Anuria due to bilateral ureterolithiasis after ...Appendectomy; ureterolithiasis; anuria. Case...

4
Grand Rounds Vol 8 pages 6–9 Speciality: General surgery; Paediatric surgery Article Type: Case Report DOI: 10.1102/1470-5206.2008.0003 ß 2008 e-MED Ltd Anuria due to bilateral ureterolithiasis after appendectomy in a child A.J. Roeth a , C.J. Krones a , J. Conze a , K.M. Ruhl b , G. Steinau a and V. Schumpelick a a Department of Surgery, Medical Faculty, RWTH Aachen, Germany; b Department of Radiology, Medical Faculty, RWTH Aachen, Germany Corresponding address: A.J. Roeth, Department of Surgery, RWTH Aachen, Pauwelsstr. 30, 52057 Aachen, Germany. E-mail: [email protected] Date accepted for publication 8 January 2008 Abstract We report on a boy who presented with acute renal failure and bilateral ureteral obstruction 5 days after an uneventful appendectomy. In contrast to the few cases described in the literature, bilateral ureterothiasis was the pathogenesis of ureteric obstruction. The clinical signs and diagnostic findings, and an overview of the literature are presented. The severity of permanent renal damage in a child underlines the importance of this report. Keywords Appendectomy; ureterolithiasis; anuria. Case report An 11-year-old boy was admitted to our hospital with a 1-day-history of abdominal pain accompanied by nausea and vomiting. Anamnesis did not provide any circumstantial evidence. On physical examination, the boy showed the usual signs of appendicitis [1] including localised abdominal tenderness with guarding in the right iliac fossa. Laboratory tests showed major leucocytosis and an increase of C-reactive-protein. At laparotomy, a perforated gangrenous appendix with a perityphlitic abscess was found. We performed a conventional appendectomy with drainage of the abscess with two easy-flow-drainages. One was placed in the Douglas cavity and the other near the coecal pole. Histopathology revealed a neutrophilic infiltrate within the mucosa and submucosa and a suppurative inflammation that extended through the appendiceal wall into the adipose tissue (Fig. 1). Initially, the further clinical course was uncomplicated. Five days post-procedure, the boy suddenly complained about nausea, vomiting, and colicky pain in both the right and left iliac fossa. At this time, the patient was free of any dietary restrictions or infusion regimens and waiting for discharge. Diagnostics, including abdominal and wound examination, laboratory tests, urine analysis, and abdominal ultrasound were normal. Initially, the little patient recovered spontaneously, but complaints returned the next day. On reflection, the boy now specified anuria for almost 20 h. Laboratory tests revealed acute renal failure with an increase in urea to 86 mg/dl, creatinine 3.1 mg/dl, and uric acid 9.0 mg/dl. Abdominal ultrasound showed a urinary stasis grade This paper is available online at http://www.grandrounds-e-med.com. In the event of a change in the URL address, please use the DOI provided to locate the paper.

Transcript of Anuria due to bilateral ureterolithiasis after ...Appendectomy; ureterolithiasis; anuria. Case...

Page 1: Anuria due to bilateral ureterolithiasis after ...Appendectomy; ureterolithiasis; anuria. Case report An 11-year-old boy was admitted to our hospital with a 1-day-history of abdominal

Grand Rounds Vol 8 pages 6–9

Speciality: General surgery; Paediatric surgery

Article Type: Case Report

DOI: 10.1102/1470-5206.2008.0003

� 2008 e-MED Ltd

Anuria due to bilateral ureterolithiasis

after appendectomy in a child

A.J. Roetha, C.J. Kronesa, J. Conzea, K.M. Ruhlb, G. Steinaua andV. Schumpelicka

aDepartment of Surgery, Medical Faculty, RWTH Aachen, Germany; bDepartment of Radiology,

Medical Faculty, RWTH Aachen, Germany

Corresponding address: A.J. Roeth, Department of Surgery, RWTH Aachen, Pauwelsstr.

