a patient patient 

which has this peculiar looking kidneys.

There was a little bit larger Law poll,

an arteriogram was done and you can see we are feeling nicely 

the upper part,

but we don't feel that area very well.

So the catheter was removed and placed in this 

position to see if there's any accessory artery.

So you'll see it in a minute.

You see that there is something in here and 

now,

as we go on,

you'll see that that other things give us exactly the 

same fighting.

We have to look for them.

And 

and here when you move your castle down,

you can see a lot of arteries.

Okay,

now,

is that again?

Just a duplication.

Well,

it could very well be.

But you have still to look very closely at the 

arteries in this area.

We felt that there was a little blush here.

And let me show you a little bit better.

See a few little arteries lying lying 

right there.

That is not a normal finding.

Kidneys does not have these arteries.

So,

diagnosis was made that there must be a small high performer 

in this kidney which looked just like the last time,

which I showed you.

Which was just a normal duplication.

The patient was operated and all they could find was what 

looked like normal tissue.

They took a biopsy.

But since they didn't find anything,

they closed and we had a lot of problems,

hypertensive crisis.

As soon as they closed in,

the pathology report came back,

it was a high performer.

So they had to go in again and take it out.

The telegram was quite 

it was quite specific.

You're showing that these findings are settled.

But that's what you're here for two to make not to make 

the obvious diagnosis.

The geologists can do that.

Now let's go into moans inflammatory disease again,

here is here.

We're starting with a kind of a lobular peculiar 

looking kidney 

that is,

that is scarring 

and 

got a little little inflammatory,

This is due to chronic inflammatory disease,

but the kidney's functional world yet you get is pseudo messes and you 

have we don't see any tumor vessels in them.

It would be disturbing something like that.

Except that everything is very organized and it looks like 

either this patient had previously Thoma and that's why we're getting this 

population here or it's a duplication or 

it's chronic inflammatory disease which is which is the case in 

this patient here.

The next case is a patient who came in with the left flank 

pain.

And if you look at the outline of the kidney,

see a nice sharp outline here.

You come to this side,

you can see the law paul but we are losing the 

upper pole.

We don't see it now.

If you look at your I.

V.

P.

That's actually for tomorrow Gambia VP.

Wasn't that good.

You still don't see that Up,

up up all.

Well,

the distance of the callouses between here and up here 

is too much 

and 

do not telegram and you can see 

there's a legion there now,

what is that legion,

they're not the vessels are not completely 

normal but they are also not what you would 

say the typical tumor vessels.

The wall is slightly thickened and if you remember 

where dr Bosnia multiple arteries about noon 

for tomography.

One africa important points he 

stresses is that if you talk about a system wall has to be 

very thin so you're kind of forced to call that a 

high performer.

That was one of these cases in the beginning,

which we call the patient was operated was found to be an abscess.

And we thought,

well you can't make the diagnosis.

But that is to to introduce it.

That subject kind of an example of a 

acute renal abscess 

which which shows you some 

of some of the science which are going to much more detail 

in the next few minutes.

He has an effect an effect.

You know,

it looks like a system here.

That isn't right.

I mean that border is not sharp,

it's fuzzy and you can,

you have to think about an aquatic terminal.

Now when we talk about the real personal 

abscesses Or when or when I mentioned 

from two a mess.

I'm not trying to differentiate these different 

entities.

I know pathologically people will 

go up and differently and you talk about the 

acute abscess here and the pentagon anomalous 

paranoia fighters and pioneer forces and in fact 

exist if that exists.

Some people don't by that as an 

entity.

I don't think I'm geographically,

we can or should differentiate them clinically.

They're fairly clear cut diagnosis.

The differences between them.

We can suspect exanta grounds was planned the fires 

because almost always associated with stones 

and very frequently there are non 

functioning kidney,

they're also probably the least important of the whole group 

because if you have a non functioning kidney doesn't really make any 

difference.

If it's a tumor or and inflammatory 

mess,

you might just really move it.

You haven't caused any damage.

But the other one the abscesses 

basically kidneys which 

can and should be salvaged.

Now the theology,

it is not Connick attacked infection 

like most people think,

but rather there is an infection uh,

most likely secondary to 

skin or lung lesions or 

intravenous injection with dirty needles.

Only the example on the first paragraph itis is 

associated with your little obstruction,

chronic urinary tract infection.

