Case Report - PSEUDO ARF
Introduction
Urinary bladder ruptures commonly are encountered in blunt or penetrating lower abdominal injuries. Spontaneous rupture of bladder is rare. Such ruptures are known to occur in a carcinoma bladder, neurogenic bladder or in post irradiation bladder. Bladder rupture is of two types: intra peritoneal & extra peritoneal. We present a case of spontaneous intra peritoneal rupture of bladder which mimicked acute renal failure without any of the causes stated above. But probably was due to focal detrusor weakness following instrumentation performed for urethral stricture.
- Suvarna Patil
Physician, Intesivist and Medical Director - Vikram Dalvi,
Physician - Abhay Desai.
Surgeon. - Netaji Patil.
Radiologist.
Case Presentation -
A 28 years old male patient, painter by occupation presented with burning micturation, dribbling & distention of abdomen since 4 days. He had undergone urethral instrumentation 3 years ago for urethral stricture with obstructive uropathy. He was found to have duplex ureter during IVP that time. As he was asymptomatic, He did not follow up for past 3 years
His vitals were stable. He had no pallor, no oedema / icterus / cyanosis / clubbing / lymphadenopathy. He had ascites. Liver & spleen not palpable. Other systems were normal. Lab investigations were – Ser. Creatinine 5mg%, Urine had 50 to 60 pus cell /Hpf but no casts; Liver function tests were normal. USG abdomen and Doppler study showed gross ascites, altered echotexture of liver & normal portal vein and spleen.
Picture 1: Cystoscopic view:
devitalized portion with an opening in it.
Patient in lithotomy position.
Abdominal paracentesis was performed. 3 liters of straw colored fluid was removed. Cyto chemical analysis of Ascitic fluid showed transudate with lot of mesotheliel cells. Ascitis was fast refilling & needed daily tapping of about 2 -3 liters. During these 4 days, patient was afebrile & vitals were stable. His creatinine gradually increased to 14mg%, potassium to 5.2mg/ltr.
Till day 5 of admission, he was not catheterised because 1) he was fully conscious & passing about 800-1000 cc urine/day, 2) USG did not suggest obstruction any where in urinary tract. He was treated with Ciprofloxacin. Finally patient was posted for diagnostic laparoscopy & peritoneal biopsy.
Repeated ascitic fluid examination was suggestive of transudate which was not fitting in any differential diagnosis. So we thought of urine leaking into peritoneal cavity to substantiate. Foley’s catheter was put in. Ascitic fluid was sent for Serum Creatinine & Urea. Ascitic fluid creatinine was 14 mg% & Urea was 234 mg% which was supporting our clinical suspicion. Hence instead of laproscopy, cystoscopy was performed, that showed a rent of 6x1 cm in the bladder dome. Margins of rent were devitalized. Then Laprotomy was done & rent was repaired following a biopsy. Biopsy did not reveal any abnormality. He made an uneventful post operative recovery with disappearance of ascitis, and creatinine, BUN level reverting to normal.
Discussion
Picture2: Urinary bladder during laparotomy
Spontaneous rupture of bladder is uncommon & only 26 Cases have been reported in the literature with alcohol abuse. Substance abuse with alcohol, cocaine & amphetamine, all have been associated with spontaneous rupture of bladder. In other cases pelvic irradiation, inflammation of bladder from interstitial cystitis, or eosinophilic cystitis or tuberculosis, entero cystoplasty, erosion by an indwelling catheter or a large vesical calculus have been implicated.
The pathogenesis involves bladder over distention & thinning of the dome from diuresis. The patient ignores natural urge to void due to alcoholic stupor. There after even trivial increase in intra abdominal pressure like coughing can rupture the bladder. Patient develops vague abdominal pain & progressive abdominal distention, developing from urinary ascites. Urinary ascites causes reverse auto dialysis wherein urea & creatinine molecules are absorbed into the blood & produce a picture of pseudo renal failure. While most ruptures are intraperitonial with resultant urinary ascites, extraperiatonial have also been described.
In this case patient was not under influence of alcohol. He gives history of some instrumention for urethra 3 years back. History of early morning painful voiding, and sudden stoppage of flow, Vague abdominal pain with gradually increasing abdominal pain over 4 days.
Picture 3:
Urinary bladder during Laprotomy
The key to management is a high index of suspicion. A history of alcoholic binge, urethral stricture, incomplete emptying of bladder all leads to over distention of bladder. A CT cystogram is diagnostic, but it is costly & not available at all places. A simple lab investigation – ascitic fluid creatinine & urea which is less expensive & available every where, is the diagnostic test. Standard methods of bladder closure are recommended. A bladder biopsy is necessary to exclude any pathology. The condition is often diagnosed late & is associated with high morbidity & mortality of 50%.