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Case 218

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Male 32 years old patient attends the emergency department with reports of vomiting , abdominal pain the ceasing of flatus and feces elimination for two days. He reports preserved diuresis. Physical examination : Dehydrated; distended abdomen with diffuse tenderness and voluntary defense , with no signs of peritonitis; rectal examination showcasing normal sized prostate. Assessment: blood count , liver function, amylase and lipase within the reference margins, creatinine : 6.71 mg / dL ; urea 70mg / dL. A chest X-ray was requested, showing no alteration, and abdominal radiography was performed (Image 1).

Considering the clinical history and images, which is the most likely diagnosis?

a) Urinary bladder rupture

25%

b) Benign prostatic hyperplasia

25%

c) Intestinal Obstruction

25%

d) Acute pancreatitis

25%
   

Image analysis

Image 1: Abdominal radiography in the supine position. Medially deviated ascending colon (yellow arrow), which may suggest the presence of abnormal intraperitoneal content.

 

Image 2: Retrograde cystography. Extravasation of contrast superiorly to the bladder (blue arrows) and to the right paracolic gutter (green arrow).

Highlights

- Extraperitoneal rupture of the bladder is associated in most cases with pelvic bone fractures , due to a piercing mechanism by bone spicules;

- Intraperitoneal bladder rupture usually occurs in situations where the intravesical pressure rises suddenly, overcoming the resistance exerted by the bladder walls;

- Laboratory findings in intraperitoneal rupture can mimic those of a renal failure due to leakage of urine into the peritoneal cavity, with reverse dialysis of its solutes.

- Retrograde cystography has an accuracy of 85-100 % to identify bladder lesion.

- Symptoms are usually non-specific and are more often represented by the triad : gross hematuria , suprapubic pain or sensitivity and difficulty or inability to urinate.

- Treatment for intraperitoneal bladder rupture is surgery.

References

- Arun KG, Salahauddin, Leela V, Noel J, Venkatesh K, Ramakrishnan S, Dilip R. Intraperitoneal bladder rupture mimicking acute renal failure. Indian J Nephrol. 2008 Jan; 18(1): 26-27.

- Quagliano PV, Delair SM, Malhotra AK. Diagnosis of blunt bladder injury: a prospective comparative study of computed tomography cystography and conventional retrograde cystography. J of Trauma. 2006; 61(2): 410-21.

- Ziran BH, Chamberlin E, Shuler FD, Shah M. Delays and difficulties in the diagnosis of lower urologic injuries in the context of pelvic fractures. J of Trauma. 2005; 58(3): 533-537.

- Gill BC, Rackley RR, Vasavada SP. Bladder Trauma. Medscape 2015. [Acesso em setembro de 2015]. Disponível em: http://emedicine.medscape.com/article/441124-overview.

- Gomes Carlos Augusto, Figueiredo André Avarese de, Soares Júnior Cleber, Bastos Netto José Murillo, Tassi Fabrício Rodrigues. Acute abdomen: spontaneous bladder rupture as an important differential diagnosis. Rev. Col. Bras. Cir.  [Internet]. 2009  Ago [citado  2015  Set  27] ;  36( 4 ): 364-365.

Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0100-69912009000400018&lng=en.  http://dx.doi.org/10.1590/S0100-69912009000400018.

Authors

Daniela de Souza Braga, 6th year medical student at UFMG.

E-mail: danibragamed[at]gmail.com

 

Lucas José Resene, 4th year medical student at UFMG.

E-mail: lucasresende.ufmg[at]gmail.com

 

Ricardo Mazilão Silva, , 4th year medical student at UFMG. 

E-mail: ricardodma789[at]gmail.com

Supervisor

Dr. Luiz Carlos Teixeira, general surgeon at Hospital João XXIII

E-mail: dr.luizcarlosteixeira[at]gmail.com

Reviewers

Fellype Borges, André Guimarães, Bárbara Queiroz, Pétala Silva and Prof. Viviane Parisotto.

Translated by

Rafael Fusaro Aguiar Oliveira, 5th year medical student at UFMG.

E-mail: rafusaro[at]hotmail.com

 

 

 

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