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Colonic Mucosal Ecchymoses After Extracorporeal Shock Wave Lithotripsy for Upper Ureteral Calculus
0022-5347/88/1405-1012$2.00/0 Vol. 140, November
THE JOURNAL OF UROLOGY
Copyright© 1988 by The Williams & Wilkins Co.
Printed in U.S.A.
COLONIC MUCOSAL ECCHYMOSES AFTER EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY FOR UPPER URETERAL CALCULUS A. S. CASS
AND
G. ONSTAD
From the Midwest Urologic Stone Unit and Gastrointestinal Service, Hennepin County Medical Center, Minneapolis, Minnesota
ABSTRACT
Bright red blood was found in stool immediately following extracorporeal shock wave lithotripsy with 2,700 shock waves to a right upper ureteral calculus beside an indwelling Double-J* stent. The vital signs remained stable and bleeding did not recur. Colonoscopy revealed small areas of mucosa! ecchymoses in the ascending colon. To our knowledge this effect of extracorporeal shock wave lithotripsy has not been reported previously. There is no evidence as yet that these ecchymoses are of any clinical significance for most patients. (J. Ural., 140: 1012-1013, 1988) Extracorporeal shock wave lithotripsy (ESWLt) has become the treatment of choice for most renal and upper ureteral stones, and few complications have been recorded during the first 5 years of experience despite the considerable shock wave exposures of nearby tissues. 1- 3 Recently gastric and duodenal erosions were reported in 32 of 40 patients receiving ESWL. 4 We report a case of colon injury after ESWL. CASE REPORT
A 70-year-old man with a right renal stone presented with a 2-day history of pain on the right side of the abdomen and flank. Excretory urography showed a 0.8 X 0.6 cm. calculus in the right ureter at the level of L3 vertebra with dilatation of the calices and ureter above the calculus. Endoscopic manipulation to push the stone into the renal pelvis was unsuccessful and, therefore, a Double-J stent was left in the ureter and the patient was referred to our lithotriptor unit. During admission evaluation 2 weeks later the patient denied any abnormal bleeding history, and bleeding studies revealed a platelet count of 357,000 per mm.3, bleeding time 3.5 minutes, coagulation time 10.8 seconds and partial thromboplastin time 25. 7 seconds. ESWL was performed with the patient under general anesthesia and 2,700 shocks (200 at 18 kv. and 2,500 at 22 kv.) were given to the calculus with the Double-J stent still in place (part A of figure). Immediately after treatment the patient had a bowel movement and the stool contained bright red blood. The vital signs remained stable and bleeding did not recur. The next day the urine was clear and an abdominal radiograph showed satisfactory fragmentation of the ureteral calculus (part B of figure ). Colonoscopy was performed and the report read, "the colonoscope was introduced through the anus and advanced to the cecum identified by the appendix. Retrograde examination of the colon was normal except for a 10 cm. area of bruising of the ascending colon and a diverticulum in the descending colon. Multiple photos obtained." The Double-J stent was removed 2 weeks later. At 6 weeks after ESWL the patient has had no bowel symptoms or recurrence of bleeding, and radiographs show no stone fragments. DISCUSSION
During the pre-clinical studies of the extracorporeal lithotriptor Chaussy exposed the abdominal cavities of 40 rats to 5 or 10 shock waves of 27 kv. and found no histopathological changes at 24 hours (20 rats) or at 14 days (20 rats). 5 In another Accepted for publication March 7, 1988. * Medical Engineering Corp., New York, New York. t Dornier Medical Systems, Inc., Marietta, Georgia.