30, 52057 Aachen, Germany.

E-mail: [email protected]

Date accepted for publication 8 January 2008

Abstract

We report on a boy who presented with acute renal failure and bilateral ureteral obstruction

5 days after an uneventful appendectomy. In contrast to the few cases described in the literature,

bilateral ureterothiasis was the pathogenesis of ureteric obstruction. The clinical signs and

diagnostic findings, and an overview of the literature are presented. The severity of permanent

renal damage in a child underlines the importance of this report.

Keywords

Appendectomy; ureterolithiasis; anuria.

Case report

An 11-year-old boy was admitted to our hospital with a 1-day-history of abdominal pain

accompanied by nausea and vomiting. Anamnesis did not provide any circumstantial evidence.

On physical examination, the boy showed the usual signs of appendicitis[1] including localised

abdominal tenderness with guarding in the right iliac fossa. Laboratory tests showed major

leucocytosis and an increase of C-reactive-protein. At laparotomy, a perforated gangrenous

appendix with a perityphlitic abscess was found. We performed a conventional appendectomy

with drainage of the abscess with two easy-flow-drainages. One was placed in the Douglas cavity

and the other near the coecal pole. Histopathology revealed a neutrophilic infiltrate within the

mucosa and submucosa and a suppurative inflammation that extended through the appendiceal

wall into the adipose tissue (Fig. 1).

Initially, the further clinical course was uncomplicated. Five days post-procedure, the boy

suddenly complained about nausea, vomiting, and colicky pain in both the right and left iliac

fossa. At this time, the patient was free of any dietary restrictions or infusion regimens and

waiting for discharge. Diagnostics, including abdominal and wound examination, laboratory tests,

urine analysis, and abdominal ultrasound were normal. Initially, the little patient recovered

spontaneously, but complaints returned the next day. On reflection, the boy now specified anuria

for almost 20h. Laboratory tests revealed acute renal failure with an increase in urea to 86mg/dl,

creatinine 3.1mg/dl, and uric acid 9.0mg/dl. Abdominal ultrasound showed a urinary stasis grade

This paper is available online at http://www.grandrounds-e-med.com. In the event of a change in the URL

address, please use the DOI provided to locate the paper.

Page 2: Anuria due to bilateral ureterolithiasis after ...Appendectomy; ureterolithiasis; anuria. Case report An 11-year-old boy was admitted to our hospital with a 1-day-history of abdominal

Fig. 1. Low magnification view of a longitudinal section of the vermiform appendix (hematoxylin–eosin, �125).

Fig. 2. Abdominal ultrasound reveals bilateral urinary obstruction with dilatation of the renal pelvis.

Fig. 3. Native body-weight adapted low dose pelvic CT scan (Somatom Sensation 16, tube voltage 120kV, 13mAseff, collimation16�1.5mm, tube rotation time 500ms) shows hyperdense structures in projection to the distal ureters bilaterally, consistentwith calculi.

Bilateral ureterolithiasis after appendectomy 7

Page 3: Anuria due to bilateral ureterolithiasis after ...Appendectomy; ureterolithiasis; anuria. Case report An 11-year-old boy was admitted to our hospital with a 1-day-history of abdominal

II with bilateral dilatation of the ureters, renal pelvis, and calyces; the empty urinary bladder had

a normal wall thickness (Fig. 2).

As the distal ureters were superposed due to intestinal gas, ultrasound could not reveal the

reason for obstruction. Thus, a native CT scan was performed, which indicated calculi in both

distal ureters (Fig. 3). During the following retrograde ureteroscopy, all stones were removed and

mono-J-catheters were inserted bilaterally. After 7 days, the boy was released without further

complaints.