But the acute ones that we talk about really,

the patients have no history of urinary tract infection.

The most common pathogens which you find all as you can 

see almost anything can do it.

The most common ones of staff 

then followed by Klebsiella and our back to 

photos and call Cheryl a collie.

Now,

the the in the meantime I had a little bit more than 20 

patients.

These are by no means all my patient credit should be 

given to dr helper.

And uh,

I don't know if self you know,

when he died last year,

he had probably the biggest collection of 

anything anybody ever had because it was at 

USC.

And that's if you ever want to write a paper about 

anything that The 20 kids of everything 

there except maybe for the VIP.

They have probably the biggest volume of anything.

And doctor Fallon from USC in san 

Francisco and versus of California san 

Francisco and dr talmadge.

They all gave me some case.

So that's a combination Of these.

So we're talking about 20 patients with 22 

affected kidney.

Eight were males,

12 a female.

That that means that that's really evenly distribution.

There's no predominant in 

either.

Although we had 14 right kidneys and eight left kidney,

there's no reason why they should be more on the right kidney.

That is not statistically valuable.

So you can say it they can affect either kidney,

they affect males and females in the same order.

Now if you talk about these apps is is there are 

three modes of dissemination.

Ah One 

are multiple small cortical 

abscesses.

The second one is parametric extension where it breaks primarily 

out and the third one is that it breaks into the collecting 

system.

Now the radiographic findings very much 

depend on what we're finding here.

They look.

So you have kind of three different groups of 

radiographic findings show you 

examples of each one of them.

The 

in advanced case obviously we have we'll have a 

mixture of the whole thing.

You don't have a specific one 

pattern or the other.

But if you catch them early enough you can 

see that either one of these dissemination 

would've dissemination uh exist.

Now.

Generally they will all start as number one because 

if it's a hammer to Janice spread,

it reaches through the blood vessels into the granola,

into the cortex,

it sits there and then you get multiple micro abscesses which 

call us the microbes is we can't see on 

exercise,

but when they get a little bit bigger we can we can we 

start seeing them?

No,

I'm afraid that that slide is out of 

that should have been at the end.

But anyway,

let's look at some cases.

And here you can see is a patient came in with 

large mass,

large flank mass 

and you do an EVP you can see very poor function the kidney is 

functioning.

This kidney is normal.

You can see there's some pressure on the bladder.

The mass is clearly outlined.

You don't see the fat line pop peritoneal fat line.

Source muscle is not well seen on either side of this patient,

but it's missing on this side and that we'll find out 

that that's an important finding 

perhaps also that 

is all which we found on that last patient.

That that was a paranoid freak.

Absolutely go back to it.

These are the plain film finding which you really find on a 

paranoid freak abscess,

you have lots of source muscle loss of outline of the 

kidney.

That is kind of a classic.

If we have them.

If we have both of these things and flank pain and 

fever,

uh,

this will be,

you can almost make diagnosis.

Let's go back and start with the 

patients which have the root of the 

cortical coalescence of cortical 

abscesses.

How do they look on the angiogram.

Here's a patient and here's a film taken in 

Genuine 1969.

I'd like to call your attention to that upper 

go uphill.

The upgrades will go up the distance from 

the upper pole and he came 

back in May and you can see 

that now that that border is no longer well seen.

It's a little bit wider and it looks like there may be a lucinschi 

here.

This was a drug addict from saN Diego was 

known to take vitamins 

intravenously.

He had flank pain fever 

and 

the navy was done for these reasons.

Now,

what does the end you look like?

Look at these arteries here again,

you have a fairly normal 

looking lower half of the kidney and 

you can see here is a band which goes to the upper pole and 

also to the capsule.

There's a poor demarcation between the cortex and the 

medulla which has seen better 

on a later phase,

compare the lower half of the kidney 

to the upper half.

See there's no border here and that's a very important finding all 

of them don't have a border.

High performers usually have a very sharp border.

In addition,

you can see spot areas here and here.

In other words,

it's not just a solitary lesion.

That is a big lesion that's a predominating lesion with the one which 

affects the collecting system.

But we have abnormal findings here here 

here.

I see all of these little think that 

micro abscesses 

the next patient and I'm going to show you a whole group of patients to make 

the point,

I know that you're supposed to use very few slides but I 

think that you can get only the feeling if you look at a lot of 

cases of the same thing and see that there is a parent.

They all look one like the other.

