Duplicated or Ectopic Renal Collecting System in Two Adult Emergency Department Patients.

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BACKGROUND:Duplicated renal collecting system is a urological anomaly often found in pediatric patients. It is less commonly diagnosed in adulthood, particularly in a pregnant patient. Many point-of-care ultrasonography users may not be aware of this diagnosis, particularly in patients in the emergency department. It is important to recognize the duplicated system because in general, patients will often have hydronephrosis in only one renal pole rather than the entire kidney, which corresponds to an unequal renal function as documented on renal nuclear medicine functional scans. As a consequence, if the sonographer only identifies one ureter and incompletely visualizes the kidney, obstruction of one of the duplicated structures may be missed. CASE REPORT:We report 2 cases of duplicated ureter in patients in the emergency department who present with flank pain and urinary symptoms. Both patients were adult females, one pregnant, with duplicated ureter and severe right upper pole hydroureteronephrosis. The first patient was admitted for intravenous antibiotic therapy for pyelonephritis in pregnancy. The second was discharged with oral antibiotics and urgent urologic follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Duplicated ureter should be considered in patients with recurrent urinary tract infections or enuresis. Point-of-care ultrasonography users should note the differential hydronephrosis between upper and lower renal poles and may visualize duplicate or ectopic ureteronephrosis or ureterocele. Patients should be prescribed prophylactic antibiotics and have urgent urologic follow-up because the untreated condition can lead to irreversible renal damage.





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Theophanous, Rebecca G, Alexander T Limkakeng and Joshua S Broder (2019). Duplicated or Ectopic Renal Collecting System in Two Adult Emergency Department Patients. The Journal of emergency medicine. 10.1016/j.jemermed.2019.10.014 Retrieved from https://hdl.handle.net/10161/19911.

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Rebecca George Theophanous

Associate Professor of Emergency Medicine

Rebecca Theophanous, MD, MHSc is an Emergency Ultrasound Faculty at Duke University Hospital and the Durham VA Healthcare System. Her research involves identifying facilitators and barriers to implementation of a new emergency ultrasound program at the Durham VAHCS and its impact on clinical care for future dissemination. She is also studying 3DUS technology at Duke as an innovative bedside tool and training ED providers on ultrasound. Her academic interests include medical education, with a focus on ultrasound and critical care.


Alexander Tan Limkakeng

Professor of Emergency Medicine

Dr. Alexander T. Limkakeng, Jr., MD, MHSc, FACEP is a Professor of Emergency Medicine, Vice Chair of Clinical Research, Director of the Acute Care Research Team, and Director of the Resident Research Fellowship for the Department of Emergency Medicine in the Duke University School of Medicine in Durham, North Carolina.

Dr. Limkakeng has served as chair of the American College of Emergency Physicians (ACEP) Research Committee, and been the Course Director of the ACEP Research Forum from 2016-2018, the largest emergency medical research platform in the nation. He is also the Assistant Director of ACEP’s Emergency Medicine Basic Research Skills course. He was elected to the Nominating Committee of the Society of Academic Emergency Medicine.

As a researcher, Dr. Limkakeng has led multiple clinical trials and interdepartmental sponsored projects and is author on over 100 peer-reviewed manuscripts. These include studies in emergency conditions such as COVID-19, traumatic brain injury, hypertension, heart failure, thrombosis, stroke, envenomations, and septic shock. His research has been funded by grants and contracts totaling over $9 million dollars. He has lectured internationally on acute coronary syndrome, responsible conduct of research, design of clinical trials, and precision medicine in emergency care. He has led Duke’s involvement in NIH-funded research networks and in industry-funded work that led to FDA approval for multiple high-sensitivity cardiac troponin assays and point-of-care COVID-19 diagnostic tests. He has servesd as Co-PI for the Duke U24 Hub in the NIH Early Phase Pain Investigation Clinical Network (EPPIC-Net) (1U24NS114416) and now serves as a co-PI on the Duke U24 Hub award (1U24NS129498) in the NIH Strategies to Innovate Emergency Care Clinical Trials (SIREN) Network and in the NIH NINDS Strokenet network (1U24NS135250)

His personal research interest is finding new ways to diagnose acute coronary syndrome. In particular, he is interested in novel biomarkers and precision medicine approaches to this problem. The common element throughout this work is a focus on time-sensitive health conditions.

Joshua Seth Broder

Professor of Emergency Medicine

Joshua Broder, MD, FACEP is Professor, Residency Director, and Vice Chair of Education in the Department of Emergency Medicine at Duke University School of Medicine.  Dr. Broder has taught medical student, graduate medical education, and continuing medical education courses for the past 20 years and mentored undergraduate and graduate students.  He has been an invited education speaker nationally and internationally, including meetings of the Society for Academic Emergency Medicine, the American College of Emergency Physicians (ACEP), the Council of Residency Directors (CORD) in Emergency Medicine, the Eurasian Congress on Emergency Medicine, and the Society for Emergency Medicine in Singapore.  Dr. Broder is a North Carolina native and earned a bachelor’s degree in biology from Duke University in 1994.  After graduating from the Yale School of Medicine, he trained and was Chief Resident in Emergency Medicine at the University of Maryland.  Dr. Broder received the ACEP National Emergency Medicine Faculty Teaching Award and CORD National Faculty Teaching Award in 2007.  He was chosen as a "Distinguished Educator" for Enduring Educational Materials by the CORD Academy for Scholarship in Education in Emergency Medicine in 2013.  He was recognized with the Duke University School of Medicine Master Clinician-Teacher Award in 2016.  In 2022, he received the Parker J. Palmer “Courage to Teach” Award for Program Director Excellence from the Accreditation Council for Graduate Medical Education (ACGME), a national education leader award.

Dr. Broder wrote and edited Diagnostic Imaging for the Emergency Physician, which received the 2011 American Publishers Award for Clinical Medicine.  Since 2007, he has written the monthly column “The Critical Image” for ACEP’s Critical Decisions in Emergency Medicine (>180 articles).  He has more than 50 PubMed indexed publications.  His research and education initiatives focus on appropriate use of emergency diagnostic imaging, as well as engineering and patient safety.  He conducts clinical research in the Emergency Department at Duke, has received foundation grant funding, and is an inventor of a novel ultrasound device.  He serves on multiple national committees including the American College of Emergency Physicians Clinical Policies Committee and American College of Radiology Appropriateness Criteria Committee.  He chaired the SAEM GRACE-2 writing committee on recurrent low-risk abdominal pain and was first author on the resulting 2022 clinical guideline.

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