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Acquired bladder diverticula can mimic obstructive extrabiliary jaundice
CASE REPORT
ACQUIRED BLADDER DIVERTICULA CAN MIMIC OBSTRUCTIVE EXTRABILIARY JAUNDICE PANAYOTIS MELIDIS, EMMANOUIL PIKOULIS, EMMANOUIL PAVLAKIS, MARIA TSILEDAKI, AND FILIPPOS I. KONDYLIS
ABSTRACT A rare case that relates benign prostatic hyperplasia-associated bladder diverticula and obstructive uropathy to extrabiliary obstructive jaundice in an older patient is presented. Immediate decompression of the bladder allowed for prompt restoration of the biliary drainage and normalization of the creatinine within a few days. A hepatobiliary etiology was discarded through prompt radiologic and serologic testing along with computed tomography-guided liver biopsy. Long-term management included open suprapubic prostatectomy and diverticulectomy. This unusual case expands the amount of sound anatomic and pathophysiologic links between urinary and extraurinary manifestations. UROLOGY 62: 351iv–351v, 2003. © 2003 Elsevier Inc.
A
cquired bladder diverticula are very rarely associated with extraurinary medical conditions.1,2 To the best of our knowledge, we report the first uncommon case of obstructive extrabiliary jaundice caused by multiple, large vesical diverticula. An 80-year-old asthenic man presented to the emergency room of the Asklipieion General Hospital in Athens, Greece, complaining of irritative voiding symptoms and recent onset of signs consistent with overflow incontinence. His physical examination showed jaundiced discoloration of the skin and the conjunctivae and palpable distension of the lower abdomen to the level of the umbilicus. His digital rectal examination showed a 50 to 60-g prostatic enlargement without evidence of palpable nodularity. The laboratory evaluation was remarkable for urea 117 mg/dL (normal range 15 to 54), creatinine 2.5 mg/dL (normal range 0.8 to 1.4), total bilirubin 6.98 mg/dL (normal range 0.1 to 1.3), direct bilirubin 4.06 mg/dL (normal range 0.0 to 0.4), glutamate-pyruvate transaminase/alanine aminotransFrom the Departments of Urology and General Surgery, and Blood Bank and Transfusion Services, Asklipieion General Hospital, Athens, Greece; and Division of Urology, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada Reprint requests: Emmanouil Pavlakis, M.D., Department of General Surgery, Asklipieion General Hospital, Kidonion 8-10 Papagos, Athens 156 69, Greece Submitted: December 12, 2002, accepted (with revisions): March 6, 2003
351iv
© 2003 ELSEVIER INC. ALL RIGHTS RESERVED
ferase 248 UI/L (normal range 0 to 35), amylase 117 UI/L (normal range 0 to 96), and prostatespecific antigen (PSA) 35.59 ng/dL (normal range 0 to 4). Electrolytes, bleeding diathesis profile, and urine culture were normal. The radiologic evaluation consisted of plain film abdominal radiography and computed tomography of the abdomen and pelvis. Plain film abdominal radiography showed cranial displacement of the small bowel, and computed tomography showed bilateral hydronephrosis and multiple large bladder diverticula occupying the entire pelvis, the biggest (14 cm) of which displaced the small bowel loops and extended to the level of the pancreas and duodenum (Fig. 1). Some of the diverticula contained calculi (Fig. 2). Additional retrograde cystourethrography imaged four large diverticula. Flexible cystoscopy did not identify any intravesical or intradiverticular tumors. Immediate insertion of a Foley catheter drained 3500 mL of clear urine. Adequate hydration and close monitoring of the excessive diuresis improved the clinical picture dramatically within 72 hours. The jaundice slowly subsided, and the laboratory evaluation reflected the overall improving medical condition. Transrectal ultrasound-guided biopsy of the prostate ruled out prostate cancer. The hepatitis profile and computed tomographyguided liver biopsy ruled out primary hepatobiliary etiology. The patient was discharged with an indwelling urethral catheter to allow for adequate recovery 0090-4295/03/$30.00 doi:10.1016/S0090-4295(03)00269-3
sidual urine volume ensued. On additional follow-up 3 months later, the patient continued to enjoy satisfactory urinary flow and his PSA level was substantially decreased and had returned to within the normal age range (5.2 ng/dL). COMMENT
FIGURE 1. Computed tomography scan of the abdomen showing diverticulum (2) extending outside the bony pelvis and displacing the small bowel.
