MORNING REPORT Rakesh Kanipakam PGY2 82 yo male

MORNING REPORT Rakesh, Kanipakam PGY-2

• 82 y/o male presents worsening back pain • He had symptoms of intermittent back pain for a week but start getting worse since 3 days. • Relived on norco. Pain was back and decided to call EMS What else would you like to know?

History: Symptoms started 1 week ago and persistent stabbing type • • • Location, duration, severity, any prior back pains. Constitutional symptoms: Fever Weight loss Constant pain worse at night Loss of bladder or bowel control. History of malignancy? h/o prostate CA s/p radiation in 2004 Anuria Nausea, no emesis Decreased appetite and PO intake

PMH: • HTN, • Crohn’s on Humira Q 2 W, • In august Crohn’s flare-up with SBO s/p Lap resection, AKI from ATN and on HD, Upper extremity cellulitis treated with cefazolin. PSH: Appendectomy Rotator cuff tear Tonsillectomy TURP for prostate CA Medications - Humira Q 2 W - Miralax - Vit D tabs - B 12 shot Q 1 M

ROS • Nausea • Decreased appetite and PO intake • Anuria • Worsening back pain Social history: - Lives with lady companion - 40 year 1 PPD, quit 30 years ago - Occasional drinker Family H/O • Father had some gastric ulcers • Sister passed away from liver issues • 6 siblings with cardiac issues

Physical exam VS- HR: 80 S, BP: 160/78, Temp: 98. 3, O 2: 94% on RA General- Elderly male, in mild distress secondary to pain otherwise calm HEENT- Normal conjunctiva, no pallor, no lymphadenopathy, moist mucosa Cardio- RRR, S 1&S 2 normal, no murmurs RS- Clear to auscultation, respirations are non-labored, breath sounds normal GI-Soft, non-distended, normal BS heard. Left lower quadrant tender on palpation. MSK: Slight tenderness on palpation to left flank region. No point tenderness on spine. CNS- A&O-3, normal strength and sensation Psych- Calm and cooperative.

Differential diagnosis

Imaging

MRI L spine • Extensive abnormal signal intensity suggested within left upper mid abdomen/retroperitoneum, • Normal-appearing left kidney not visualized • Radiologist recommended: • CT abdomen/pelvis

CT abdomen & pelvis 1. Large lobulated loculated fluid collection in the left retroperitoneum extending along the psoas muscle and into the perirenal space and posterior pararenal space. This measures 15. 6 x 15 x 24 cm and displaces the left kidney anteriorly. Mild left hydronephrosis. This measures simple fluid in density and may represent a large urinoma. This may be amenable to percutaneous aspiration or drainage. 2. Diffusely thickened urinary bladder wall along the dome. This may represent bladder neoplasm. Further evaluation with cystoscopy would be helpful if this is of clinical concern.

Any other tests? ?

Serum results: WBC – 16. 5, Hgb-8, Pt-300 K BMP- Na-134, K-6. 1 Cl 101, Bicarb-28, Blood sugar- 93, BUN-45 and Cr-8. 85. Checked his LFTs- WNL

Timeline 8/5 -8/24 Crohn’s flare up with bowel resection and SBO-NG tube Developed ATN 8/26 -9/6 Upper extremity cellulitis s/p cefazolin Gen swelling and ESKD-HD 9/18 -9/25 Lower back pain biateral ureteral strictures, bladder mass with bilateral hydronephrosis(Mild on Rt) with URINOMA-got bilateral stents, transurethral resection of bladder mass-high grade nonpapillary urolethial CA

USG 8/22/17

Right Kidney The right kidney measures 10. 7 cm. No masses are identified. No shadowing renal calculus seen. The cortex of the right kidney is thin. There is mild right renal collecting system dilation. Left Kidney The left kidney measures 12. 1 cm. No masses are identified. No shadowing renal calculus seen. The cortex of the left kidney is thin. There is mild left renal collecting system dilation. The proximal left ureter is dilated. Bladder Bilateral ureteral jets are not visualized with color Doppler. Pre-void bladder volume: 8. 7 sag x 6. 4 AP x 7. 4 trv cm = 214 m. L. No significant post void residual is present. Bladder wall is thickened and irregular in appearance, measuring 1. 7 cm.

Today’s topic Urinoma

Objectives: • Risk factors for developing urinomas • Diagnostics

What is a urinoma? ?

Urinomas, or uriniferous fluid collections, are urine collections usually found in the retroperitoneum, most commonly in the perianal spaces, as a consequence of renal track leakage caused by urinary obstruction, trauma, or post-instrumentation.

Risk factors: Any reasons for urinary obstruction • Calculus • Ureteropelvic junction obstruction • Retroperitoneal fibrosis • Retroperitoneal malignancy • Cancer of the pelvis, ureter or bladder • Abdominopelvic trauma • Surgery causing ureter trauma • Instrumentation-Ureteroscopy

Pathogenesis Urine extravasates into the retroperitoneum, it can cause lipolysis of the surrounding fat with resultant encapsulation of urine, forming a urinoma

Clinical presentation: - Asymptomatic - Vague malaise and abdominal pain - Back pain - Hematuria, pyuria - Nausea, vomiting - Paralytic ileus and acute abdomen

Differentials: Hematomas Abscess Lymphadenopathies Neoplasms-Lipomas Sarcomas

Cystic lesion of retroperitoneal region Neoplastic Non-neoplastic

Making the diagnosis Renal leaks: USG CT w IV Contrast Ureteral leaks Anterograde/retrograde pyelogram IVP is not the greatest choice with sensitivity of 33% Ghali AM, El Malik EM, Ibrahim AI, Ismail G, Rashid M. Ureteric injuries: diagnosis, management and outcome. J Trauma 1999; 46: 150 -158

Retroperitoneal hematoma

Treatment overview - Small urinomas are treated conservatively- self absorption, close monitoring - Larger, persistent or symptomatic urinomas: percutaneous drainage with/without stent placement

Complications

Complications: • ESKD • Abscess • Peritonitis • Sepsis • Damage to urinary tract by fibrosis • Granuloma formation • Urinothorax

Urinothorax: It is the only cause of a low p. H transudative pleural effusion defined by a pleural fluid p. H <7. 40

1) Obstructive uropathy from detrusor sphincter dyssynergia 2) Emphysematous pyelonephritis-abscess from ureteral stent fragment 3) Pelvis mass, ascites and pleural effusion h/o renal calculi radioisotope renography with 99 m tech Management • requires a collaborative, multidisciplinary approach involving the urologist and pulmonologist The American Journal of the Medical science: The Urinothorax: A Comprehensive Review With Case Series by - Adam Austin MD, Sidharth Navin Jogani MD, Paul Bradley Brasher MD, Rahul Guptha MD, John Terrill Huggins MD and Amit Chopra MD.

Take home points

MKSAP TIME

References - Dynamed Uptodate Radiopedia Radiological Society of North America Journal of Medical Case Reports American Journal of the Medical Sciences,

Special thanks to Tony