A girl with a giant bladder stone

A girl with a giant bladder stone

The Journal of Emergency Medicine, Vol. 26, No. 1, pp. 123–125, 2004 Copyright © 2004 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/...

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The Journal of Emergency Medicine, Vol. 26, No. 1, pp. 123–125, 2004 Copyright © 2004 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/04 $–see front matter

Letters to the Editor e To the Editor:

Dr. Allen addresses another issue, the 40 million Americans who do not have access to primary care. Although Dr. Allen clearly identifies another healthcare crisis in the United States, he does not endorse a solution to the problem, like national healthcare insurance for all citizens of our country. Consequently, I would recommend national healthcare insurance to be implemented immediately.

In the Editorial entitled, “A National Epidemic of Unassigned Patients,” Dr. Edlich concludes that, “The hospitalist provides an attractive solution to this potential healthcare crisis in the United States.” Although a great supporter of the hospitalist concept, I would argue that this downstream approach in no way should be acknowledged as a solution to our health care crisis as it leaves unaddressed those 40 million Americans without access to primary care. These patients either go without health care or seek it in our nation’s Emergency Departments (EDs), often in a decompensated state. This type of sporadic and uncoordinated care, although most certainly commendable on behalf of the caregiver, ignores the basic role primary care plays in our health care system. The solution to the National Epidemic of Unassigned Patients to which the author refers needs to come long before these patients present to the ED for admission by the hospitalist.

Richard F. Edlich,

MD, PhD

doi:10.1016/j.jemermed.2003.10.004

e A GIRL WITH A GIANT BLADDER STONE Bladder stones are more common among the poor than the well-to-do, suggesting that nutrition may be involved as a possible etiologic factor. The disease is typically seen in children under 10 years of age, with a strong male predominance. The stones are usually large, sometimes almost filling the entire bladder (1). Herein, we report a case of a giant bladder stone because of an unusual presentation. A 10-year-old girl was admitted with a 3-year history of strangury and urinary incontinence during day and nighttime, and a 1-year history of encopresis and mild rectal bleeding after defecation. The personal and family histories were unremarkable. On physical examination, the weight and height were 19 kg (below the 3rd percentile), and 125 cm (below the 3rd percentile), respectively. The vital signs were normal. Widespread hyperemic and squamatous skin lesions were seen in the perianal and perivaginal regions. The remainder of the physical findings were normal. On laboratory investigation, urinalysis revealed pH 8; density 1.017; protein 300 mg; and 6821 erythrocytes and 758 leukocytes on microscopic examination. Urinary calcium/creatinine ratio was 0.71 (Normal: ⬍ 0.21). Hemoglobin was 10.7 g/dL, leukocyte

Kevin M. Allen, MD, FAAEM Department of Emergency Medicine Northwest Texas Healthcare System Amarillo, Texas doi:10.1016/j.jemermed.2003.10.003 e Response to Letter to the Editor: In the Editorial, “A National Epidemic of Unassigned Patients: Is the Hospitalist the Solution?”, we address only the issue of the treatment of patients in the hospital without insurance as well as patients whose primary care physicians are unwilling to treat their patients in the hospital. The presence of a hospitalist in the hospital is one solution to care for the unassigned patients. The salaries for the hospitalists are paid primarily by the hospital.

Guidelines for Letters—Letters will appear at the discretion of the editor as space permits and may be subjected to some editing. Three typewritten, double-spaced copies should be submitted. 123

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Figure 1. Our patient’s direct pelvic X-ray study shows giant bladder stone.

count was 7800/mm3, and thrombocyte count was 628,000/mm3. On biochemical analysis, blood glucose level, serum sodium, potassium, chloride, blood urea nitrogen, creatinine, calcium, phosphorus, total protein, albumin, uric acid, aspartate aminotransferase, and alanine aminotransferase were normal. Prothrombin and partial thromboplastin times were normal. Direct urinary system X-ray study and pelvic computed tomography scan showed a giant bladder stone, which was 6 ⫻ 5 ⫻ 5 cm in diameter and severe destruction of the posterior bladder wall (Figures 1 and 2). Urogenital ultrasonogra-

