Combined Conference - NCKU

Combined Conference - NCKU

Case Presentation Presenter: PGY November 3, 2016 Patient Information : Chart Number : 141**734 Age : 5-year-11-month old Sex : Male

Admission Date: 2016/10/20 Ethnicity : Taiwanese Name Chief Complaint Left upper abdominal pain for 2 days

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 Present Illness (2) Constipation

history Seldom do exercise Drink few water Stool passage: 1 time/day, hard solid stool. Vegetarian

Buddhist Eat vegetables everyday Present Illness (3) 10/19 09:00 LUQ abdominal dull pain 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 Past History (1) Birth history:

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. Past History (2) At Birth 1-year-old 2016/02/17

2016/03/02 2016/05/27 2016/06/17 2016/07/04 2016/07/11 2016/08/15 Left Hydronephrosis under Dr. Chiu OPD follow up 1-month

4- month 10-month Kawasaki disease, admitted to NCKUH Abdominal pain and vomiting NCKUH ER or OPD for help Family History

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

KUB at ER KUB at ER KUB showed: (1) The bowel gas is unremarkable. (2) No obvious urolithiasis.

(3) Stool impaction over the descending, transverse & ascending colon. IMP: 1. Suboptimal study at right upper abdomen due to gas-block. 2. Left hydronephrosis.

- 617 Abdominal CT + CT Urogram Delayed phase IMP: Left UPJ stenosis with delayed excretory renal function

Diagnosis Left severe hydronephrosis with left ureteropelvic junction stenosis Plan Percutaneous

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

IMP: Left PCN is done smoothly Voiding Cystourethrogram (VCUG) IMP: No vesico-ureteral reflux (VUR) Antegrade Pyelogram

(AP) IMP: (1) Left UPJ stenosis with severe degree hydronephrosis. (2) s/p left PCN insertion. 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% Comprehensive Renal Function Test (CRFT) Left T1/2 = 23.1 min

Right T1/2 = 4.0 min Left Uptake = 51.7% Right Uptake = 48.3% IMP: (1) Obstruction of left collecting system. (2) No obstruction of right collecting system. Laparoscopic Dismembered Pyeloplasty + Double J Stenting

Discussion Ureteropelvic Junction Stenosis 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 Clinical Manifestations Hydronephrosis Abdominal, Palpable

flank, or back pain renal mass Pyelonephritis Failure or UTI

to thrive, vomiting, diarrhea Etiology of Antenatal Hydronephrosis Etiology of UPJ Stenosis Congenital

stenosis Intrinsic stenosis Extrinsic: accessory artery to kidney Postnatal evaluation of unilateral fetal hydronephrosis RPD: Renal pelvic diameter

Postnatal evaluation of unilateral fetal hydronephrosis Treatment Pyeloplasty Success rates: 91-98% Types

Open pyeloplasty Laparoscopic and robotic pyeloplasty Differential Diagnosis Vesicoureteral reflux (VUR) with marked dilation and kinking of the

ureter Megacalycosis Midureteral or distal ureteral obstruction Retrocaval

ureter Thank You! Abdominal Echo at OPD Kidneys: bil. size normal, mild left pelviectasis.

Delayed phase KUB 1 hr later Percutaneous Nephrostomy (PCN) IMP: Left PCN is done smoothly

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