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Diagnosis Please  n 

Case 205: Renal Stone Ileus1

Case 205

Lois S. MacDonald, MA, MBBChir, FRCR Gill Rumsby, PhD, FRCPath Snehal Lapsia, MBChB, FRCR

History

An 80-year-old woman presented to the on-call surgical team with a 2-day history of abdominal distention and vomiting. Clinical examination revealed a distended tympanic abdomen with generalized tenderness but no evidence of peritoneal signs at physical examination. Relevant surgical history included previous intervention for renal stones, cholecystectomy, and cardiovascular and respiratory comorbidities. Abdominal radiography was performed in the emergency department, and computed tomography (CT) was performed based on the radiographic findings.

Imaging Findings

Part one of this case appeared 4 months previously and may contain larger images. Published online 10.1148/radiol.14120636  Content code: Radiology 2014; 271:615–618 1 From

the Department of Radiology, Royal Blackburn Hospital, Haslingden Rd, Blackburn, Lancashire BB2 3HH, England (L.S.M., S.L.); and Department of Clinical Biochemistry, University College London Hospitals, London, England (G.R.). Received March 17, 2012; revision requested April 26; revision received November 25; final version accepted December 21. Address correspondence to L.S.M. (e-mail: [email protected]). Conflicts of interest are listed at the end of this article. q RSNA, 2014

Both plain-film radiography and contrast material–enhanced CT showed multiple grossly dilated predominantly fluid-filled small-bowel loops and collapsed distal small-bowel findings, consistent with small-bowel obstruction (Figs 1, 2a) (1). The large angular calcific mass pro­jected over the pelvis on the plain radiograph was shown to be within the ileum on CT images (Fig 2b) at the transition point. The right kidney was grossly atrophic and contained multiple stones. The left kidney was normal in appearance and contained no stones (Fig 3a, 3b). A fistula was seen between the right renal pelvis and the second part of the duodenum (Fig 3c, 3d). A small volume of ascites was present. There was no pneumobilia, and the patient’s status was postcholecystectomy. The patient proceeded to surgery. The loop containing the calculus was identified, and a limited small-bowel resection was performed. At the time of surgery, the patient was deemed too frail to explore the retroperitoneum and excise the fistula. The stone was sent for biochemical analysis, which revealed a 5023-mg calcium phosphate (carbapatite) stone, with no evidence of

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cholesterol or bile pigments (Fig 4). This is consistent with a stone of renal origin and not suggestive of a gallstone. Unfortunately, the patient died from multiorgan failure 3 days after surgery.

Figure 1 

Figure 1:  Supine abdominal radiograph shows small-bowel dilatation. Angular calcific mass is seen in the pelvis (arrow). Multiple calcific densities are seen in the right upper quadrant (arrowheads). 615

DIAGNOSIS PLEASE: Renal Stone Ileus

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Figure 2 

Figure 4 

Figure 4:  Macroscopic image of extracted stone.

Discussion

Figure 2:  (a, b) Coronal reformatted contrast-enhanced CT images in the portal venous phase. There is a large calcific mass within the lumen of a loop of ileum (arrow). Note the multiple grossly dilated fluid-filled small-bowel loops and collapsed loops of ileum within the pelvis, consistent with mechanical small-bowel obstruction.

Figure 3 

Figure 3:  (a–d) Contrast-enhanced (100 mL iohexol, Omnipaque 350; Nycomed Amersham, Oslo, Norway) axial CT images in the portal venous phase. The right kidney is grossly atrophic, containing multiple renal stones (arrowheads). There is a fistula between the right renal pelvis and the second part of the duodenum (arrow). 616