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phy revealed bilateral grade III hydroureteronephrosis and chronic cystitis. Biochemical analysis of the stone showed that it was a strivute (magnesium-ammoniumcarbonate) stone, and the weight was 72.2 g. The patient was hospitalized and the stone was transvaginally extracted by surgical intervention. Additionally, ceftriaxone was given for 10 days because Klebsiella pneumonia was cultured from the urine culture. No complication was noted during or after the operation. However, her strangury and urinary incontinence did not improve after the operation. She was not admitted to control examination after discharging the hospital. Bladder stones forming in the absence of underlying uropathy are termed primary or endemic bladder stones. In the Western world, with industrialization they have almost disappeared. Symptoms of renal colic are uncommon, but dysuria caused by either the stone itself or the associated urinary infection may be seen. Recurrence after surgical removal of the stone is unusual (1). In a retrospective study, 1067 (6.8%) of 15,624 urinary tract stones were bladder stones, of which 216 (20.2%) were magnesium ammonium phosphate stones (2). Bas¸aklar and Kale reported that of 196 children aged between 1 and 14 years with urinary stones, 96 (49%) children had renal, 52 (26.5%) bladder, and 32 (16.3%) ureter stones (3). They also noted that calcium oxalate and phosphate stones were diagnosed in 121 (61.7%), struvite stones in 60 (30.6%), and uric acid stones in 15 (7.6%) children. Bladder stones particularly were diagnosed in children under 5 years of age, and the 34.5% of bladder stones were of the struvite type (3). In the series by Serkissian

Figure 2. Computed tomography scan showing giant bladder stone.

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et al., primary bladder stone was diagnosed in 18 (83% male) of 198 Armenian children with urolithiasis. In the same series, 72% of bladder stones were calcium oxalate, 22% uric acid, and 6% ammonium acid stones (4). In the 120 Tunisian children with urolithiasis, 69% and 22% of bladder stones were whewellite and struvite, respectively (5). Davies et al. reported a 2-year-old boy with bladder stones, which filled the entire bladder, 6 in number, between 1 and 3 cm in diameter, and rich in calcium (6). Pitrelli et al. described a case of giant vesical calculus in an 89-year-old patient, with the stone weighing about 380 grams, of a mixed type (7). In conclusion, we would like to emphasize that bladder stone should be considered in children with urinary incontinence. Bu¨ lent Atas¸, MD Hu¨ seyin C¸ aksen, MD S¸ u¨ kru¨ Arslan, MD Sinan Akbayram, MD Ercan Kırimi, MD Og˘ uz Tuncer, MD Cihangir Akgu¨ n, MD Department of Pediatrics, Faculty of Medicine Yu¨ zu¨ ncu¨ Yıl University Van, Turkey

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Burhan Ko¨ seog˘ lu, MD Department of Pediatric Surgery, Faculty of Medicine Yu¨ zu¨ ncu¨ Yıl University, Van Turkey Mustafa Kayan, MD Department of Radiology, Faculty of Medicine Yu¨ zu¨ ncu¨ Yıl University Van, Turkey doi:10.1016/j.jemermed.2003.10.006 REFERENCES 1. Kher KK. Urinary stone disease. In. Kher KK, Makker SP, eds. Clinical pediatric nephrology. 1996:699 –723. 2. Gault MH, Chafe L. Relationship of frequency, age, sex, stone weight and composition in 15,624 stones: comparison of results for 1980 to 1983 and 1995 to 1998. J Urol 2000;164:302–7. 3. Bas¸aklar AC, Kale N. Experience with childhood urolithiasis. Report of 196 cases. Br J Urol 1991;67:203–5. 4. Serkissian A, Babloyan A, Arikyants N, Hesse A, Blau N, Leumann E. Pediatric urolithiasis in Armenia: a study of 198 patients observed from 1991 to 1999. Pediatr Nephrol 2001;16:728 –32. 5. Kamoun A, Daudon M, Abdelmoula J, et al. Urolithiasis in Tunisian children: a study of 120 cases based on stone composition. Pediatr Nephrol 1999;13:920 –5. 6. Davies MG, O’Brion E, O’Sullivan BJ, Lennon F. A bladder full of stones—a case report. Ir Med J 1991;84:28. 7. Pitrelli N, Basti M, Nardi M, Marrone A, Vacca M, D’Amico G. Giant bladder calculus. Report of a clinical case. Minerva Chir 1995;50:155–7.