FIGURE 2. Computed tomography scan of pelvis showing the bladder and various diverticuli (1), (2), (3), (4). Arrow points to bladder (anteriorly) and the origin of diverticulum (2). Calculi in diverticula (3), and (4).
before surgical management. Six weeks later, on re-admission, the laboratory evaluation showed normalization of the liver profile and creatinine (1.4 mg/dL). Considering the patient’s anesthesia risk, the intent to cure at once, and the complexity of the disease, the patient underwent bladder diverticulectomy and open suprapubic prostatectomy. His convalescence was uneventful, and spontaneous urination with a minimal postvoid re-
UROLOGY 62 (2), 2003
Bladder diverticula are acquired during the decompensation phase of bladder outlet obstruction and quite often are associated with recurrent infection, stone formation, and tumorigenicity.3 Although very rarely, extraurinary manifestations such as thrombophlebitis,1 and inguinal herniation2 have been described. Our case is another fascinating extraurinary manifestation, the first ever reported, and relates diverticula and obstructive uropathy to extrabiliary obstructive jaundice. The expansion of the largest of the diverticula displaced the enteral loops cranially and might therefore have distorted the second portion of the duodenum, causing partial obstruction of the drainage of the choledochal duct. Immediate decompression of the bladder allowed for prompt restoration of the biliary drainage. This sequel of events supports the anatomic basis of this unusual presentation and adds to the differential diagnostic pattern of obstructive jaundice. Furthermore, the dramatic postoperative decline of the PSA level credits prostatic adenoma as the main contributor of the PSA level and reiterates the significant impact of benign prostatic hyperplasia component in patients who present with significantly elevated PSA levels and are repeatedly negative for adenocarcinoma by transrectal ultrasound-guided biopsies of the prostate. REFERENCES 1. Jepson PM, Nickson KL, and Silber I: Giant vesical diverticula with thrombophlebitis. Urology 1: 606 –608, 1973. 2. Bolton DM, and Joyce G: Vesical diverticulum extending into an inguinal hernia. Br J Urol 73: 323–324, 1994. 3. Melekos MD, Asbach HW, and Barbalias GA: Vesical diverticula: etiology, diagnosis, tumorigenesis and treatment—analysis of 74 cases. Urology 30: 453–457, 1987.
351v
ACQUIRED BLADDER DIVERTICULA CAN MIMIC OBSTRUCTIVE EXTRABILIARY JAUNDICE PANAYOTIS MELIDIS, EMMANOUIL PIKOULIS, EMMANOUIL PAVLAKIS, MARIA TSILEDAKI, AND FILIPPOS I. KONDYLIS
ABSTRACT A rare case that relates benign prostatic hyperplasia-associated bladder diverticula and obstructive uropathy to extrabiliary obstructive jaundice in an older patient is presented. Immediate decompression of the bladder allowed for prompt restoration of the biliary drainage and normalization of the creatinine within a few days. A hepatobiliary etiology was discarded through prompt radiologic and serologic testing along with computed tomography-guided liver biopsy. Long-term management included open suprapubic prostatectomy and diverticulectomy. This unusual case expands the amount of sound anatomic and pathophysiologic links between urinary and extraurinary manifestations. UROLOGY 62: 351iv–351v, 2003. © 2003 Elsevier Inc.