He was an older lady who came in with what looks like 

an obvious renal mass.

I think everybody can make a diagnosis quite easily.

And that was before the days of ultrasound 

today.

We would probably do an ultrasound to see if it has 

Floyd or or if it's solid.

Anyway.

At that time we used to do and your guns 

and you get a peculiar pattern of the 

angiogram.

The whole bunch of how they cyst.

They certainly are not.

They don't look like to most is not like the typical tumors.

And when you get the late phase you see this 

very nice that Hayes like 

like see all these 

hazy appearance surrounding the palaces and 

the surrounding these masses.

What it is,

what we're seeing is hypothermia and the capillaries 

and that's a very characteristic finding is not only in the 

kidney.

And when we go over case this afternoon,

you'll see,

I'll show you a group of abscesses in in 

other organs which looks very much like 

what you see here.

You have a very nice haziness And it's one of those things that you've seen 

at once you remember and you try to tie 

these finding findings with with his and 

geographic the clinical fight with your geographic 

findings.

That was also one of the rare case we did not make that.

We thought that we were peculiar cysts of 

possibly narcotic terminal.

These are multiple abscesses each of these and absence.

And that's that haziness is very,

very characteristic.

It is the type of leukemia.

Okay,

another patient,

there's a stone here.

Non functioning kidney mass on that side.

You do it together and you get this very distorted collecting 

system.

Most certainly if you look at that,

that could be a happening former.

No question about the non functioning kidney distorted carry 

seeds.

But you do the angiogram and it doesn't look like a husband a 

former.

I mean,

here is again.

Look at this capsule vessel here 

and the capital faces Far more 

important.

You get a little bit slightly delayed film 

and that is about to second film.

I'm sure some of you have been already on 

angiography rotation,

you come from some institutions in some places,

there is an emphasis on angiography 

early in others,

it's not so for those who have not done in 

geography.

The original the arthur is shot clear 

within or quarter to half a 

second after the end of the injection.

So that is a markedly delay 

delayed feeling of all his artery.

The reason is that there is an increased pressure 

into a real pleasure because of the 

very tense capsule around the kidney.

It's not a specific sign.

You can see that with rejection for instance,

but but it indicates a grossly abnormal 

flow.

Blood flows to the kidney.

And if you look at that upper pole or if you 

look at the program later look at this 

multiple spots.

The appearance is you do not see at all the renal 

cortical cortical border which 

is a fighting with your normal kidneys or even high 

performers should always see the normal public.

It is just gone and you have just 1000 of 

micro abscesses were the biggest one being up here 

with that funny artery.

Let me go back.

You see that auto It goes to and if you again look at the border 

here,

it's gone until here then we have a little bit border.

Then we have large capsule of vessels which are 

coming out 

to give you the appearance.

Also this palace aiding of these 

contrast medium area which is probably contrast medium in 

the Toby als 

is rather characteristic.

There's not one single sign but the loss of outline of 

the cortex of the kidney,

the cortical Myrna loy border or loss of it.

These palisades.

The uh um 

the increase in vessels in the 

capital vessels are all very characteristic finding 

which we do not see in high performers.

And here's a close up view and you can see these cortical 

obsesses,

small code collapse.

This kidney was of course a non functioning kidney 

it turned out to be exact example going out as part of the 

fight is but it's also important.

But the acute actresses will look the same.

They may not involve the entire kidney but they will involve.

Let's see the upper half like here and look look what's happening to the board of the 

kidneys just gone.

It's full with narcotic tissue.

And if you and if you have seen how this kidney 

look,

they are yellowish to Marie faction of 

the material in these 

kidneys.

But here is a very similar to accept you're dealing with 

functioning kidney again,

a drug addict and this kidney is normal.

But if you look at the upper pole is missing 

but not missing.

But we don't see the clear outline.

Look here in a central part which should look like 

that is there is fatty anomaly and 

I'm sure many of you have been exposed to more miles 

with all his 

compartments and fed liner.

It's very correct.

There should be a line here and it's gone.

And if you look at the end you gone very much like the last 

case.

First of all here,

at the end of injection,

look at the arteries and look what's happening in that relatively 

normal part of the kidney is compared to the upper part of the kidney 

from here on.

We are losing the normal perfusion of the 

cortex.

Pay attention.

This author.

You'll see it in a minute that that that that are particularly 

doesn't empty at all.

He was a delayed face.

