Author(s): Cuenca Ramirez MD*, Botto Lugo SM, Utiel Atienzar A, Beamud Cortes M, Moratalla Charcos LM, Palau Roig M and Vidal Moreno JF
The biggest morbimortality issue that patients with radical cystectomy and ileal conduit as urinary diversion have is related to the intestinal anastomosis and the stoma. Stomal early complications are usually secondary to vascular deficiency, therefore it is crucial to examine the mesenteric irrigation prior to the diversion construction and the viability of anastomotic edges. The most common immediate post operative complications are intestinal necrosis, hemorrhage, dermatitis, hernia, stenosis, stoma obstruction and retraction [1,2].
When a clinical case of urostomy necrosis is presented an early diagnosis of intestinal ischemia should be made with the use of an arteriography or abdominopelvic CT scan with intravenous contrast administration that may facilitate the delimitation of necrosis extension and plan urgent surgery for the segment resection. In hospitalized patients, during the immediate post operative time, physical examination, blood tests and imaging tests make the diagnosis a lot easier [1-3]. Nevertheless, in a patient with urinary diversion that presents to the ER with acute abdominal pain, the diagnosis can be delayed for its unusual occurrence [4].
A fifty-nine years old woman presented to the ER with diarrhea and general discomfort of many days, normal body temperature, arterial hypotension and tachycardia.
Her medical records registered Amyotrophic Lateral Sclerosis (ALS) being treated with fingolimod, and muscle-invasive bladder cancer treated in another medical center with radical cystectomy and urinary diversion with ileal conduit five years prior. The patient did not take any other medication.
During the physical examination, abdominal distension was found with peritoneal irritation signs and color change of the stoma which altogether suggest ischemia.
The blood tests showed renal function deterioration (creatinine: 1.65 mg/dL; glomerular filtration rate: 34) and elevated acute phase reactants (CRP: 112mg/L; leucocytes: 27000; lactate: 14.9g/ dL).
She was hospitalized in the ICU for multiorgan failure reversion and study of the subjacent cause. An abdominopelvic CT scan with IV contrast was performed and showed ileal conduit and small bowel hypodensity (Fig. 1,2), also a hematoma in the mesenteric root that could be the cause of the hypoperfusion by compressive mechanism (Fig. 3).
A contrast-enhanced ultrasound was also performed to confirm the indirect signs of intestinal ischemia and that the mesenteric collection was compatible with a hematoma given its hypoechogenicity and absence of heterogeneous content (Fig.4).
Figure 1: Abdominopelvic CT scan with IV contrast. Ileal conduit hypodensity
Figure 2: Abdominopelvic CT scan with IV contrast. Small bowel hypodensity
Figure 3: Abdominopelvic CT scan with IV contrast. Mesenteric root hematoma
Figure 4: Contrast-enhanced ultrasound. Mesenteric collection with hematoma: hypoechogenic and absence of heterogenous content
Urgent exploratory laparotomy was performed finding a moderate amount of hemoperitoneum, a retroperitoneal hematoma compressing the mesenteric root with secondary hypoperfusion, 15cms of ileal conduit necrosis and 80cms of small bowel necrosis corresponding to the previous ileo-ileal mechanical anastomosis section used for the urinary diversion.
Ileal conduit was resected, because of short ureteral length and small bowel affection, a bilateral cutaneous ureterostomy was performed, as well as ischemic bowel resection and a loop ileostomy. Anatomopathological study of the resected ileal conduit reported ulcer-hemorrhagic ischemic enteritis. Patient had a torpid postoperative time period with dehydration secondary to hyperfunction of the ileostomy, S. epidermidis infectious endocarditis and multiple urinary tract infections that prolonged the hospitalization.
This case report describes an acute intestinal ischemia secondary to a spontaneous retroperitoneal hematoma and shows the importance of a detailed clinical assessment including past medical and surgical history as well as current treatment for an early diagnosis. In the examination of an acute abdomen on an unstable patient, the CT scan is the ideal imaging test to perform, given the capacity to identify the cause of the symptoms referred. In this specific case, it showed a mesenteric root hematoma as responsible for the ischemic enteritis [5].
Retroperitoneal hematomas are usually related to traumatic accidents or invasive procedures. There are spontaneous retroperitoneal hematomas (SRH) reported to be associated to arterial hypertension, anticoagulation, hemodialysis or vasculopathy [4-7]. In these cases, it is important to make a differential diagnosis that includes this alternative given the variety of symptoms presented. In our specific case, patient did not have any of these diagnoses registered in her past medical history.
The treatment of SRH should be decided depending on the patient’s stability and the possibility of an interventionist radiology approach. In cases of stable patients, an expectative approach is also accepted (antibiotics administration, blood transfusion and clinical follow-up). Otherwise, in unstable patients, endovascular treatment is recommended. Finally, in patients with organs compromised secondary to the hematoma, open surgery is the election choice. In our case, with a settle intestinal ischemia, open surgery was our best choice [4-7].