A
cquired bladder diverticula are very rarely associated with extraurinary medical conditions.1,2 To the best of our knowledge, we report the first uncommon case of obstructive extrabiliary jaundice caused by multiple, large vesical diverticula. An 80-year-old asthenic man presented to the emergency room of the Asklipieion General Hospital in Athens, Greece, complaining of irritative voiding symptoms and recent onset of signs consistent with overflow incontinence. His physical examination showed jaundiced discoloration of the skin and the conjunctivae and palpable distension of the lower abdomen to the level of the umbilicus. His digital rectal examination showed a 50 to 60-g prostatic enlargement without evidence of palpable nodularity. The laboratory evaluation was remarkable for urea 117 mg/dL (normal range 15 to 54), creatinine 2.5 mg/dL (normal range 0.8 to 1.4), total bilirubin 6.98 mg/dL (normal range 0.1 to 1.3), direct bilirubin 4.06 mg/dL (normal range 0.0 to 0.4), glutamate-pyruvate transaminase/alanine aminotransFrom the Departments of Urology and General Surgery, and Blood Bank and Transfusion Services, Asklipieion General Hospital, Athens, Greece; and Division of Urology, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada Reprint requests: Emmanouil Pavlakis, M.D., Department of General Surgery, Asklipieion General Hospital, Kidonion 8-10 Papagos, Athens 156 69, Greece Submitted: December 12, 2002, accepted (with revisions): March 6, 2003
351iv
© 2003 ELSEVIER INC. ALL RIGHTS RESERVED
ferase 248 UI/L (normal range 0 to 35), amylase 117 UI/L (normal range 0 to 96), and prostatespecific antigen (PSA) 35.59 ng/dL (normal range 0 to 4). Electrolytes, bleeding diathesis profile, and urine culture were normal. The radiologic evaluation consisted of plain film abdominal radiography and computed tomography of the abdomen and pelvis. Plain film abdominal radiography showed cranial displacement of the small bowel, and computed tomography showed bilateral hydronephrosis and multiple large bladder diverticula occupying the entire pelvis, the biggest (14 cm) of which displaced the small bowel loops and extended to the level of the pancreas and duodenum (Fig. 1). Some of the diverticula contained calculi (Fig. 2). Additional retrograde cystourethrography imaged four large diverticula. Flexible cystoscopy did not identify any intravesical or intradiverticular tumors. Immediate insertion of a Foley catheter drained 3500 mL of clear urine. Adequate hydration and close monitoring of the excessive diuresis improved the clinical picture dramatically within 72 hours. The jaundice slowly subsided, and the laboratory evaluation reflected the overall improving medical condition. Transrectal ultrasound-guided biopsy of the prostate ruled out prostate cancer. The hepatitis profile and computed tomographyguided liver biopsy ruled out primary hepatobiliary etiology. The patient was discharged with an indwelling urethral catheter to allow for adequate recovery 0090-4295/03/$30.00 doi:10.1016/S0090-4295(03)00269-3
sidual urine volume ensued. On additional follow-up 3 months later, the patient continued to enjoy satisfactory urinary flow and his PSA level was substantially decreased and had returned to within the normal age range (5.2 ng/dL). COMMENT
FIGURE 1. Computed tomography scan of the abdomen showing diverticulum (2) extending outside the bony pelvis and displacing the small bowel.
FIGURE 2. Computed tomography scan of pelvis showing the bladder and various diverticuli (1), (2), (3), (4). Arrow points to bladder (anteriorly) and the origin of diverticulum (2). Calculi in diverticula (3), and (4).
before surgical management. Six weeks later, on re-admission, the laboratory evaluation showed normalization of the liver profile and creatinine (1.4 mg/dL). Considering the patient’s anesthesia risk, the intent to cure at once, and the complexity of the disease, the patient underwent bladder diverticulectomy and open suprapubic prostatectomy. His convalescence was uneventful, and spontaneous urination with a minimal postvoid re-
UROLOGY 62 (2), 2003
Bladder diverticula are acquired during the decompensation phase of bladder outlet obstruction and quite often are associated with recurrent infection, stone formation, and tumorigenicity.3 Although very rarely, extraurinary manifestations such as thrombophlebitis,1 and inguinal herniation2 have been described. Our case is another fascinating extraurinary manifestation, the first ever reported, and relates diverticula and obstructive uropathy to extrabiliary obstructive jaundice. The expansion of the largest of the diverticula displaced the enteral loops cranially and might therefore have distorted the second portion of the duodenum, causing partial obstruction of the drainage of the choledochal duct. Immediate decompression of the bladder allowed for prompt restoration of the biliary drainage. This sequel of events supports the anatomic basis of this unusual presentation and adds to the differential diagnostic pattern of obstructive jaundice. Furthermore, the dramatic postoperative decline of the PSA level credits prostatic adenoma as the main contributor of the PSA level and reiterates the significant impact of benign prostatic hyperplasia component in patients who present with significantly elevated PSA levels and are repeatedly negative for adenocarcinoma by transrectal ultrasound-guided biopsies of the prostate. REFERENCES 1. Jepson PM, Nickson KL, and Silber I: Giant vesical diverticula with thrombophlebitis. Urology 1: 606 –608, 1973. 2. Bolton DM, and Joyce G: Vesical diverticulum extending into an inguinal hernia. Br J Urol 73: 323–324, 1994. 3. Melekos MD, Asbach HW, and Barbalias GA: Vesical diverticula: etiology, diagnosis, tumorigenesis and treatment—analysis of 74 cases. Urology 30: 453–457, 1987.
351v