See all the other arteries are gonna get outta is still hanging 

it.

There's no cloth yet.

There was no estrogenic injection.

What happened is that area is under much more tension.

So,

so there's a delay in empty.

And look at that border compared to these 

borders.

You can see if it's the only one case like that.

You don't really know what it is.

But there are one looks like the other.

That's a diagnosis.

But you can make it.

It's just there and here when 

you look closer,

that's just a close up of the upper pole.

And he was still a little bit of that artery left again.

You see these funny palace aiding the 

cortical meddler border is just gone.

There's no way you can outline it.

It should be about here.

We don't see it and the outline of the kidney is gone.

They don't see that.

So that that's very characteristic appearance of an 

acute abscess of the kidney.

Okay,

I'll show you here.

Just Another one.

Just to show the same thing.

And you can see again,

look at that here where the whole kidney was involved.

You see these multiple cortical abscesses which 

are coalescing poor border.

It almost looks like like like kind of it's 

a lot and the whole kidney is no good.

I mean,

there's just you see here,

this kelly says there's a little bit cortex and it's gone.

There's a nice larger abscess in the center 

they have a lot of areas which don't 

fail.

Closer view looks very much like the last case.

Okay.

And a little bit different example is 

here again a nonfunctioning large loan functioning mass.

Probably kidney ivP.

You cannot say what it is.

Little good.

Doesn't look normal but doesn't look too distorted.

But there could be a high performer in there.

The arteriogram again showed you 

the the 

capsule arteries large and we'll go into the 

capital R two a little bit in the second group because they are predominantly 

enlarged when when there's paranoia thick 

extension.

You wait a lotto is here.

That's a catheter in the photo and you can see your way to 

lotteries and look now look at this palace that the 

only reason I'm showing this case because it will show you these 

retention of contrast palace setting unusually 

well.

And here you can see I'm sorry that that should have been turned the 

other way.

But that's the same kidney.

But see here when that kidney issue that's about a 

six second film there should be nothing left.

The data is and look how the data is very,

very slowly emptying and you're starting to get his 

appearance 

And here these lines.

I have not seen that in anything but inflammatory in 

abscesses to see these peculiar appearances 

and the loss of cortical Nedlloyd border.

I think when you see case like that you can almost say 

that is an abscess.

Nothing else.

That's an abscess.

Okay let's go to the second 

would inspire the one where the 

absence bikes through primary bike store and gets into the 

parent africa paranoia,

thick areas,

here's a patient which again,

history of drug addiction 

and we find a mass.

It's obviously there's something on this kid now there's no 

that cyst could give us that.

There's no reason to say that necessarily is an absolute certainly 

cannot make a diagnosis on I.

V.

P.

I don't know what they teach you in your institutions but I can tell you 

that all residents 

being drummed into them not to 

make ever diagnosis of cyst was human.

IVP.

I think you'd find that 

especially we go out and practice that.

You would be pressured into making a 

diagnosis.

You see clear legion and the urologist 

or the referring physician say,

well can't you tell,

what do you think it is?

The only thing?

It could be either desist order them as well if you want to guess 

guess sis because 10 times more system happening formats 

but you really cannot make any diagnosis 

of a cyst versus term on I.

V.

P.

It's just you're gonna get burned just 

because you're getting away the first five times it's purely because the 

odds are in your favor.

And the only thing which really helps.

If you can see invasion into the currency,

then you can say it's a tumor because this don't invade but 

obstructions like here this carries a little 

obstructed,

just deviated.

That could be a benign cyst 

and here's a battle going down and you can see it's a very peculiar 

looking kidney.

It doesn't really look like it says too much.

But it could be I think obstructed a little bit 

infected.

Obstruction and assist could give you that 

and ups.

I don't know.

And as you do the arteriogram,

you start seeing a rather peculiar patterns.

Let's look at the arteries here.

It's only one artery.

We have decreased flaw 

into the center of the kidney.

These arteries are split that would fit very 

nicely with that mass which we saw in the middle.

We look we see good cortex here.

But you come out here and the other has come all the way right 

out and you don't get a cortical melody 

border.

We don't see any here at all.

But another finding is if you look at this capsule arteries 

look how far they are away from the kidney 

and you can see this hazy find 

out a little bit difficult to photograph.

I think we can see them.

But on film you can see that much better.

But that is if you follow them.

They go all the way out here and we have a mass which is 

predominantly outside the kidney.