study of rats he eventrated the liver and intestine into the field of focus of the shock wave. After 2 shock wave exposures of the large intestine, isolated and widely disseminated petechial bleeding was observed on the verge of the mesentery but in no case was any severe bleeding or serous or intestinal wall lesions seen. The organs then were replaced in the abdominal cavity, the laparotomies were closed and the rats were kept in a controlled environment in cages for 14 days, during which time no histopathological changes were seen. Chaussy also examined the large intestines of dogs given 500 shock waves to the kidney, 17 with stones implanted in the kidney and 6 without stones. In all dogs histological examination revealed no changes caused by the traumatizing effect of shock wave. 5 However, Al Karawi and associates recently reported gastric and/or duodenal erosions in 32 of 40 patients receiving ESWL with general anesthesia, which were detected by endoscopy of the upper gastrointestinal tract just before and immediately after ESWL. 4 There was no control group of patients in whom endoscopy was performed after other procedures with general anesthesia. The most common site (24 patients) was the proximal portion of the stomach. No difference was noted in the frequency of erosions in patients treated for right or left renal calculi. In some patients a dose-response effect appeared to be operative, with more erosions developing with greater numbers of shock waves and higher energy intensity. In most patients the early onset of hematuria indicated development of more erosions. In our patient 2,700 shock waves were administered, which exceeds the limit of 2,000 shock waves recommended by the Food and Drug Administration, and we speculate that the colonic mucosal ecchymoses resulted from this large number of shock waves. Several authors have reported that ureteral stones treated in situ required a significantly greater number of shock waves at a higher kilovoltage. 1 • 3 Evans and associates administered an average of 2,400 shock waves to 29 ureteral stones and they noted, "when stones are large, difficult to fragment or located in the ureter, greater than 2,000 shocks often are needed to obtain complete fragmentation. Up to 3,000 shocks per treatment were used in our study even though a limit of 2,000 shocks has been suggested by the Food and Drug Administration. No long-term effects of the additional shocks have been detected. The risk of morbidity associated with an increase in shocks would appear to be slight for ureteral stones that are located away from kidney, lung and liver." 6 It is postulated that in our case the edge of the ascending colon was adjacent to the area of the upper right ureter, which allowed for exposure to much of the force of the shock waves. Such exposure caused petechial hemorrhage in the colonic wall resulting in bleeding into the large bowel. Because the gastroin-
1012
COLONIC MU CO SAL ECCHYMOSES AFTER EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY
1013
Radiographs of abdomen. A, stone in upper ureter with indwelling Double-J stent. B, fragmentation of stone after 2,700 shocks with ESWL
testinal tract contains considerable amounts of air, a good conductor of shock waves, perhaps its susceptibility to injury by ESWL should not be surprising. However, there is no evidence as yet that this injury is of any clinical significance for most patients. REFERENCES 1. Chaussy, C. G. and Fuchs, G. J.: Extracorporeal shock wave litho-
tripsy. Monographs in Urology, vol. 8, No. 4, pp. 92-97, 1987. 2. Report of the American Urological Association Ad Hoc Committee to Study the Safety and Clinical Efficacy of Current Technology of Percutaneous Lithotripsy and Non-Invasive Lithotripsy. Baltimore: American Urological Association, Inc., May 16, 1985. 3. Lingeman, J. E., Coury, T. A., Newman, D. M., Kahnoski, R. J.,
Mertz, J. H. 0., Mosbaugh, P. G., Steele, E. and Woods, J. R.: Comparison of results and morbidity of percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy. J. Urol., 138: 485, 1987. 4. Al Karawi, M.A., Mohamed, A. R. E., El-Etaibi, K. E., Abomelha, M. S. and Seed, R. F.: Extracorporeal shock-wave lithotripsy (ESWL)-induced erosion in upper gastrointestinal tract. Prospective study in 40 patients. Urology, 30: 224, 1987. 5. Chaussy, C. G.: In vitro and in vivo studies in biological systems. In: Extracorporeal Shock Wave Lithotripsy: New Aspects in the Treatment of Kidney Stone Disease. Munich: S. Karger Publishers, Inc., p. 21, 1982. 6. Evans, R. J., Wingfield, D. D., Morollo, B. A. and Jenkins, A. D.: Ureteral stone manipulation before extracorporeal shock wave lithotripsy. J. Urol., 139: 33, 1988.