This case illustrates a rare cause of smallbowel obstruction due to a renal stone within the small bowel (ie, renal stone ileus). There are two case reports in the literature in which a renal stone caused small-bowel obstruction. In one case, the level of obstruction was at the ileum (2), as in this patient. In the other, the level of obstruction was at the duodenum (3). In the first case, the patient had a history of trauma to the flank, and this was postulated as the underlying cause of the fistula; however, in the second case, chronic infection was thought to be the cause. In this patient, the underlying cause of the fistula was uncertain. The patient had undergone previous renal intervention; however, this intervention was performed at a different institution, and details were not available. As such, we can only postulate that the previous intervention might have contributed to fistula formation. For a patient to develop renal stone ileus, there must be a sequence of events. First, the patient must develop a renal stone large enough to potentially cause small-bowel obstruction. Second, a fistula must form between the small bowel and the renal collecting system. Third, the calculus must pass into the small bowel and cause obstruction. Urinary tract stones are a common condition, with a reported incidence of between seven and 21 cases per 10 000 people. The underlying cause of renal stones is varied. In the majority of patients, there is an underlying meta-

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DIAGNOSIS PLEASE: Renal Stone Ileus

bolic abnormality, such as idiopathic hypercalcuria. Other causes include chronic infection. Patients with chronic infection produce triple phosphate stones, and this subtype often produces a large staghorn stone. Presenting symptoms of patients with renal stones include loin pain, hematuria, and dysuria (4). The cause of a pyeloduodenal fistula can be divided into traumatic causes (including iatrogenic causes) and spontaneous causes (5). The majority of spontaneous fistulas are associated with chronic infection and are more likely to occur when obstruction is also present. Regardless of the cause, the fistula occurs because of the close proximity of the renal pelvis and posterior duodenum, and the relatively fixed position of the duodenum allows the fistula to form. Pyeloduodenal fistulas can manifest in a variety of ways, including urologic symptoms, gastrointestinal symptoms, and constitutional symptoms. The management of a renal stone ileus is surgical. The first step is to remove the stone causing the obstruction. The second step is to treat the fistula. It is suggested that if the kidney is nonfunctioning, nephrectomy and fistula repair is the optimal management; however, if the kidney is functioning, ureteric stent placement is advised to divert urine from the fistula so it can heal (5). In general, the causes of small-bowel obstruction can be divided into extrinsic (eg, hernias), intrinsic (eg, Crohn disease), and intraluminal causes (6). In this patient, plain-film radiography depicted a large calcific mass within the pelvis. CT revealed this mass was an intraluminal stone within a loop of dilated ileum. The small bowel just distal to this was collapsed, and it appeared the stone was at the transition point and thus was causing the obstruction. Intrinsic causes are relatively uncommon. The more common causes of intraluminal obstruction are gallstones, bezoars, and foreign bodies. The patient’s status was postcholecystectomy. Although this did not lead us to completely exclude the diagnosis of gallstone ileus, it made this diagnosis significantly less likely. Pneumobilia commonly is seen in patients with gallstone ileus and is a key

MacDonald et al

diagnostic feature that was absent in this patient (7). There was no history of foreign body ingestion. In this patient, the intraluminal mass was uniformly heavily calcified, angular, and large. This appearance was not in keeping with that of a gallstone, which is usually round and lamellar, or a bezoar, which is typically a heterogeneous mottled mass, often containing gas locules (8). The axial CT images showed an atrophic right kidney containing multiple large stones and further stones within the right ureter. A fistula was seen between the right renal pelvis and the duodenum. This constellation of findings led to a preoperative diagnosis of renal stone ileus. Renal stone ileus is a rare diagnosis; however, this case shows that with a systematic radiologic approach to small-bowel obstruction, an accurate preoperative diagnosis can be made. Disclosures of Conflicts of Interest: L.S.M. No relevant conflicts of interest to disclose. G.B. No relevant conflicts of interest to disclose. S.L. No relevant conflicts of interest to disclose.