But it's starting in the kidney and that's kind 

of Case,

which could combine the spread of one 

versus two.

In other words,

it started the kidney,

it's called Les became a large abscess.

It broke out and now it's caught in 

that paranoia thick area.

And you can see it better as you go 

on in the the angiogram,

you can see the others are not emptying 

well that they're not as delayed as that last case,

which was with a non functioning kidney.

But that is too long.

You don't generally catch too much of that.

And and look here at the difference between relatively normal 

kidney up here,

relatively normal kidney and that part of and 

then of normal kidney here and particularly 

abnormal in this area.

And then look,

look how nicely you can see these 

group of vessels here which are sitting sitting right on top 

of the kidney.

If it would be the ideal,

you could talk about a tumor but A is not 

in that position.

B doesn't look like that.

There is something there and what it is.

It's of course,

an inflammatory mess.

A lot of deregulation tissue.

There are a lot there.

There's not just passing there and there's hypothermia 

and these vital supply and that's what we're seeing here really is the 

hypothermia in the 

uh inflamed paran 

africa tissue 

here.

You can see it on a close up view,

you see these vessels that's just blow up of 

that last time.

You can see that these vessels,

you can see them lying right here 

and again,

notice that he feels done in 

geography.

That should have should be a very sharp 

line sharper than here.

Here.

It's not bad.

But he was totally fuzzy and right under 

that.

You should see the cortical medal of the border.

Okay,

another patient non functioning in a large 

mass.

Okay,

let's see what happens here.

You do the angiogram and you see a very similar appearance.

It's unfortunate.

Very light slide.

But look look at these arteries going right out into 

the paranal thick area 

and the mass is really going all the way down to hell.

Now that that is.

And here's another artery and the cortical miller border.

Gone again,

ill defined kidney.

It is not patrick pneumonic.

And I'll show you a little bit later,

a few examples of other things which can do that.

That's the unfortunate thing.

It would be nice to be public pneumonic,

but but that combined with the clinical 

science should allowed us 

to do that.

Being an abscess.

Paranoia thick abscess.

And here a little bit later on,

you can see these are capital vessels by the way.

I don't I don't remember with a teaching now in 

anatomy in medical school.

But when I went to medical school a while ago or 

not that long ago we were talking.

We were told about green light as being end 

arteries and all these things.

I think that as we start doing.

Andrew gone.

We thought all that is incorrect.

I mean,

if you have a pathological processes happening around the 

kidney on the ball,

these artists go right into them 

and just like beau lotto could go into 

the right opportunity.

Um,

if you have a term of for instance,

and so the 

kidney,

they don't just stay right in the kidney,

the capital or they will go right out and 

these are branches of arteries which are supposed to be 

and artery that is and he can see nicely 

how it lights up.

There is and that is select.

That is a selective win lottery.

So it's supplied by the rain lottery.

And that's a parametric abscess.

It's a close up view of that law pole with his.

And look that you can see again that that kind of the 

hazy net like appearance which is 

another characteristic for um,

for hypothermia,

which is generally associated with inflammatory disease.

Now,

what do you do with a patient like that?

This slide should have been turned around.

That should be the right side.

That looks like classically an 

internal lesion.

It was a middle aged woman.

About 50 had no he 

had no material had no pain and she 

had not iVP done because of 

hypertension.

And you find that mass.

Well,

what would be your diagnosis?

The most likely thing of course would be a high performer.

Although we can't be sure it's not assist.

Let's assume we didn't ultrasound,

which we didn't do at that time.

And it would be kind of fairly solid.

So you have to do an angiogram.

What does it look like?

Well,

here is the 

selective real injection and look what's happening here.

You have kidney 

first of all.

The surprising thing is that the kidney is relatively little 

deformed.

Despite the fact that the callouses looked as if it is 

classically an entire in a lesion.

I've seen our four or five cases like that,

which we had all the cafeteria classic brain lesion 

yet turned to a VIP area.

The reason is again,

because we're very stiff capsule around 

the kidney and if there's enough pressure that it could push into the kidney and 

can give you an appearance which would be the same as if it started 

in the kidney itself.

But in contrast to what you have in a normal high 

performer,

these vessels are fairly organized.

They are not wild looking and they are going to 

er multiple vessels starting from going right into 

that.

Is it whole bunch of small vessels here,

The couple of capital vessels going all the way down.

