|
Case Report
L. T. Seeberg1 J. Edenberg2 H. Sætren1
1Department of Surgery,
2Department of Radiology, Sykehuset Innlandet Lillehammer, N-2629 Lillehammer, Norway
Correspondence to: L. T. Seeberg, Department of Surgery, Sykehuset Innlandet Lillehammer, N-2629 Lillehammer, Norway Email: seel@sb-hf.no
Acute renal failure due to bilateral ureteral obstruction is a rare complication after appendectomy in children. We report a case of anuria in an 11-year-old boy five days after surgery for a perforated acutely inflamed appendix. No abscess was found with CT. After saline-filling of the urinary bladder, transabdominal ultrasound demonstrated echogenic “plugs” in the distal parts of both ureters. Cystoscopy revealed inflammatory changes in the bladder base. Following introduction of bilateral ureteric stents, there was rapid normalisation of urinary output and serum creatinine. A review of the literature disclosed 15 similar cases, all boys in the age group 6 to 15 years
Keywords: Acute postrenal obstruction, anuria, appendectomy, haematuria, distal obstruction of ureters, ultrasound Surgeon, 1 February, 2005, 45-47
Appendicectomy is a common surgical procedure in children. Well known complications include abscess formation, peritonitis and wound infection. Urologic complications are uncommon and usually result from right-sided ureteral obstruction, in most cases due to an appendiceal abscess. Bilateral ureteral obstruction causing renal failure is a rare complication. We report a case of anuria due to bilateral ureteral obstruction, not related to an abscess, in an 11-year-old boy. In the diagnostic work-up, the use of saline-filled bladder for ultrasound of the bladder base and distal ureters is described.
CASE PRESENTATION AND MANAGEMENT
An 11-year-old boy underwent laparotomy for a perforated acutely inflamed appendix. Antibiotics were administered. The early postoperative course was uneventful. There was no history of renal disease.
Three days after surgery the patient complained of nausea, and the following day of right-sided flank pain. On the fifth day postsurgery he developed macroscopic hematuria and oliguria. Blood pressure was elevated (150/92), and serum creatinine was 315 micromol/L. Later that day he became anuric.
Ultrasound of the urinary tract demonstrated bilateral hydronephrosis of moderate degree and an empty urinary bladder. Due to clinical suspicion of a pelvic abscess causing ureteral obstruction, the patient was referred for a computed tomographic (CT) study. This examination excluded an abscess, but confirmed bilateral hydronephrosis and hydroureter of uncertain aetiology.
A new ultrasound study was performed in cooperation between the examining radiologist and the urologic surgeon. To permit examination of the posterior bladder region, saline was installed into the bladder through the indwelling catheter. With this fluid as an acoustic window, ultrasound disclosed a marked swelling of the right osteal region (interpreted as oedema).
Distal parts of both ureters were dilated and, in the proximity of the orifices, filled with a plug-like, echogenic material with posterior shadowing (Figure 1).
Figure 1
Shortly after the ultrasound study, a cystoscopy under general anaesthesia showed inflammatory changes in the bladder base and a swollen right-sided osteal region with a whitish “plug” protruding from the orifice. When cannulated there was emptying into the bladder lumen of cloudy, whitish material from both ureters. A ureteric stent was introduced bilaterally.
On the following days, the patient had normal urine production after a short polyuric phase. Flank pain and nausea subsided. Serum creatinine decreased gradually to 77 micromol/ L three days after stent introduction, and the stents were removed. He was discharged five days after cystoscopy.
Ultrasound control 14 days after stent removal showed no hydronephrosis. Distal parts of both ureters were non-dilated without visible “plugs”, and ureteric jet (color doppler) was observed on both sides. Intravenous pyelography carried out four months later was normal.
There is a well-known influence of acute appendicitis on the urinary tract. Microscopic haematuria is a well recognised, incidental finding, and transient (and mild) pyelocalyceal dilatation of the right kidney has been detected in 38 % of patients prior to appendicectomy.1 Appendicitis may also simulate right ureteric colic.
Unilateral obstruction of the right ureter is well-recognised complication, and in most cases is related to an abscess.1,2
Bilateral obstruction is less common, but may also be due to mechanical obstruction by an abscess.3-6 However, without abscess formation, bilateral obstruction is a rare complication.7
Our search in the literature revealed sporadic reports, most of these describing a few patients only, and with a total number of 15 patients.7-13 In these reports, the condition has exclusively been described in boys aged 6 to 15 years, and, in most cases, with a perforated appendix (10 of 15 cases). Anuria developed on the fourth to sixteenth post-operative day (mean seven day). Cystoscopy in 13 patients cases revealed inflammatory changes and oedema affecting the posterior bladder wall and the ureteric orifices. Twelve patients were treated with ureteric stenting. In no case was the condition diagnosed with imaging prior to cystoscopy.