References 1. Fukuya T, Hawes DR, Lu CC, Chang PJ, Barloon TJ. CT diagnosis of small-bowel obstruction: efficacy in 60 patients. AJR Am J Roentgenol 1992;158(4):765–769; discussion 771–772. 2. Bahn DK, Brown RK, Reidinger AA, et al. Renal stone ileus. AJR Am J Roentgenol 1988; 150(1):145–146. 3. Jones GR. Renal calculus ileus. J Can Assoc Radiol 1983;34(1):51–52. 4. Sandhu C, Anson KM, Patel U. Urinary tract stones. I. Role of radiological imaging in diagnosis and treatment planning. Clin Radiol 2003;58(6):415–421. 5. Desmond JM, Evans SE, Couch A, Morewood DJ. Pyeloduodenal fistulae: a report of two cases and review of the literature. Clin Radiol 1989;40(3):267–270. 6. Silva AC, Pimenta M, Guimarães LS. Small bowel obstruction: what to look for. RadioGraphics 2009;29(2):423–439. 7. Lorén I, Lasson A, Nilsson A, Nilsson P, Nirhov N. Gallstone ileus demonstrated by CT. J Comput Assist Tomogr 1994;18(2): 262–265. 8. Delabrousse E, Brunelle S, Saguet O, Destrumelle N, Landecy G, Kastler B. Small bowel obstruction secondary to phytobezoar CT findings. Clin Imaging 2001;25(1):44–46.

Radiology: Volume 271: Number 2—May 2014  n  radiology.rsna.org

Congratulations to the 147 individuals and 12 resident groups that submitted the most likely diagnosis (renal stone ileus) for Diagnosis Please, Case 205. The names and locations of the individuals and resident groups, as submitted, are as follows:

Individual responses Osamu Abe, MD, PhD, Itabashi-ku, Tokyo, Japan Gholamali Afshang, MD, Tinley Park, Ill Harry A. Allen, III, MD, Virginia Beach, Va Canan Altay, MD, Izmir, Turkey Albert J. Alter, MD, PhD, Blanchardville, Wis Nabil F. Ammouri, MD, Zahle, Lebanon Roger L. Antonelli, MD, Dayton, Ohio Dean E. Baird, MD, Potomac, Md Thomas J. Barloon, MD, Iowa City, Iowa Dhiraj Baruah, MD, Wauwatosa, Wis Rupert Bauer, MD, Holzminden, Germany Richard J. Beedie, MBBCh, Auckland, New Zealand Sasha N. Bhan, MD, MBA, Hamilton, Ontario, Canada Manon N. Braat, MD, Nieuwegein, the Netherlands Eric L. Bressler, MD, Minnetonka, Minn Douglas C. Brown, MD, Virginia Beach, Va Jose Antonio Camilo Machado, Sr, MD, Goiania, Goias, Brazil Antonio A. Cavalcanti, MD, Sao Paulo, Brazil Sloane C. Chen, MD, Encinitas, Calif Phillip M. Cheng, MD, MS, Culver City, Calif Michael H. Childress, MD, Washington, DC Haris Chrysikopoulos, Corfu, Greece Christopher Chu, MBBS, FRANZC, Sydney, New South Wales, Australia Theresa M. Corrigan, MD, Louisville, Ky Marco A. Cura, MD, Highland Park, Tex Bart D'herde, MD, Hasselt, Belgium Fabio A. Dalpra, MD, Sao Paulo, Brazil Anil K. Dasyam, MD, Pittsburgh, Pa Peter de Baets, MD, Damme, Belgium Kristof De Meerleer, MD, Sint Blasius Boekel-Zwalm, Belgium Eduardo P. de Oliveira, Sao Jose do Rio Preto, Brazil Renata de Oliveira e Silva Brenner, MD, Sao Jose dos Campos, Brazil Thaworn Dendumrongsup, MD, Songkhla, Thailand Dionisios Drakopoulos, MD, Palaio Faliro, Athens, Greece Seyed A. Emamian, MD, PhD, Rockville, Md Francis T. Flaherty, MD, Ridgefield, Conn Enrique Flores, MD, Santa Cristina, Oleiros, A Coruna, Spain Barak Friedman, MD, New York, NY Akira Fujikawa, MD, Tokyo, Japan Toshihiro Furuta, MD, Minato-ku, Tokyo, Japan Bradley S. Gluck, MD, Southampton, NY