Um 

you can see the late fair,

the kidney is really relatively little affected.

And look at that peculiar haze which you 

have here right around these,

out of the,

I mean,

the ball of the kidney,

if you do a midstream injection,

which of course we did first.

You can see that it's also supplied by 

renal arteries,

by lumber arteries,

that artery,

that artery the typical appearance with that little 

hook in the lumbar artery.

And you can also see that,

hey,

so the upper part is primarily supplied what seems to be 

the kidney or the renal artery while the lower 

border of it is supplied by the lumber artery.

Well,

that S.

U.

K.

It was done in 1966 and 

as far as I learned in the the 

way I was handling it was any any 

mass lesion.

The kidney,

which is not clear,

is happening former.

There's nothing else that patient was operated.

And if you think that the surgeon can see the difference,

you'd be mistaken because quite often if it's a comic,

in fact,

it looks it's a tumor faction.

It looks like one of the very large veins lying on top of it and 

they have to try to remove the whole thing.

What happened.

That's why they were trying to dissect it away from the source.

Somebody's fingers slipped into the bulk.

About 80060s of pass came 

out.

There is another large paran effect 

upset.

That's all it is.

They didn't have take out the kidney.

They drained the whole thing,

put large drains in the kidney was saved.

It was by chance because we did not make a diagnosis.

But if you compared with the other case will show 

you today,

we would have at least allow them say that looks like an 

abscess.

And then if you really look go back into the history,

you would find that she had flank pain.

She had locus ketosis shared everything which goes with it.

They are not silent enough like abscesses.

Similar case.

Just to show that that's the same thing.

See the peculiar looking kidney here and then look at all 

these wild looking vessels coming out there 

immediately 

there.

You see it another paranoia thick abscess.

Now,

I'll grant you that.

You see a leader like that in an asymptomatic 

patient that could very well be a tumor.

And I'm not trying to tell you here today that these patients should not be 

operated when they look like that.

These are no longer the typical for an abscess can think 

about absence.

But I can see an entrepreneur tumor invading the kidney could 

give you something.

It's not a high performer in all likelihood,

but it could be a rare tumor.

But it does justify a biopsy or at 

least possibly stick a needle in and see if you can 

get past out of it.

But you don't have to do a radical operation right away 

because it may be a inflammatory lesion.

Just a different patient against which looks more like 

the one I showed before.

He has a large mass and look how these vessels.

Just go wired into it from the kidney and look at it 

defined border most.

No cortical metal ball and that's just another 

Lord Tyrion ethical abscess.

That's the same thing a little bit later on the and geographic phase.

You see the look one looks like the other.

There's really a repeating the same things.

But I don't think you'll 

get if I show you just one or two cases and we went into 

another.

Uh huh covers another entity.

You just just forget it.

See here all some micro aps is as you can see 

that it's not only paran effect.

Obviously there are multiple absences in this kidney 

everywhere.

But look how these authors go in.

Not the end out.

There is no way.

Okay.

Finally,

the third type of 

spread which the absence could take 

if instead of breaking out,

they could break into collecting system.

And then we get the so called pound of force is 

usually kidneys which are basically dead.

We're not going that is very 

advanced.

And generally you don't pick them up in time there when you do not 

repeal have a non functioning kidney.

But the appearance of the angiogram is fairly 

characteristic.

Here's a patient,

the IBP was not functioning.

The retrograde shows this very 

weird looking careless.

I mean when you see the thing that either all full with 

terminal,

which and then just contact me getting between them 

or it has to be a big abscess.

I mean,

there's just nothing else looks like that.

Either terminal abscess.

You do the angiogram.

I'm sorry that something jumped out 

out of order while he was the MvP on his patient.

And and and here 

they are.

Tier gum.

And now look at what these arteries 

are doing.

They look very peculiar a little bit like hi donna forces 

maybe.

Except we're getting these haziness again.

These filling between like the old lady to shorten the 

beginning which had four or five abscesses but had a 

nice normal functioning kidney that is just 

far more advanced.

The same thing.

Far more advanced with the kidney.

Almost been completely replaced by this multiple 

abscesses.

Here's a different case,

very similar history.

We see a mass hell 

and you get this appearance here.

These are the markedly dilated terraces which are 

now just filled with pasa 

with a 

necrotic tissue.

And you get again these peculiar haziness appear.

And how do the forces will not give you that hard on the forces 

clean.

