1. Presenter: PGY 鄭偉宏 November 3, 2016
Case Presentation
Presenter: PGY 鄭偉宏
November 3, 2016

2. Patient Information Chief Complaint Name :黃○丞 Chart Number : 141**734
Age : 5-year-11-month old
Sex : Male
Admission Date: 2016/10/20
Ethnicity : Taiwanese
Chief Complaint
Left upper abdominal pain for 2 days
黃圓丞

3. Present Illness (1)
LUQ abdominal pain was noted one day before admission
Onset: At unexpected time
Pattern and duration: Intermittent, <30 mins
Characteristic: Dull pain
Severity: Moderate to severe
Aggravation: Pressing the area
Alleviation: Crouching position
Radiation: Nil
Accompanied by vomiting
Vomited 5 times/day
Food vomitus
This 5-year-10-month old boy had underlying disease of left hydronephrosis. This time he had abdominal pain for 2 days. Severe vomiting was noted and he came to NCKUH ED for help. According to his mother's statement, the patient had stool passage everyday but in minimal amount. He seldom does exercise and drinks few water. They are vegatarian and ate adequate amount of green vegetable everyday. This time the patient had moderate left upper quadrant abdominal pain. He couldn't tell the characteristic of the pain or the aggrevating factors of the pain, such as before or after meals. Whenever the pain occured, his mother found that he was in crouching position and he droped tears. He vomited 5 times yesterday and 2 times today. The vomitus was what he ate in last dinner. No blood, no coffee-ground substance, not green in color was noted in the vomitus. He had no fever in this course. No joint pain or petechia or ecchymosis was noted. His urine is color normal and he had no frequency, no urgency, no dysuria. At ED, vital sign was stable. Lab data showed no leukocytosis: WBC=12000, Band=5 %, Seg=69 %. Urinalysis showed no pyuria. Lipase=24. KUB showed stool packing in the descending, transverse and ascending colon. Abdominal echo showed 1. suboptimal study at right upper abdomen due to gas-block. 2. left hydronephrosis. Under the impression of abdominal pain, caused to be determined, he was admitted for further evaluation and treatment. 3

4. Present Illness (2) Constipation history Vegetarian Seldom do exercise
Drink few water
Stool passage: 1 time/day, hard solid stool.
Vegetarian
Buddhist
Eat vegetables everyday

5. Present Illness (3) 10/19 09:00 LUQ abdominal dull pain NCKUH ER
10/19 22:00
NCKUH ER
No fever.
No cough. No dyspnea. No chest pain.
No trauma history.
No heart burn. No hoarseness.
No diarrhea. No change in bowel habit.
No dysuria. No frequency. No urgency.
10/20 11:30
Admitted to NCKUH Ped Ward

6. Past History (1) Birth history: Vaccination: Growth:
G2P1, NSD, GA:39+6 weeks, BBW:3100g, Apgar score: 9->10
Vaccination:
As Taiwanese routine schedule
Rotavirus(+)
Pneumococcus(+)
Growth:
BW: 19.6kg(25th-50th%), BL: 115.4cm (25th-50th%)
Developmental milestones: No delay.

7. Past History (2) Left Hydronephrosis under Dr. Chiu OPD follow up
1-month
4- month
10-month
At Birth
1-year-old
Kawasaki disease, admitted to NCKUH
Nexium inj 40mg/vial (Esomeprazole) : 0.50 vial STAT Magnesium Oxide 250mg/tab(Magnesium Oxide): 0.50 TAB QID
Evac enema 118mL/btl(Sodium phosphate/ Disodium phosphate): mL STAT
2016/10/20
Morphine inj 10mg/mL/amp(Morphine) : 2.00 mg STAT
Buscopan inj 20mg/mL/amp(Hyoscine N-Butylbromide) : 0.50 amp STAT
2016/02/17
2016/03/02
2016/05/27
2016/06/17
2016/07/04
2016/07/11
2016/08/15
Abdominal pain and vomiting
 NCKUH ER or OPD for help

8. Family History

9. Physical Examination Consciousness: clear General appearance: fair
HEENT: conjunctiva: not pale, sclera: anicteric
Neck: supple, no JVE, no LAP
Chest: symmetric expansion, bilateral clear breath sounds, crackle(-), wheezing(-)
Heart: regular heart beat, murmur(-),S3(-),S4(-)
Abdomen: flat and soft, normoactive bowel sound (+), left upper quadrant tenderness(+), periumbilical tenderness (+), rebound tenderness (-), muscle guarding (-), left knocking pain(+)
Extremities: warm, pitting edema (-)
Skin: no edema, petechiae or ecchymosis °C

