Inferior Vena Cava Thrombosis, Appendicitis Mimic

ABSTRACT Right lower quadrant abdominal pain is a common presentation to the Emergency Department. While appendicitis is a frequently diagnosed pathology associated with this complaint, there are multiple, well-documented alternatives that must be considered. The authors present a unique case of a 20 year old active duty male who presented with 3 days of acutely worsening right lower quadrant abdominal pain, right flank pain, and anorexia. Following a detailed work-up, computed tomography and magnetic resonance imaging (MRI) demonstrated a bland thrombus within the inferior vena cava (IVC) secondary to a vascular web. This case highlights the difficulty in astutely diagnosing appendicitis utilizing clinical examination and scoring metrics. While IVC thrombosis is a rare phenomenon, it should be considered in the emergency physician’s differential for right lower quadrant abdominal pain, particularly when additional nonspecific symptoms are present.

Inferior vena cava thrombosis as a possible cause of nephrotic-range proteinuria: two case reports

Background Nephrotic-range proteinuria is a common reason for nephrological consultation in clinical practice. The differential diagnosis is wide, and generally focuses on different forms of glomerulonephritis, but other causes should not be overlooked, as illustrated in this article. Case presentations We report two female patients with nephrotic-range proteinuria. In the first case, a 46 year old Caucasian patient who suffered from extreme obesity (Body mass index (BMI) 77 kg/m2), acute kidney injury and nephrotic-range proteinuria were discovered during an emergency consultation for acute abdominal pain. The second patient (aged 52, also Caucasian) developed stage 4 chronic kidney disease and nephrotic proteinuria (protein/creatinine ratio 1821 g/mol) after accidental rupture of the inferior vena cava during a gastric bypass operation. On split-urine collection, both had a much higher degree of proteinuria during the day than during the night, compatible with orthostatic proteinuria. At further work-up, inferior vena cava thrombosis was diagnosed in both patients, whereas renal veins were patent. Discussion After simple anticoagulation in the first case, and anticoagulation plus endovascular recanalization in the second, there was almost complete resolution of the orthostatic proteinuria and a strong improvement of the estimated glomerular filtration rate in both patients. These cases highlight that nephrotic-range proteinuria can be linked to inferior vena cava thrombosis, and that a split-urine collection may also be very useful in the diagnostic work-up of proteinuria in adults.

Prognosis of patients operated on for renal cell carcinoma and tumor venous thrombosis: experience of the Urology Clinics, N.N. Blokhin National Medical Research Center of Oncology

Objective: to identify independent risk factors affecting survival of patients with renal cell carcinoma (RCC) and tumor venous thrombosis who have undergone nephrectomy and thrombectomy.Materials and methods. This study included 768 patients with RCC complicated by tumor venous thrombosis who have undergone nephrectomy and thrombectomy. Median age was 58 years (range: 16-82 years); the male to female ratio was 2.3:1. The symptoms of tumor venous thrombosis were identified in 232 patients (30.2 %); laboratory abnormalities at baseline were observed in 456 patients (59.3 %). Grade I and II tumor thrombosis was diagnosed in 456 (59.3 %) and 201 (26.2 %) patients, respectively; grade III and IV thrombosis was found in 171 (22.3 %) and 177 (23.0 %) patients, respectively. One hundred and twenty-nine participants (16.8 %) had infrarenal inferior vena cava thrombosis. Regional metastases were detected in 188 individuals (24.4 %), distant metastases were registered in 274 patients (35.7 %). All patients have undergone surgery: either radical (n = 555; 72.3 %) or cytoreductive (n = 213; 27.7 %). All primary tumors were histologically classified as RCC (G3-4 in 337 cases; 43.9 %). A total of 719 patients (93.6 %) survived the perioperative period; 183 patients with metastasis (23.8 %) received systemic antitumor therapy.Results. The median follow-up was 24 months (range: 1-200 months). The 24-month overall and cancer-specific survival of all patients were 96.9 and 99.7 %, respectively; recurrence-free survival of patients after radical surgery reached 92.9 %. Progression-free survival among those patients who underwent cytoreductive surgery and received first-line therapy/follow-up was 41.7 %. Negative predictive factors of overall survival included hepatomegaly (p = 0.024), ascites (p = 0.033), level IV tumor thrombosis (p <0.0001), infrarenal inferior vena cava thrombosis (p = 0.002), regional metastases (p <0.0001), and cytoreductive surgery (p = 0.012). Depending on the number of risk factors, we have identified 3 prognostic groups: favorable (0 factors), intermediate (1-2 factors), and poor (3-6 factors). Median overall survival differed significantly between the groups and was 128.6 ± 11.8; 40.9 ± 6.7 and 12.3 ± 2.2 months, respectively (p <0.0001 for all).Conclusion. Stratification of patients operated on for RCC and venous tumor thrombosis with their allocation to prognostic groups will ensure the choice of an optimal management strategy.

A young woman presented with massive pulmonary embolism with inferior vena cava thrombus as a complication of nephrotic syndrome: a case report

Nephrotic syndrome (NS) was first described in 1827 as the presence of proteinuria of ≥ 3.5 g/24 h, hypoalbuminemia < 3.0 g/dl, peripheral edema, hyperlipidemia, lipiduria, and increased thrombotic risk. Nephrotic syndrome has an incidence of three cases per 100,000 each year in adults. Nephrotic syndrome also has serious complications due to hypercoagulable state in both various venous and arteries which could lead thromboembolic events. The pathophysiology of hypercoagulability in the nephrotic syndrome is due to an imbalance of prothrombotic and antithrombotic factors, as well as impaired thrombolytic activities.Here, we will present a 19-year-old woman who presented to the emergency department complaining of chest pain and shortness of breath for 3 days. The patient was quickly diagnosed with pulmonary embolism and inferior vena cava thrombosis as a complication of nephrotic syndrome, allowing prompt initiation of anticoagulant therapy. After 2 weeks of admission, the patient’s condition resolved, her laboratory results returned to almost normal and the patient was discharged with oral prednisolone, coumadin, atorvastatin, and ramipril. We aim to determine which is the likely cause of pulmonary embolism in patients with nephrotic syndrome.