If you have a non infected,

highly forces you will get markedly displayed 

splayed out theories.

But you will not get these peculiar 

appearing see the 

thick walled 

pseudo cyst.

They're not cysts.

But looking like this.

That is characteristic of basically a dead 

kidney.

There's not much you can do with that kidney except remove it.

You can all see the ureter lotto is here literally 

outlining the Euro.

Two 

different patient showing very much 

the same thing again,

spares artery narrowed artery 

by the way,

the reason the arteries are never is not necessarily because of pleasure 

but the how to respond 

to.

Is there any tissue left to 

feed?

I mean,

and and if you tie for instance,

experimented tile,

it's in the renal vein or the auto 

almost instantly the artery shrinks in size.

So the artery purely reflective of 

what real parang commas left.

So it doesn't mean anything otherwise.

Here.

This kidney has very little real prank on my left.

That's why the arteries are small.

There's nothing to feed and 

therefore you cannot really use the size of the 

other is a criterium to save something is 

longstanding another.

If something is congenital or not,

there was an attempt to try to differentiate 

congenital hyper plastic 

kidneys,

let's say from acquired them by looking at the outer is smaller.

Note that doesn't work because the artery will almost 

instantly change.

It's just like if you get an A.

V.

M.

And suddenly there's a lot of flow.

The artery will just respond to that very fast and become 

much larger.

And again,

here you see these peculiar findings,

the haziness but also notice that you have here 

the nice capital of vessels 

filling the and and separating the 

capital from the kidney.

Here they are.

In a close up view that's kind of combination of 

both inter and next,

you know.

Mhm involvement.

Now,

how does hide on the forces look,

look how much cleaner that is.

That's how can afford the kidneys.

Youtube such as your toe and 

you don't get all these haziness which we're seeing here,

which we saw in the other cases,

you see it's clean.

It's very little brain normally and pike and I left 

here.

But you don't have any of these big 

uh irregular kind of ugly 

looking Kerry sees 

uh,

which are markedly widened and with 

inflammatory cells,

inflammatory masses around them giving hyper liam and 

giving you these ill defined 

borders.

Okay,

if we now quickly summarize the 

findings of these patients,

you could see it out of the 21 or 22 

patients,

13 had no non functioning kidney,

91 functioning kidney.

Of course,

these are the ones which are really interested in here,

it's maybe academic interest to try to make a 

diagnosis because Dead kidney,

its prognostic Lee very nice if they turned out to 

go in and find out it was just an absence and not to happen former,

but patient would be much happier when it comes out,

but it doesn't change very much.

But the functioning kidney you don't want to remove.

So,

nine out of the 22 were functioning 

kidneys 19 of the kidneys were 

larger than the normal ones.

We were small ones.

And you can see that out of the 1912 had 

what looked like a mass effect.

While seven were defused the enlarged.

Again,

the masses were usually associated with the functioning 

kidney while the diffusion enlarge were more associated with non 

functionally just the whole kidney was already so full with past that it was 

just one big diffuse mass.

Mhm.

Now,

if you look at the 

arteries and the veins,

especially the capital ones,

you'll see that.

Yeah,

five head slightly Increased.

# eight had the moderate increase in four had a lot,

very markedly increased arteries or 

veins.

Now,

if you look what are these are obviously the ones 

which primarily broke out into the 

into the paranoia thick area are the ones which 

are giving you most of the arteries?

Well,

the one which is the least are the ones which are still confined to the 

kidney.

Nevertheless,

if you take all these numbers together and see the majority of 

them did have abnormal capital vessels.

Now,

what are the radiographic findings really the plain 

films?

We'll have a large kidney 

possibility and calculate lots 

of and irregular renal outlines 

and an indistinct puzzle source outline.

Now,

these two things are very,

very important.

And you'll see in a minute,

I'll show you the statistics,

the numbers which we collect on them.

I would say if both are missing.

In other words,

if you don't,

if you can see clearly the out of the kidney,

you can see clearly the source muscle,

it's almost for sure.

Not going to be an abscess.

The other thing is if you read the literature,

they'll tell you that patients have a scoliosis towards the 

side of the 

affected kidney,

we did not find it in a single patient.

So I don't think it's a very reliable science.

Now,

if you look at just if you take these two things,

the outline of sauce muscle and the outline of the kidney,

you can see that you have Absent of 

source more than 17 cases And the other and 

the kidney was not seen in 10 cases and these were not the same.

