Nephrol Dial Transplant (2000) 15: 409-411
© 2000 European Renal Association-European Dialysis and Transplant Association
Brief Report
Intestinal pseudo-obstruction following renal stone extracorporeal lithotripsy in a diabetic patient
Adamasco Cupisti1,
Roberto Spisni2,
Francesco Carlino2,
Ester Morelli1,
Fabio Zampieri2,
Mario Meola1 and
Giuliano Barsotti1
1 Dipartimento di Medicina Interna and
2 Dipartimento di Chirurgia, Università di Pisa, Pisa, Italia
Correspondence and offprint requests to:
Dott. Adamasco Cupisti, Dipartimento di Medicina Interna, Universita' di Pisa, via Roma 67, I-56100 Pisa, Italia.
Keywords: adynamic ileus; lithotripsy; pseudo-obstruction; renal stones
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Introduction
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Extracorporeal shock wave lithotripsy (ESWL) is the first choice
treatment for renal calculi. Up to now, this approach was appropriate
for almost all cases of urolithiasis whereas traditional surgery
or percutaneous procedure were indicated only in a small number
of complicated patients [
1]. The efficacy and safety of ESWL
have largely improved, although this procedure is not totally
free from unwanted side effects or complications. Urinary tract
obstruction, gross haematuria, subcapsular or perirenal haematoma,
colic pain and infections are the most frequent complications
and are seldom severe [
2,
3]. Extrarenal injuries including pancreatitis,
splenic rupture, pulmonary contusions, colonic mucosal ecchymoses
or cardiac arrhythmias have been sporadically reported [
2].
We describe a case of adynamic intestinal obstruction which occurred in a diabetic patient following ESWL treatment of a renal pelvic calcium stone.
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Case
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A 61-year-old male patient was admitted because of chronic loin
pain due to a kidney stone in the left renal pelvis. At 48 years
of age type 2 diabetes mellitus was diagnosed and treated with
oral anti-diabetic drugs for 3 years and then by insulin. Peripheral
vascular disease was also reported. Two weeks before admission,
the patient experienced left loin pain with gross haematuria.
Sonography and plain radiography demonstrated a calcium stone
in the left renal pelvis (Figure 1
). Excretory urography confirmed
the presence of a 18 mm diameter calcium-containing stone in
the left kidney without significant dilation of pelvis or caliceal
structures. Physical examination was unremarkable. The patient's
body weight was 69 kg, body mass index 26.0 kg/m
2 and arterial
blood pressure was 125/80 mmHg. Plasma biochemistry showed fasting
glucose levels of about 150 mg/dl, HbA
1c 8.2%, and normal values
for ALT, AST, pseudocholinesterase, creatinine, electrolytes
and coagulation tests.
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Fig. 1. Abdominal plain radiograph before ESWL, showing the calcium-containing stone in the left kidney. Bilateral vascular calcifications are also detectable.
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The patient was treated with ESWL in the morning. The duration
of the session was 33 min and 1600 shock waves (14000–17000
V spark discharges) were delivered using a Dornier MFL 5000
Lithotripter [
4]. Analgesia consisted of 30 mg ketorolac i.m.
30 min before the initiation of therapy. The ESWL session was
well tolerated and the stone fragmentation was documented by
X-ray monitoring. During the night, the patient complained of
flank pain, nausea, and vomiting which was treated with 10 mg
metoclopramide, 75 mg diclofenac and anti-cholinergic (40 mg
N-butyl bromide joscine) administration. Later, some small stone
fragments were passed. On day 2 after ESWL he had vomiting,
painless abdominal distension with infrequent bowel sounds,
but no clinical evidence of peritonitis. The next day, plain
abdominal X-ray revealed distension of the large bowel, presence
of gas in the rectum, some air-fluid levels in the small intestine
(Figure 2
) but no gas under the diaphragm. Sonography excluded
the presence of renal, subcapsular or perirenal haematoma, retroperitoneal
collection or fluid in the abdomen. The residual pelvic stone
appeared fragmented and stone fragments were detected in the
left ureter. Blood pressure values ranged from 120/65 to 145/80
mmHg. Biochemistry showed no significant changes in amylase
(15 U/l), AST (11 U/l), ALT (14 U/l), LDH (323 U/l), and CK
(42 U/l) plasma levels. The WBC count was 9800/mm
3 and haematocrit
was 38.7%. A rectal tube was inserted without relief. Colonoscopy
was performed, but no organic obstacles and no mucosal bleeding
were detected. He was treated with nasogastric aspiration (using
Cantor's device) and total parenteral nutrition for 5 days.
