anuria due to bilateral ureterolithiasis after ...appendectomy; ureterolithiasis; anuria. case...
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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: aroeth@kullen.rwth-aachen.de
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
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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
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.
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
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