There are today several imaging modalities used for the investigation of urinary tract obstruction in children. Magnetic resonance imaging and renography are less practical tools in the acute setting. Intravenous pyelography includes the use of a contrast agent with possible nephrotoxic effect, and the display of pathology in the distal parts of the ureters is in many cases suboptimal. Coputerised tomography (CT) without contrast agents has been introduced as a rapid method to image ureterolithiasis in adults. However, the considerable radiation dose of a CT of the abdomen should give rise to caution.10 Children are also more sensitive to radiation than adults by a factor of ten.11
The ultrasound diagnosis of ureteral obstruction is characterised by detection of hydronephrosis, detection of ureteric jets from the orificies with color doppler and examination of the ureter.12 A mere exclusion of hydronephrosis is insufficient, as dilatation may be minimal or absent in spite of obstruction.9
With a filled urinary bladder as an acoustic window, transabdominal ultrasound can display an excellent view of the posterior bladder wall, the ureteric orificies and distal parts of the ureters. This technique has proven to be of great value in patients with distal ureteric calculi. In addition, demonstration of ureteric jets may provide evidence to distinguish between total and partial obstruction. Inflammatory changes of the posterior bladder wall is described as a complication to severe appendicitis (gangrenous or perforated), and probably is related to a localised peritonitis.10,11 The subsequent oedema may compromise the urinary flow and in some cases give rise to complete ureteral obstruction.
Flank pain, nausea and oliguria should lead to suspicion, even if no hydronephrosis is detected. Ultrasound examination of the bladder base and distal parts of ureters (if necessary through a saline-filled bladder) may provide a rapid diagnosis, without exposing the child to unnecessary radiation. Early diagnosis and intervention is important to prevent irreversible renal damage, and ureteric stenting has been suggested as the treatment of choice.10,11 In our patient this procedure had an immediate clinical effect with normalisation of diuresis, serum creatinine and blood pressure.
Copyright 15 December 2004
1. Dueholm S, Bagi P, Nordsten M. Ureteric obstruction as a complication to the appendicular abscess. Case report. Acta Chir Scand 1987; 153: 557-59.
2. Tripp BM, Homsy YL, Kiruluta G. Bilateral ureteral obstruction secondary to a perforated appendiceal abscess. J Urol 1995; 154: 1158.
3. De Jong M, Debruyne F, Monnens L. Anuria following appendectomy in a 10-year old boy. Ned Tijdschr Geneeskd 1978; 122: 974-75.
4. Buckley K, Buonomo C. Bilateral ureteral obstruction and renal failure due to a perforated appendix. Pediatr Radiol 1994; 24: 308-9.
5. Aronson DC, Moorman-Voestermans CG, Tiel-van Buul MM, Vos A. A rare complication of acute appendicitis: complete bilateral ureteral obstruction. Lancet 1994; 344: 99-100.
6. Hugen CA, Mulders PF, Monnens LA, Dijkman-Neerinex RH, de Vries JD. Bilateral ureteral obstruction after appendectomy in children. J Pediatr Surg 1995; 30: 1666-67
.
7. Timm K, Illi OE, Leumann E, Stauffer UG. Postrenal anuria after appendectomy in childhood. Eur J Pediatr Surg 1997; 7: 237-38.
8. Tiel-Van Buul MMC, Aronson DC, Groothoff JW, Van Baren R, Frenkel J, Van Royen EA. The role of renal scintigraphy in the diagnosis and follow-up of unilateral ATN after complete bilateral ureteral obstruction as a complication of acute appendicitis. Clin Nucl Med 1998; 23: 141-45.
9. 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: 754-56.
10. Denton ER, MacKenzie A, Greenwell T, Popert R, Rankin SC. Unenhanced helical CT for renal colic - is the radiation dose justifiable? Clin Radiol 1999; 54: 444-47.
11. Slovis TL, Hall ET, Huda W, et al. The Alara Conference: executive summary. Pediatr Radiol 2002; 32: 221.
12. Puskar D, Bedalov G, Fridrih S, Vuckovic I, Banek T, Pasini J. Urinalysis, ultrasound analysis, and renal dynamic scintigraphy in acute appendicitis. Urology 1999; 45: 108-11.
13. Sandermann J, Hansen LS. Bilateral ureteral obstruction as a complication to a perforated appendix. Report of a case. Acta Chir Scand 1983; 149: 535-36.
14. Kaplan GW, Keiller DL. Ureteral obstruction after appendectomy. J Pediatr Surg 1974; 9: 559-60.