March 15, 2010

Renal Riddle #001

Consider a 65 year-old male presenting with right-sided flank pain radiating to the groin.  The following CT scan was taken to confirm a presumed diagnosis of renal colic:

image 114 Renal Riddle #001

image 210 Renal Riddle #001

Questions

Q1.  Describe the CT scan

CT scan is non-contrast; however, there is:

  • right-sided retroperitoneal blood evident.
  • an abdominal aortic aneurysm.

It is important to remember that the commonest cause of the ‘classic’ presentation of renal colic amongst patients presenting to have a post-mortem is ruptured abdominal aortic aneurysm.

This patient needs an emergency AAA repair.

The patient was taken to theatre for emergency surgery.
The following biochemistry results were taken post-operatively:

image 37 Renal Riddle #001

Q2.  Describe the biochemistry.  What diagnosis is suggested by these biochemical findings?

Biochemistry demonstrates acute renal failure with a reduced urea-to-creatinine ratio.

The likely diagnosis is rhabomyolysis in this clinical context. Features suggestive of this diagnosis are:

  • increased urea and creatinine with a reduced urea-to-creatinine ratio
  • hyperphosphataemia, hypocalcaemia, hyperkalaemia
  • metabolic acidosis
  • increased CK (usually to greater than 40,000)
  • Although not measured here, AST, and LDH are also increased in rhabdomyolysis

Q3.  What are the other potential causes of renal failure to consider in this clinical situation?

  1. hypovolaemia from bleeding
  2. renal artery occlusion during operation
  3. use of contrast in pre-operative CT scan (not in this case)
  4. use of nephrotoxic drugs like gentamicin
  5. low cardiac output from peri-operative myocardial infarction
  6. abdominal compartment syndrome

Print

Related posts:

  1. Laboratory Tester #002
  2. Quiz Investigation 007
  3. Radiological Oddity #018
  4. Quiz Lab Tests 003
  5. Neurological Mind-boggler #001

About Paul Young

3 Tweets 3 Other Comments

Comments

  1. Bongi says:

    great. thanks for the mention.

    This comment was originally posted on Suture for a Living

  2. Great post…I have to tell you, after hitting most of your recommendations, you are right on to mention them all. Now, though, I am ready to collapse in a great fit of sleep!

    Thanks, as always, for a great post!

    This comment was originally posted on Suture for a Living

  3. Mike Cadogan says:

    Fantastic post
    Congratulations on a great start to the 2010 collection of SurgeXperiences.
    Has stimulated the team to write more surgical related posts (from the ED perspective)
    Mike

    This comment was originally posted on Suture for a Living

Trackbacks/Pingbacks

  1. 'In the Fast Lane': Renal Riddle #001 http://su.pr/18dVk7 It's not a problem with the kidney… or is it?

  2. [...] This post was mentioned on Twitter by precordialthump, Joel Topf. Joel Topf said: AAA presenting as renal colic. I have not seen that. Cool. http://lifeinthefastlane.com/2009/12/renal-riddle-001/ [...]

  3. fragilex says:

    RT @kidney_boy: AAA presenting as renal colic. I have not seen that. Cool.

    http://lifeinthefastlane.com/2009/12/renal-riddle-001/

Speak Your Mind

Additional comments powered by BackType