THE JOURNAL OF UROLOGY
Copyright© 1988 by The Williams & Wilkins Co.
Printed in U.S.A.
COLONIC MUCOSAL ECCHYMOSES AFTER EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY FOR UPPER URETERAL CALCULUS A. S. CASS
AND
G. ONSTAD
From the Midwest Urologic Stone Unit and Gastrointestinal Service, Hennepin County Medical Center, Minneapolis, Minnesota
ABSTRACT
Bright red blood was found in stool immediately following extracorporeal shock wave lithotripsy with 2,700 shock waves to a right upper ureteral calculus beside an indwelling Double-J* stent. The vital signs remained stable and bleeding did not recur. Colonoscopy revealed small areas of mucosa! ecchymoses in the ascending colon. To our knowledge this effect of extracorporeal shock wave lithotripsy has not been reported previously. There is no evidence as yet that these ecchymoses are of any clinical significance for most patients. (J. Ural., 140: 1012-1013, 1988) Extracorporeal shock wave lithotripsy (ESWLt) has become the treatment of choice for most renal and upper ureteral stones, and few complications have been recorded during the first 5 years of experience despite the considerable shock wave exposures of nearby tissues. 1- 3 Recently gastric and duodenal erosions were reported in 32 of 40 patients receiving ESWL. 4 We report a case of colon injury after ESWL. CASE REPORT
A 70-year-old man with a right renal stone presented with a 2-day history of pain on the right side of the abdomen and flank. Excretory urography showed a 0.8 X 0.6 cm. calculus in the right ureter at the level of L3 vertebra with dilatation of the calices and ureter above the calculus. Endoscopic manipulation to push the stone into the renal pelvis was unsuccessful and, therefore, a Double-J stent was left in the ureter and the patient was referred to our lithotriptor unit. During admission evaluation 2 weeks later the patient denied any abnormal bleeding history, and bleeding studies revealed a platelet count of 357,000 per mm.3, bleeding time 3.5 minutes, coagulation time 10.8 seconds and partial thromboplastin time 25. 7 seconds. ESWL was performed with the patient under general anesthesia and 2,700 shocks (200 at 18 kv. and 2,500 at 22 kv.) were given to the calculus with the Double-J stent still in place (part A of figure). Immediately after treatment the patient had a bowel movement and the stool contained bright red blood. The vital signs remained stable and bleeding did not recur. The next day the urine was clear and an abdominal radiograph showed satisfactory fragmentation of the ureteral calculus (part B of figure ). Colonoscopy was performed and the report read, "the colonoscope was introduced through the anus and advanced to the cecum identified by the appendix. Retrograde examination of the colon was normal except for a 10 cm. area of bruising of the ascending colon and a diverticulum in the descending colon. Multiple photos obtained." The Double-J stent was removed 2 weeks later. At 6 weeks after ESWL the patient has had no bowel symptoms or recurrence of bleeding, and radiographs show no stone fragments. DISCUSSION
During the pre-clinical studies of the extracorporeal lithotriptor Chaussy exposed the abdominal cavities of 40 rats to 5 or 10 shock waves of 27 kv. and found no histopathological changes at 24 hours (20 rats) or at 14 days (20 rats). 5 In another Accepted for publication March 7, 1988. * Medical Engineering Corp., New York, New York. t Dornier Medical Systems, Inc., Marietta, Georgia.