617

DIAGNOSIS PLEASE: Renal Stone Ileus

Mark G. Goldshein, MD, Andover, Mass Wataru Gonoi, MD, PhD, Bunkyo-ku, Tokyo, Japan Allen Goodman, MD, New York, NY Maria A. Gosein, MBBS, FRCR, Santa Cruz, Trinidad And Tobago Navraj S. Grewal, MD, Rancho Cucamonga, Calif Michael Griffin, MD, PhD, Milwaukee, Wis Philippe Grouwels, MD, Hasselt, Belgium Pramod K. Gupta, MD, Plano, Tex Akifumi Hagiwara, MD, Tokyo, Japan Christoph Hefel, Feldkirch, Austria Nerea Hormaza, MD, Barakaldo, Bizkaia, Spain Takashi Ikeuchi, Moriyama, Shiga, Japan Akitoshi Inoue, MD, Otsu, Shiga, Japan Richard N. Irion, MD, Murray, Utah S. Pinar Karakas, MD, Oakland, Calif Shanigarn Keoplung, MD, Muang Nonthaburi, Nonthaburi, Thailand Patrick Kiely, MBBCh, Limerick, Ireland Takao Kiguchi, MD, Niigata, Japan Osamu Kizu, MD, Ohtsu, Japan Mitchell A. Klein, MD, Mequon, Wis Masamichi Koyama, MD, PhD, Tokyo, Japan John J. Krol, MD, Lexington, Ky Richard A. Kutilek, MD, Omaha, Neb Ryo Kuwahara, MD, Kyoto, Nakagyogu, Japan Mau Chu Lam, MBBCh, Hong Kong, Hong Kong Stefanie Lee, Toronto, Ontario, Canada David A. Lisle, MBBS, Brisbane, Queensland, Australia Rafael M. Loureiro, MD, Sao Paulo, Brazil Stephen C. Machnicki, MD, Weston, Conn Stephen V. Manghisi, MD, Closter, NJ Claire McArthur, MBChB, FRCR, Glasgow, United Kingdom Nikhil R. Mehta, Jr, MBBS, Sangli, Maharashtra, India Flavia Mendez, MD, Porto Alegre, Brazil Steven J. Michel, MD, Bend, Ore Steven F. Millward, MBBCh, Peterborough, Ontario, Canada Manabu Minami, MD, PhD, Yokohama, Japan Tiago N. Morato, MD, Brasilia, Brazil Toshio Moritani, MD, PhD, Iowa City, Iowa Kyoko Nagai, MD, Yokohama, Japan Tuan Duc Nguyen, MD, Ski, Norway Tomokazu Nishiguchi, MD, PhD, Osaka, Japan Mizuki Nishino, MD, Boston, Mass