11. KUB at ER KUB shows: >The bowel gas is unremarkable.
>No obvious urolithiasis.
呂佳興醫師-放診專 835

12. KUB at ER KUB showed: (1) The bowel gas is unremarkable.
(2) No obvious urolithiasis.
(3) Stool impaction over the descending, transverse & ascending colon.
KUB shows:
>The bowel gas is unremarkable.
>No obvious urolithiasis.
呂佳興醫師-放診專 835

13. 1. Suboptimal study at right upper abdomen due to gas-block.
Sonography of upper abdomen shows:
Normal size and echogenicity of the liver parenchyma. No abnormal space occupying lesion found in the liver. The gall bladder is well distended with smooth wall. The CBD, IHDs, and portal vein are not dilated. Both pancreas and spleen are unremarkable. No special abnormality over abdominal aorta and inferior vena cava. Dilated left renal pelvis is noted.
IMP:1.Suboptimal study at right upper abdomen due to gas-block.
2.Left hydronephrosis.
郭宗男醫師-放診專617
IMP:
1. Suboptimal study at right upper abdomen due to gas-block.
2. Left hydronephrosis.
郭宗男醫師-放診專617 13

14. Abdominal CT + CT Urogram
Delayed phase
Clinical information: Severe left hydronephrosis,　請加做CT urogram ■1.Abdominal pain, suspected related to left kidney or stool impaction Multiple transaxial whole abdominal CT scan from diaphragmatic dome to pubic symphysis without and with IV contrast medium enhancement is performed. Film study shows the following findings: 1. The visible liver, gallbladder, spleen, and pancreas are unremarkable. 2. Right kidney and urinary bladder show normal. Left UPJ stenosis with dilated left renal pelvis and imparied excretory renal function. 3. No evidence of retroperitoneal para-aortic, pelvic, and inguinal lymphadenopathy is noted. 4. The visible mesentery and bowel loops appear normal. IMP: Left UPJ stenosis with Delayed excretory renal function. 蔡依珊醫師-放診專 682
Nephrogenic phase
Delayed phase
IMP: Left UPJ stenosis with delayed excretory renal function

15. Diagnosis
Left severe hydronephrosis with left ureteropelvic junction stenosis

16. Plan Percutaneous Nephrostomy (PCN) Voiding Cystourethrogram (VCUG)
Antegrade Pyelogram (AP)
24 hours Creatinine Clearance Rate
Comprehensive Renal Function Test (CRFT)

17. Percutaneous Nephrostomy (PCN)
Left PCN: Indication: Left hydronephrosis Puncture site: Left posterior axillary line Catheter: 6Fr. pigtail (COOK) without string lock Findings: The dilated left renal pelvis is noted on previous examination. The puncture needle approaches left renal pelvis under ultrasonographic guidance. Then the drainage tube is inserted under Seldinger's procedure. The aspirated urine seems clear. The whole procedure is smoothly done. No immediate complication could be found. Impression: 1) Left PCN is done smoothly. 郭宗男醫師-放診專617 / 林佳穎醫師
IMP: Left PCN is done smoothly

18. Voiding Cystourethrogram (VCUG)
Voiding Uretherocystogram: Clinical: acute onset severe left hydronephrosis VCUG is performed with infusion of diluted Telebrix 180ml (Telebrix 80ml)into the urinary bladder via Foley catheter. The result shows: >S/P left PCN in place. >UB is well distended without any abnormal filling defect or outpouching. >The urethra is well demonstrated, no stricture. >There is no evidence of vesicoureteral reflux of contrast medium from UB. >Minimal residual urine is noted after voiding. Impression: 1)No image evidence of vesico-ureteral reflux. 蔡依珊醫師-放診專 682 / 林佳穎醫師
IMP: No vesico-ureteral reflux (VUR)

19. Antegrade Pyelogram (AP)
Antegrade pyelography Clinical: Left UPJ stenosis wtih hydronephrosis s/p PCN Findings: >Preliminary film shows acceptable position of left PCN. >Well opacification of left collecting system. >The left renal pelvis and calices are dilated. Left UPJ stenosis is depicted. >The urinary bladder is opacified gradually. Impression: -Left UPJ stenosis with severe degree hydronephrosis. -S/P left PCN insertion. Function of left PCN is preserved. 劉婉貞醫師-放診專 883 / 林佳瀅醫師
IMP: (1) Left UPJ stenosis with severe degree hydronephrosis. (2) s/p left PCN insertion.

