Morning Report

Julia Rawlings, PGY2 27 January 2012

Presentation
y 13 m.o. previously healthy male presented to OSH w/ 1
week of vomiting, fatigue, and decreased urine output

y Thursday (day before symptoms started) mom found

him eating peacock feces

y Friday had decreased appetite, then began vomiting,

nb/nb

y Over weekend vomited multiple times. No diarrhea.

No fever.

Presentation
y Seen by PCP on Monday and Tuesday w/out
improvement and decreased UOP.

y Tuesday sent to OSH for fluid bolus. Had 1 wet diaper

before leaving of 11 ml urine.

y Tuesday Friday continued to have vomiting and NO

urine output.

y Also only had two formed stools during the illness

Outside Hospital
y Admitted on 7th day of illness for dehydration y Labs on admit: BUN 66, Cr 3.2 y Received NS 20 ml/kg and placed on MIVF y Cr decreased to 1.7 on 2nd day of hospitalization and
patients UOP improved

y Day 3 of hospitalization Cr increased to 2.2 and patient

had no UOP since 0600, so transferred to PCMC

More History
y Past Medical History: Full term birth, no complications; no
hospitalizations or medical problems; no history of UTI

y Past Surgical History: none y Family History: Sister with possible reflux noted on prenatal
ultrasound, but normal after birth

y Medications: None y Social History: Lives in Orem with parents and 3 siblings. y ROS: Positive for vomiting, decreased stool output,
decreased urine output, decreased appetite, mouth sores

Physical Exam
y VS: T 37.3, HR 134, RR 24, BP 94/69, SaO2 94% on RA, Weight 10
kg

y General: Alert, awake, cries w/ exam, but consoles easily y Head: NC/AT, AFOSF y Eyes: RR+, PERRL, EOMI, no conjuctival injection or scleral icterus y Nose: no discharge or obstruction y Ears: normal y Mouth: Moist mucus membranes, white plaques or mucus
membranes

y Neck: supple, no LAD or tenderness to palpation

Physical Exam
y CV: RRR, no M/G, pulses 2+, cap refill 2 seconds y Lungs: CTAB, no retractions, decreased at the bases y Abd: soft, distended, mildly tender to palpation, no gaurding, no
masses or HSM

y Back: Normal y GU: Circumcised male, testes descended bilaterally, scrotal edema y Extremities: WWP, no clubbing or cyanosis, non-pitting LE edema y Skin: No rashes, jaundice y Neuro: 2+ DTR, non-focal

Differential Diagnosis
y y y y y y y y
13 m.o. male with 10 days of vomiting and decreased urine output Neurologic: Increased ICP, (tumor, TBI, intracranial bleed), CNS abscess, vertigo, migraine Infectious: Gastroenteritis, UTI, food poisoning, otitis media, meningitis/encephalitis, PNA GI: Appendicitis, cholecystitis, gastritis/esophagitis, pancreatitis, constipation, food allergy, hepatitis, peptic ulcer disease, reflux Metabolic: Inborn error of metabolism (PKU, galactosemia, glycogen storage disease), fructose intolerance Endocrine: Diabetes/DKA, electrolyte imbalance Anatomical: Pyloric stenosis, bowel obstruction, volvulus, malrotation, achalasia, hiatal hernia, intussusception, superior mesenteric artery syndrome Other: Ingestion, cyclical vomiting, Addisons disease, Reyes syndrome, Uremia, nephrolithiasis

Labs
y CMP: Na 133, K 5.8, Cl 110, CO2 14, BUN 28, Cr 2.13,
Glu 105, Ca 8.1, Prot 5.7, Alb 3, Bili 0.3, Alk Phos 479, ALT 12, AST 32

y ICa 0.8 y CBC: WBC 12, Hct 32 25.4, Plts 497 y Urine: Na, calcium, and uric acid levels normal y Retic Count 1.1

Imaging
y Abdominal Ultrasound: No intussuseption, moderate
ascites, bilateral hydronephrosis, no hydroureter, no e/o chronic kidney disease

y CT Abd/Pelvis: Bilateral obstructive nephrolithiasis w/ 5

mm stones at each ureteropelvic junction, bilateral hydronephrosis, ascites, and bilateral pleural effusions

Nephrolithiasis
y Rate in kids 2-4 % of adults, but 5 fold increase in
pediatrics over the last 10 years

y Males > Females y Caucasian > African American y Clinical Presentation:

y Gross/microscopic hematuria (30-90%) y Sterile pyuria y Pain (non-specific in children, adolescent pain is similar to
adults w/ flank pain radiating to groin)

Nephrolithiasis
y Risk factors for stone formation:
y High urine concentration of calcium (hyper-PTH, Vit. D
excess, loop diuretics, excess Na), urea (high protein diet, tumor lysis syndrome), oxalate, or cystine Hypercalciuria found in 30-50% of kids w/ stones Low concentration of citrate, magnesium Low pH (except struvite) Low urine volume UTI w/ Proteus, Klebsiella, Pseudomonas, Enterococci

y y y y y

45-65%

Types of Stones
4%

CaPhos 14-30%

13%

5%

Diagnosis
y Labs:
y y y y
Urinalysis BMP Urine calcium/creatinine ratio (>0.2 mg/mg concerning) Metabolic evaluation

y 24 hour urine collection: Ca, oxalate, citrate, uric acid,

Cr, Na, phosphate, pH, volume, cystine

y Imaging Renal ultrasound or CT scan y Analysis of stones

Treatment
y Increase urine volume by increasing fluid intake y Reduce dietary sodium if hypercalciuria present y Do not reduce calcium in diet, but encourage calcium
to come from food sources, not supplements reabsorbtion in distal tubule)

y Thiazide diuretic reduce Ca excretion (stimulate y Some large stones need endoscopic surgical removal
or lithotripsy with shockwaves or lasers

This Patient
y Likely has congenital UPJ partial obstruction which led
to the formation of kidney stones

y When he became dehydrated, the stones settled into

the UPJ and caused complete obstruction causing acute kidney failure

y Had stents placed in the OR and urology plans to

remove stents and stones in 2 weeks

y May or may not need to reconstruct UPJ

Resources
y McKay, Charles P. Renal Stone Disease. Pediatrics in
Review Vol. 31 No. 5 May 2010

y Gillespie, Robert S. Nephrolithiasis in Children

Pediatrics in Review. Vol. 25. No. 4 April 2004

y Worcester, Elaine M. Calcium Kidney Stones NEJM

363;10, Sept 2010, 954-963.