Clinical and radiological conditions progressively ameliorated
and 12 days after ESWL he was discharged. One week later, abdominal
X-ray revealed no air-fluid levels, a reduced kidney stone (7
mm) and several small fragments in the lower third of the left
ureter (Figure 3
). The fragments were completely passed a few
weeks later and the chemical analysis showed a calcium–oxalate
stone composition. X-ray enema was also performed but no luminal
or extra luminal lesions were observed. Subsequently, motor
and sensory nerve conduction velocities were performed to assess
peripheral neuropathy, but no alteration was found. Instead,
autonomic dysfunction was demonstrated by the low heart rate
variability and by the onset of postural hypotension during
the tilting test (systolic blood pressure fell from 130 to 85
mmHg, at 60° position). Six months later, the patient underwent
a second ESWL session to treat the residual stone in the left
renal pelvis. The procedure was successful and totally free
from complications.
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Fig. 2. Abdominal plain radiograph in stand-up position 3 days after ESWL. Large bowel distension, air-fluid levels in the small bowel and air in the rectum are present.
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Fig. 3. Abdominal plain radiograph 3 weeks after ESWL treatment. The renal stone appears reduced in size, several small fragments are in the lower tract of the left ureter, no bowel distension or air-fluid levels are present.
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Discussion
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This case describes a complication following ESWL treatment
of a urinary tract stone. ESWL was successfully performed in
terms of localization, fragmentation and clearance of stones,
but an intestinal pseudo-obstruction syndrome occurred. The
causes of this complication are speculative. Adynamic ileus
could be induced by injury to the visceral or parietal peritoneal
layer as in the cases of retroperitoneal bleeding, perirenal
haematoma or pancreatitis, but none of these conditions was
found in our patient. In addition, neither intestinal diseases
nor relevant gastro-intestinal discomfort emerged from the history.
Acute pseudo-obstruction of the colon has been described in several situations including sepsis, cardiac failure, pancreatitis, pelvic or retroperitoneal surgery such as caesarean section or urologic interventions [5], but adynamic ileus following ESWL treatment has never been reported. The hypothesis of a retroperitoneal injury linked to ESWL, leading to bowel functional obstruction must be considered. The autonomic dysfunction, detected in this diabetic patient in the cardiovascular system and then probably also affecting the intestinal tract, could be an important precipitating factor. Moreover, the use of an anti-cholinergic drug could have contributed to reducing intestinal tract motility [5].
In summary, acute intestinal pseudo-obstruction occurred after ESWL treatment and anti-cholinergic drug administration in a diabetic patient. The cause of this complication is uncertain. The temporal link to the ESWL session indicates that it may have been the inciting event, potentially favoured by diabetic autonomic dysfunction and by anti-cholinergic treatment. Then pseudo-obstruction of the intestine should be included in the list of the rare unwanted side-effects following ESWL treatment of urinary stones. It is noteworthy that early diagnosis and treatment of this condition is important to reduce the frequency of more serious complications.
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References
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Renner C, Rassweiler J. Treatment of renal stones by extracorporeal shock wave lithotripsy. Nephron 1999; 81 [Suppl. 1]: 71–81
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Lingeman JE, Newmark JR. Adverse bioeffects of shock-wave lithotripsy. In: Coe FL, Favus MJ, Pak CYC et al. ed. Kidney Stones, Medical and Surgical Management. Lippincott-Raven Publishers, Philadelphia: 1996: 605–614
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Copcoat MJ, Webb DR, Kellett MJ. The complications of extracorporeal shock wave lithotripsy: management and prevention. Br J Urol 1986; 58: 578–580[Medline]
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Graff J, Benkert S, Partor J, Senge T. Experience with a new multifunctional lithotripter, the Dornier MFL 5000: results of 415 treatments. J Endourol 1989; 3: 315–319
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Clayman RV, Reddy P, Nivatvongs S. Acute pseudo-obstruction of the colon: a serious consequence of urologic surgery. J Urol 1981; 121: 415–417
Received for publication: 20. 7.99
Accepted in revised form: 29.10.99
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