Fever, Pain, and Failure to Thrive in a 9-Year-Old Boy

Arun Phophalia, MBBS, MS; Madhu Phophalia, MD, MBBS, MS

Disclosures

December 16, 2015

UPJ obstruction, although most often a congenital problem, can present clinically at any time of life. In older children or adults, intermittent abdominal or flank pain is a frequent presenting symptom. This is occasionally associated with nausea or vomiting as well. Hematuria, either spontaneous or associated with otherwise relatively minor trauma, may also be an initial symptom. Laboratory findings of microhematuria, pyuria, or frank urinary tract infection might also bring an otherwise asymptomatic patient to the healthcare system. Rarely, hypertension may be a presenting finding.[2,6]

Figure 1.

Figure 2.

Radiographic studies should be performed with the goal of determining both the anatomic site and the functional significance of an apparent obstruction. Excretory urography remains a reasonable first-line option for radiographic diagnosis. Classically, findings on the affected side include delay in function associated with a dilated pelvicalyceal symptom. Ultrasonography also has an important role in diagnosing UPJ obstruction. It can be used in patients whose poor renal function precludes the use of intravenous contrast studies. Because of its current widespread use, CT scanning more frequently raises the suspicion of UPJ obstruction. The CT scan should first be performed without contrast in order to rule out obstructing stones, followed by a scan with contrast to assess for lack of drainage from the pelvis as well as detect any potential tumors in the collecting system (ureter or pelvis).

Nuclear renography can also be performed for all patients with suspected UPJ obstruction. Specifically, a technetium 99m-labeled mercaptoacetyltriglycine (MAG3) scan can differentiate the split functions of both kidneys and can quantify the drainage from each kidney. Specifically, it measures the t, which is the time it takes for half of the radiolabeled MAG3 to wash out of the renal pelvis. In cases of obstruction, the t is typically greater than 15 minutes.[2,3,4]

The following entities should be considered in the differential diagnosis: (1) megacalycosis, a congenital nonobstructive dilatation of the calyces without pelvic or ureteric dilatation; (2) vesicoureteral reflux, with marked dilatation and kinking of the ureter; and (3) midureteral or distal ureteral obstruction (when the ureter is not well visualized on the urogram).[2]

The patient was admitted to the hospital, and an open dismembered pyeloplasty was planned. The short obstructing segment of the ureter was resected, and the free end of the ureter was sutured to the open renal pelvis. This anastomosis was performed using 4-0 vicryl. A stent bridging the anastomosis was placed from the kidney to the bladder, and a drain in the perinephric space was inserted. The drain was removed on the sixth postoperative day, and the sutures were removed on the tenth day. The internal stent is typically removed in postoperative week 4-6 with an office-based cystoscopy.

The postoperative course was uneventful. While retrograde endoscopic approaches have been described, laparoscopic pyeloplasty is rapidly becoming the standard of care. This minimally invasive approach offers the advantages of less pain, a reduced need for pain medications, a shorter hospital stay, quicker convalescence, and better cosmesis. Most importantly, the results of establishing good drainage from the pelvis with laparoscopic pyeloplasty have been shown to be equivalent to those of open pyeloplasty. The patient was doing well after discharge, and he had gained height and weight at both the 3-month and 6-month follow-up.[2]

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