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Hiroshi Nobusawa, MD, PhD, Ota, Tokyo, Japan Roque Oca, MD, Vigo, Pontevedra, Spain Michael D. Orsi, MD, San Antonio, Tex Hugo J. Paladini, MD, Buenos Aires, Argentina David M. Panicek, MD, New York, NY Ioannis E. Papachristos, MD, Agrinio, Greece Patouras Paraskevas, MD, Agia Paraskevi, Attiki, Greece Narendrakumar P. Patel, MD, Newburgh, NY Satish D. Patel, MD, Shavertown, Pa Aruna R. Patil, MD, FRCR, Bangalore, Karnataka, India Yeliz Pekcevik, Izmir, Turkey Francesco Pierazzoli, MD, Padua, Italy Daniel Knight Powell, MD, New York, NY Elias Primetis, MD, Athens, Greece Shawn P. Quillin, MD, Charlotte, NC Daniel C. Rappaport, MD, Toronto, Ontario, Canada Natally D. Rocha, MD, Sao Paulo, Brazil Mathieu H. Rodallec, MD, Paris, France Hugo Rodriguez Requena, MD, Madrid, Spain Daniel Romeu Vilar, MD, Bertamirans, A Coruna, Spain Stefan Roosendaal, MD, PhD, Amsterdam, the Netherlands Akihiko Sakata, MD, Kyoto, Japan Steven M. Schultz, MD, Fort Worth, Tex Matthew P. Shapiro, MD, Charlottesvle, Va Hideki Shima, MD, Narita, Chiba, Japan Taro Shimono, MD, Osaka, Japan Paul J. Shogan, MD, Clarksville, Tenn Andre Simoes, MD, Barcelos, Portugal David F. Sobel, MD, La Jolla, Calif Isabel Sousa, MD, Lisboa, Portugal Oliver S. Springer, MD, Basel, Switzerland Evan G. Stein, MD, PhD, New York, NY Hongliang Sun, MD, Beijing, China Ayako Tamura, MD, Tokyo, Japan Eliko Tanaka, MD, Yokohama, Japan Takashi Tanaka, MD, Okayama, Japan Satoshi Tatsuno, MD, Ichikawa, Chiba, Japan Douglas L. Teich, MD, Brookline, Mass Ajay B. Tokala, MRCP, FRCR, Manchester, United Kingdom Ulysses S. Torres, MD, Sao Paulo, Brazil Jeffrey Tseng, MD, Menlo Park, Calif Meric Tuzun, MD, Ankara, Turkey Atsushi Uehara, Niigata, Japan Piet K. Vanhoenacker, MD, Moorsel, Belgium

Chaitanya Vemulapalli, MD, Flint, Mich Publio C. Viana, MD, Sao Paulo, Brazil Pier Carlo Villani, MD, Bari, Italy Rahul A. Virani, MD, MBBS, Rajkot, Gujarat, India Ainhoa Viteri, MD, Bilbao, Biscay, Spain Christopher P. Vittore, MD, Belvidere, Ill Lynne Voutsinas, MD, Staten Island, NY Garrett L. Walworth, MD, Milford, Mich Haruo Watanabe, MD, Gifu, Japan Burt T. Weyhing, III, MD, Grosse Pointe, Mich Tatsuya Yamamoto, MD, Yoshida-gun, Fukui, Japan Yi Yang, MD, Suzhou, Jiangsu, China Koichiro Yasaka, MD, Tokyo, Japan Kurata Yasuhisa, MD, Kobe, Hyogo, Japan Hajime Yokota, MD, Chiba, Japan Rika Yoshida, MD, Utsunomiya, Tochigi, Japan Satoru Yoshida, MD, PhD, Muroran, Hokkaido, Japan Kaneko You, Gifu, Japan Carlos A. Zamora, MD, PhD, Lutherville, Md Ahmed Zidan, MD, Barcelona, Spain

Resident group responses Hospital de Santa Maria Radiology Residents, Lisbon, Portugal ICESP Residents, Sao Paulo, Brazil Mater Dei Hospital Radiology Residents, Malta Montefiore Medical Center Radiology Residents, Bronx, NY Prince of Songkla University Radiology Residents, Songkla, Thailand Thomas Jefferson University Radiology Residents, Philadelphia, Pa Tsukuba University Hospital Radiology Residents, Tsukuba, Ibaraki, Japan Universidad Nacional Autonoma de Mexico CT Scanner Residents, Mexico City, Mexico University of Pennsylvania Radiology Residents, Philadelphia, Pa University of Washington Radiology Residents, MD, Seattle, Wash Virginia Commonwealth University Radiology Residents, Richmond, Va Yale University Radiology Residents, New Haven, Conn

radiology.rsna.org  n  Radiology: Volume 271: Number 2—May 2014

Case 205: renal stone ileus.

History An 80-year-old woman presented to the on-call surgical team with a 2-day history of abdominal distention and vomiting. Clinical examination re...
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