So that's why I said if most of these signs are 

not there,

it is highly unlikely that you'll be dealing with with 

inflammatory disease.

The EVP is a very little 

value.

It's very non specific.

You may find compression,

you may find a non functioning kidney,

but you really can't make can't 

make it a specific diagnosis VP.

Nor can you make too much out of the retrograde 

the arteriogram.

The arterial phase is stretching of the 

arteries,

increase in size of capital vessels,

relatively orderly distribution of the vessels.

In contrast to happen a former where vessels just 

go into all kinds of 

directions.

And finally,

you may get some blood supply from the arteries.

Now,

the one slide which came in out of all the 

water which capillary and the the 

venous and capillary phase,

which I showed in the beginning with the other side,

which should be the next slide really basically that we summarize them 

Because I've said it a thing at least 20 times.

You lose the cortical Nedlloyd border,

you lose the outline of the kidney and you get vessels which are going 

out.

These are some of the signs.

That is the slide.

We should have come earlier.

These are basically mixed up.

These two slightly clinical findings are 

fever,

chills and malaise and they should be associated with your 

radiographic findings.

You have to look for them.

The patients will have some of that.

They don't if they don't have any of these,

they are not going to heavily lapses.

They don't just come from nowhere.

The abscesses.

Okay,

I have a thing about three minutes left.

Let me just show you a few 

examples of things which can look like that.

Unfortunately like that.

It is not a product.

Pneumonic fighting.

There are several lesions which can look similar.

First of all,

of course the worst problem is the 

narcotic hype in a form or they can give us almost any picture.

And it's something which we have to consider 

and if the clinical findings don't fit.

Always think about here is a patient with a large mass.

I got cookie fast with them.

This patient had different history.

He fell from a scaffold 

his kidneys completely transacted 

and there is a large hematoma which can little bit look a 

little bit like it.

Of course.

The history helps you here and there's no reason for him to have 

that to have an abscess.

And you can see.

But you can see that the picture is very similar.

That is only about four or five hours after the 

injury.

And yet it looks like what if I didn't have any history.

It would be a 

could easily be a parametric abscess.

He was the same thing.

Another patient that patient,

carcinoma of the testicle metastases could look 

like that.

You can see the kidneys kind of split open almost 

by the extrinsic pressure.

And if you look at the his appearance here,

it looks very much like an abscess.

We knew adam he had testicular tumor and he 

had none of the clinical science,

but that can look like it.

Carcinoma of the larynx.

Funny looking appearance of the collecting 

system.

Look at the they look like the kind of invasion 

of the breaks into the palaces.

Large veins like Otto is again,

the history is helpful,

but that ah 

another patient looks very much like some of the ones I showed you that 

carcinoma of the lung with multiple metastases.

He was a kidney,

you know,

see poorly,

poorly filling,

poorly filled.

See the appearance very similar to what I showed you before.

Finally,

a patient with,

I believe it's going to be another customer 

of allowing look at these vessels here.

No cortical malloy bordeaux 

very similar.

So,

metastases are a real problem,

patients with Hodgkin's disease.

Paran ethic.

Hopkins is indistinguishable form an abscess except for 

the history.

Look at these other.

Another one who's Hodgkin's disease just gives you very large 

masses.

Look at this large cortical artery.

See them.

So,

these are some of the things that you can should think about.

Whereas a differential diagnosis that's just a patient with lymphoma,

sarcoma totally surrounding surrounding the kidney,

giving you the very similar appearance 

which is look like the 

paranoia thick extension.

It is basically para nothing except being an 

inflammatory disease.

Happened to be in your plastic 

and you can see it very much 

like the patient that should before.

So I think you cannot make the 

diagnosis without history.

Here is just a small ball on that same patient which is 

kind of looks very similar to what we 

have,

what we had with typical infrastructure and with 

the whole thing is just matted together by the tumor.

So basically 

you can see that there are fairly characteristic 

patterns.

If you tie them together with the clinical history,

there are differential diagnostic points.

It is not a clear cut diagnosis but it's something which you can 

when you tie together with the clinical findings,

you can make the diagnosis or at least suspected 

if the kidney is functioning.

It warrants a biopsy or puncture so that 

you don't remove any young person,

a kidney which need not be removed.

Thank you.

Okay,

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R.

E.

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C.

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