Discussion

Cases of bilateral ureteral obstruction after appendectomy in a child are rare[2–7]. Nevertheless, all

cases in the literature have common features. All patients suffered from severe appendicitis with

perityphlitic abscess formation. Symptoms like anuria, renal failure, nausea, and colicky pain

started several days after surgery. Finally, in all cases the pathogenesis of the obstruction was an

oedema of the posterior bladder wall. Contaminated by the perityphlitic abscess, the peritoneal

cavity caused an inflammatory oedema of the local environment[5]. Consequently, conservative

treatment including insertion of ureterocatheters and application of antibiotics restored

diuresis[6].

Our patient showed similar features. Five days after severe appendicitis, the boy suffered from

pain in both iliac fossae. The pain was accompanied by anuria, nausea, and vomiting and finally

led to renal failure. However, the reason for the obstruction was different and very rare.

Concrements in both ureters hindered renal drainage, although the posterior wall of the bladder

appeared normal. It is very likely that these calculi formed after surgery due to lack of liquid

supply. The patient probably did not drink enough during his hospitalization. Since the

appendectomy was performed 5 days before, he was free of any dietary restrictions and

intestinal complaints. As the initially complaints recovered spontaneously for more than 24h and

all primary tests did not reveal any pathologic findings, the diagnosis was further delayed.

Superposed by intestinal gas, only a native CT scan could finally reveal ureteral calculi on both

sides. Because of the severity of permanent renal damage in a child, an abdominal ultrasound

should always be performed if a patient presents with colicky pain or anuria after an

appendectomy. A CT scan should be arranged, if an ultrasound does not detect a reason for

the anuria. Due to the rarity of the diagnosis, conservative treatment was not followed; the calculi

present in both ureters were removed.

Teaching point

We report on a case of bilateral ureteral obstruction 5 days after an uneventful appendectomy.

The rarity of the disease and the danger of permanent renal damage in the case of deficient

treatment stress the impact of this report. Diagnostics can be challenging as complaints vary.

Detailed anamnesis and clinical examination, laboratory and urine analysis, and an abdominal

ultrasound should be carried out. A native CT scan may also be necessary. After diagnosis,

routine treatment should be uncomplicated. Nevertheless, it has to start immediately.

Acknowledgements

We gratefully acknowledge Alexander Bauer (Institute of Pathology, RWTH Aachen) for performing

the histopathological examinations.

References

1. Schumpelick V, Dreuw B, Ophoff K, Prescher A. Appendix and cecum. Embryology, anatomy,

and surgical applications. Surg Clin North Am 2000; 80: 295–318.

2. Aronson DC, Moorman-Voestermans CG, Tiel-van Buul MM, Vos A. A rare complication of acute

appendicitis: complete bilateral distal ureteral obstruction. Lancet 1994; 344: 99–100.

3. Buckley K, Buonomo C. Bilateral ureteral obstruction and renal failure due to a perforated

appendix. Pediatr Radiol 1994; 24: 308–9.

4. de Jong M, Debruyne F, Monnens L. Anuria following appendectomy in a 10-year-old boy.

Ned Tijdschr Geneeskd 1978; 122: 974–5.

8 A.J. Roeth et al.

Page 4: Anuria due to bilateral ureterolithiasis after ...Appendectomy; ureterolithiasis; anuria. Case report An 11-year-old boy was admitted to our hospital with a 1-day-history of abdominal

5. Hugen CA, Mulders PF, Monnens LA, Dijkman-Neerincx RH, de Vries JD. Bilateral ureteral

obstruction after appendectomy in children. J Pediatr Surg 1995; 30: 1666–7.

6. Timm K, Illi OE, Leumann E, Stauffer UG. Postrenal anuria after appendectomy in childhood.

Eur J Pediatr Surg 1997; 7: 237–8.

7. van Linde ME, van Pinxteren-Nagler E, Klinkert P, de Jong TP, Schroder CH. Acute renal

insufficiency caused by bilateral ureteral obstruction after appendectomy in a 6-year old boy.

Ned Tijdschr Geneeskd 2000; 144: 754–6.

Bilateral ureterolithiasis after appendectomy 9