Ureteropelvic junction obstruction: an overlooked cause of cyclic vomiting

Schulte-Bockholt, A.; Kugathasan, Subra; Mesrobian, H.-G. O.; Werlin, Steven L.

doi:10.1111/j.1572-0241.2002.05626.x

Cited by 12 publications

(3 citation statements)

References 8 publications

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“…Clinicians experienced in evaluating CVS may treat without performing an extensive evaluation, but expert opinion supported performing screening tests in all children with a cyclic vomiting pattern just before administration of intravenous fluids to include electrolytes (Na + , K + , Cl − , HCO 3 − ), glucose, and upper gastrointestinal radio‐graphs to exclude malrotation (26–28). An abdominal ultrasound to rule out transient hydronephrosis, preferably during a crisis, could also be considered in refractory cases (29,30). If a patient has hyponatremia or hypoglycemia, then further evaluation should be performed to exclude Addison disease (31,32) and disorders of fatty acid oxidation (33).…”

Section: Diagnostic Approach To Recurrent Episodic Vomitingmentioning

confidence: 99%

North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Consensus Statement on the Diagnosis and Management of Cyclic Vomiting Syndrome

Lefèvre

Chelimsky

et al. 2008

J. pediatr. gastroenterol. nutr.

237

267

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Cyclic vomiting syndrome (CVS) is a disorder noted for its unique intensity of vomiting, repeated emergency department visits and hospitalizations, and reduced quality of life. It is often misdiagnosed due to the unappreciated pattern of recurrence and lack of confirmatory testing. Because no accepted approach to management has been established, the task force was charged to develop a report on diagnosis and treatment of CVS based upon a review of the medical literature and expert opinion. The key issues addressed were the diagnostic criteria, the appropriate evaluation, the prophylactic therapy, and the therapy of acute attacks. The recommended diagnostic approach is to avoid "shotgun" testing and instead to use a strategy of targeted testing that varies with the presence of 4 red flags: abdominal signs (eg, bilious vomiting, tenderness), triggering events (eg, fasting, high protein meal), abnormal neurological examination (eg, altered mental status, papilledema), and progressive worsening or a changing pattern of vomiting episodes. Therapeutic recommendations include lifestyle changes, prophylactic therapy (eg, cyproheptadine in children 5 years or younger and amitriptyline for those older than 5), and acute therapy (eg, 5-hydroxytryptamine receptor agonists, termed triptans herein, as abortive therapy, and 10% dextrose and ondansetron for those requiring intravenous hydration). This document represents the official recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition for the diagnosis and treatment of CVS in children and adolescents.

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Section: Diagnostic Approach To Recurrent Episodic Vomitingmentioning

confidence: 99%

North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Consensus Statement on the Diagnosis and Management of Cyclic Vomiting Syndrome

Lefèvre

Chelimsky

et al. 2008

J. pediatr. gastroenterol. nutr.

237

267

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“…In 4 cases where cyclic vomiting syndrome was considered, an underlying UPJ obstruction was identified as the etiology with symptomatic imaging. 5 We strongly advocate the use of IVP in children while symptomatic for intermittent UPJ obstructions. In cases that are less clear, noncontrast computed tomography is also a viable form of imaging.…”

Section: Discussionmentioning

confidence: 99%

The Value of Imaging at the Time of Symptomatic Presentation

Delaney

Zderic²

2005

Pediatric Emergency Care

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M ost anatomic findings on radiographic imaging are stable and hence unaffected by the time at which the study is obtained. Rare situations do arise where the timing of imaging is critical to developing an accurate diagnosis. Emergency physicians may be asked to assist in the evaluation of these patients when they become symptomatic. In a busy emergency department, this may become frustrating, particularly when recent images appear in the medical record. However, for the properly selected patient, imaging at the time of symptoms can provide valuable information that guides proper treatment. We present a case where surgical management was greatly enhanced by imaging at the time of symptoms. CASEA 6-year-old boy presented to the gastroenterology department for evaluation of intermittent abdominal pain. A previous upper gastrointestinal tract examination ruled out malrotation, bowel obstruction, and severe constipation. An abdominal ultrasound revealed hydronephrosis of the left kidney, and our urology service was consulted with a presumptive diagnosis of a classic ureteropelvic junction (UPJ) obstruction.At the time of clinical outpatient evaluation, the patient presented in good health and was asymptomatic. A technetium99m MAG-3 renal scan with lasix washout demonstrated good function to both kidneys (differential function, left 54%/right 46%); however, a significant delay in drainage was observed from the left collecting system. An intravenous pyelogram (IVP) obtained in preparation for surgery (Fig. 1) demonstrated large calyces, a very small renal pelvis, and free flow across the UPJ. With no direct evidence of obstruction, these radiographic findings were most consistent with a diagnosis of megacalycosis, a nonsurgical condition.In spite of these results, our differential diagnosis continued to include an intermittent UPJ obstruction, because the patient was asymptomatic at the time of the initial IVP. The family was instructed to return immediately upon the onset of symptoms for an additional imaging study. Ten days later, the patient returned to the emergency department with left-sided abdominal and flank pain accompanied by emesis and a second IVP was obtained. The study demonstrated a marked delay in excretion on the left side and prompt excretion with normal anatomy on the right. Delayed films (Fig. 2) ultimately revealed a faint opacification of the dilated left renal pelvis with an abrupt cutoff at the level of the UPJ.An open dismembered left pyeloplasty corrected the anatomic cause of the intermittent obstruction. Eighteen months after the repair, the patient remains asymptomatic, and a renal/ bladder ultrasound examination displayed full resolution of the hydronephrosis. FIGURE 1. Asymptomatic IVP consistent with the megacalycosis. Note the free unobstructed flow through the ureter.

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“…Older children and adults typically present with intermittent abdominal pain with nausea or vomiting. 13 Schulte-Bockholt et al 14 found UPJ obstruction as the etiology in 4 cases where the working diagnosis had been cyclic vomiting syndrome. Hematuria, pyuria, hypertension, enuresis, or urinary tract infection 13 may bring some patients to a urologist for followup or result in the appropriate radiographic study from which the diagnosis is made.…”

mentioning

confidence: 98%

The Use of an Emergency Physician-Directed Bedside Ultrasound Examination to Clarify a Diagnosis in an 8-Year-Old Boy With Chronic Abdominal Pain

Godambe

Boulden²

2007

Pediatric Emergency Care

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Abdominal pain is a common presenting complaint to the emergency department. Often, patients with chronic, intermittent histories of abdominal pain with multiple visits to medical providers find it difficult to be taken seriously. We describe a patient with a history of episodic abdominal pain who was found to have intermittent ureteropelvic junction obstruction after a timely ultrasound examination by the treating emergency physician.

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Ureteropelvic junction obstruction: an overlooked cause of cyclic vomiting

Cited by 12 publications

References 8 publications

North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Consensus Statement on the Diagnosis and Management of Cyclic Vomiting Syndrome

North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Consensus Statement on the Diagnosis and Management of Cyclic Vomiting Syndrome

The Value of Imaging at the Time of Symptomatic Presentation

The Use of an Emergency Physician-Directed Bedside Ultrasound Examination to Clarify a Diagnosis in an 8-Year-Old Boy With Chronic Abdominal Pain

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