study of rats he eventrated the liver and intestine into the field of focus of the shock wave. After 2 shock wave exposures of the large intestine, isolated and widely disseminated petechial bleeding was observed on the verge of the mesentery but in no case was any severe bleeding or serous or intestinal wall lesions seen. The organs then were replaced in the abdominal cavity, the laparotomies were closed and the rats were kept in a controlled environment in cages for 14 days, during which time no histopathological changes were seen. Chaussy also examined the large intestines of dogs given 500 shock waves to the kidney, 17 with stones implanted in the kidney and 6 without stones. In all dogs histological examination revealed no changes caused by the traumatizing effect of shock wave. 5 However, Al Karawi and associates recently reported gastric and/or duodenal erosions in 32 of 40 patients receiving ESWL with general anesthesia, which were detected by endoscopy of the upper gastrointestinal tract just before and immediately after ESWL. 4 There was no control group of patients in whom endoscopy was performed after other procedures with general anesthesia. The most common site (24 patients) was the proximal portion of the stomach. No difference was noted in the frequency of erosions in patients treated for right or left renal calculi. In some patients a dose-response effect appeared to be operative, with more erosions developing with greater numbers of shock waves and higher energy intensity. In most patients the early onset of hematuria indicated development of more erosions. In our patient 2,700 shock waves were administered, which exceeds the limit of 2,000 shock waves recommended by the Food and Drug Administration, and we speculate that the colonic mucosal ecchymoses resulted from this large number of shock waves. Several authors have reported that ureteral stones treated in situ required a significantly greater number of shock waves at a higher kilovoltage. 1 • 3 Evans and associates administered an average of 2,400 shock waves to 29 ureteral stones and they noted, "when stones are large, difficult to fragment or located in the ureter, greater than 2,000 shocks often are needed to obtain complete fragmentation. Up to 3,000 shocks per treatment were used in our study even though a limit of 2,000 shocks has been suggested by the Food and Drug Administration. No long-term effects of the additional shocks have been detected. The risk of morbidity associated with an increase in shocks would appear to be slight for ureteral stones that are located away from kidney, lung and liver." 6 It is postulated that in our case the edge of the ascending colon was adjacent to the area of the upper right ureter, which allowed for exposure to much of the force of the shock waves. Such exposure caused petechial hemorrhage in the colonic wall resulting in bleeding into the large bowel. Because the gastroin-
1012
COLONIC MU CO SAL ECCHYMOSES AFTER EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY
1013
Radiographs of abdomen. A, stone in upper ureter with indwelling Double-J stent. B, fragmentation of stone after 2,700 shocks with ESWL
testinal tract contains considerable amounts of air, a good conductor of shock waves, perhaps its susceptibility to injury by ESWL should not be surprising. However, there is no evidence as yet that this injury is of any clinical significance for most patients. REFERENCES 1. Chaussy, C. G. and Fuchs, G. J.: Extracorporeal shock wave litho-
tripsy. Monographs in Urology, vol. 8, No. 4, pp. 92-97, 1987. 2. Report of the American Urological Association Ad Hoc Committee to Study the Safety and Clinical Efficacy of Current Technology of Percutaneous Lithotripsy and Non-Invasive Lithotripsy. Baltimore: American Urological Association, Inc., May 16, 1985. 3. Lingeman, J. E., Coury, T. A., Newman, D. M., Kahnoski, R. J.,
Mertz, J. H. 0., Mosbaugh, P. G., Steele, E. and Woods, J. R.: Comparison of results and morbidity of percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy. J. Urol., 138: 485, 1987. 4. Al Karawi, M.A., Mohamed, A. R. E., El-Etaibi, K. E., Abomelha, M. S. and Seed, R. F.: Extracorporeal shock-wave lithotripsy (ESWL)-induced erosion in upper gastrointestinal tract. Prospective study in 40 patients. Urology, 30: 224, 1987. 5. Chaussy, C. G.: In vitro and in vivo studies in biological systems. In: Extracorporeal Shock Wave Lithotripsy: New Aspects in the Treatment of Kidney Stone Disease. Munich: S. Karger Publishers, Inc., p. 21, 1982. 6. Evans, R. J., Wingfield, D. D., Morollo, B. A. and Jenkins, A. D.: Ureteral stone manipulation before extracorporeal shock wave lithotripsy. J. Urol., 139: 33, 1988.