20. 24 hours Creatinine Clearance Rate
PCN. Left kidney
Voiding. Right kidney
CCr(PCN, Left) : CCr (Voiding, Right)
= [23mg/dl*829ml] : [15ng/dl*1145ml]
= 52.6% : 47.4%

21. Comprehensive Renal Function Test (CRFT)
Left T1/2 = 23.1 min
Right T1/2 = 4.0 min
CRFT+LASIX [Clinical History] Left hydronephrosis. [Procedure] 1. Furosemide (13 mg) was given intravenously 15 minutes before injection of Tc-99m MAG3. 2. Following the intravenous injection of 1 mCi of Tc-99m MAG3, dynamic renal images were performed for 20 minutes by gamma camera with low energy high resolution collimator. 3. Blood sample was taken for quantitative analysis 44 minutes after injection of Tc-99m MAG3. [Findings] Tc-99m MAG3 diuretic renal scan shows the differential left and right renal function is 51.7% and 48.3%, respectively. The left renogram shows depressed 2nd segment, flat 3rd segment with poor response to Lasix. The right renogram is normal in appearance with good response to Lasix. [Impression] 1. Obstruction of left collecting system. 2. No obstruction of right collecting system. 住院醫師:許思偉 / 主治醫師:邱南津 核專48
Left Uptake = 51.7%
Right Uptake = 48.3%
IMP: (1) Obstruction of left collecting system. (2) No obstruction of right collecting system.

22. Laparoscopic Dismembered Pyeloplasty + Double J Stenting
Pyeloplasty, in which the stenotic segment is excised and the normal ureter and renal pelvis are reattached.

23. Discussion Ureteropelvic Junction Stenosis

24. Ureteropelvic Junction Stenosis
The most common obstructive lesion in childhood
Incidence: 1 in 500 live births
60% of on the left side
Bilateral in only 10% of cases
Male : Female = 2 : 1

25. Clinical Manifestations
Hydronephrosis
Abdominal, flank, or back pain
Palpable renal mass
Pyelonephritis or UTI
Failure to thrive, vomiting, diarrhea
hydronephrosis without a dilated ureter

26. Etiology of Antenatal Hydronephrosis

27. Etiology of UPJ Stenosis
Congenital stenosis
Intrinsic stenosis
Extrinsic: accessory artery to kidney

28. Postnatal evaluation of unilateral fetal hydronephrosis
Prenatal Ultrasonogram
VCUG:10-15% of patients have ipsilateral vesicoureteral reflux
Postnatal Ultrasonogram
after the 3rd day of life
at 1 mo of age
Comprehensive Renal Function Test (CRFT) at 4-6 wk of age
RPD: Renal pelvic diameter

29. Postnatal evaluation of unilateral fetal hydronephrosis
Renal pelvic diameter RPD

30. Treatment Pyeloplasty Types Success rates: 91-98% Open pyeloplasty
Laparoscopic and robotic pyeloplasty
Indication for prompt surgery:
An abdominal mass
Bilateral severe hydronephrosis
Solitary kidney
Diminished kidney function

31. Differential Diagnosis
Vesicoureteral reflux (VUR) with marked dilation and kinking of the ureter
Megacalycosis
Midureteral or distal ureteral obstruction
Retrocaval ureter
megacalycosis, a congenital nonobstructive dilation of the calyces without pelvic or ureteric dilation; vesicoureteral reflux with marked dilation and kinking of the ureter; midureteral or distal ureteral obstruction when the ureter is not well visualized on the urogram; and retrocaval ureter.

32. Thank You!

33. Abdominal Echo at OPD
Kidneys: bil. size normal, mild left pelviectasis. 33

34. Delayed phase
KUB
1 hr later

35. Percutaneous Nephrostomy (PCN)
Left PCN: Indication: Left hydronephrosis Puncture site: Left posterior axillary line Catheter: 6Fr. pigtail (COOK) without string lock Findings: The dilated left renal pelvis is noted on previous examination. The puncture needle approaches left renal pelvis under ultrasonographic guidance. Then the drainage tube is inserted under Seldinger's procedure. The aspirated urine seems clear. The whole procedure is smoothly done. No immediate complication could be found. Impression: 1) Left PCN is done smoothly. 郭宗男醫師-放診專617 / 林佳穎醫師
IMP: Left PCN is done smoothly