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Left Hydronephrosis Caused by Crohn Disease Successfully Treated Conservatively
Left Hydronephrosis Caused by Crohn Disease Successfu Ily Treated Conservatively HAIM BEN-AMI, MD; ALEXANDRA LAVY, MD; DORON M. BEHAR, MD; YEOSHUA GINESIN, MD; DORON FISCHER, MD; YEOUDA EDOUTE, MD, PHD
ABSTRACT: We report the case of a 35-year-old man who presented with fever, diarrhea, and a left abdominal mass. Diagnostic studies confirmed Crohn disease and revealed an abdominal massobstructing the left ureter with hydroureter and hydronephrosis. The patient was successfully treated conservatively, with corticosteroids and mesalamine. A review of the literature indicates apredominance of right ureteral involvement in Crohn disease,
O
bst r u ct ive uropathy attributed to Crohn disease was initially described by Hyams! and has since been discussed by many others.s-" The appropriate treatment for ureteral obstruction caused by Crohn disease is still controversial. Some advocate the necessity of formal ureterolysis- and others recommend only resection of involved intestine." However, the difficulty of ureterolysis, whereby the ureter is freed from the surrounding fibroinflammatory tissue," and the high rate of morbidity noted by some" has led to a staged approach to management. Initially, medical treatment is given for inflammatory bowel disease, with subsequent nephrostomy or ureteral stent for significant obstruction. Associated abscess, if present, is drained, and antibiotic therapy is given. Bowel surgery is recommended if conservative treatment fails. If ureteral obstruction progresses or becomes complicated after bowel resection, ureterolysis may be necessary."
associated with a high incidence of ileocecal disease. Most of these patients were treated surgically, with resection of ileocecal lesion and/or ureterolysis. Ureteral obstruction as a complication of Crohn disease is discussed, with emphasis on conservative treatment. KEY INDEXING TERMS: Crohn disease; Obstructive uropathy; Conservative treatment [Am J Med Sci 2000;320(4):286-7.]
mentation rate, 70/hr; hemoglobin, 11.6 g/dL; creatinine, 1.6 mg/dL (reference range, 0.5-1.3 mg/dL). Total protein, albumin, and liver function tests were all normal. On the second hospital day, an abdominal CT showed a large soft tissue mass located in the left peritoneum obstructing the left ureter and thickened bowel wall with infiltration of the mesenteric fat (Fig. 1). Upper and lower GI series demonstrated an inflamed terminal ileum and sigmoid colon. The histology of biopsies taken from the sigmoid colon revealed a focal, transmural inflammation, with presence of noncaseating granuloma; findings consistent with Crohn disease. After institution of "pulse therapy" with corticosteroids (hydrocortisone sodium succinate, 300 mgld during 10 days), mesalamine, 4 gld, percutaneous nephrostomy and ureteral stent insertion, he improved gradually. The hydroureter and hydronephrosis resolved, and the nephrostomy was closed and removed. Corticosteroids were tapered. He was readmitted to the hospital in April 1995 and November 1998 because of exacerbation of Crohn disease with diarrhea, weight loss, and finding of an abdominal mass. He was treated conservatively with steroids and mesalamine. No ureteral obstruction was observed on these 2 occasions. Today, after 8-year follow-up, he is doing well on 3 g of mesalamine daily.
Discussion Case Report A 35-year old man was admitted to the hospital in July 1991 because of fever, diarrhea, and low back pain. On admission, the patient had a temperature of 38.0°C, blood pressure of 120/90 mm Hg, and heart rate 80/min. The physical exam was significant for lower abdominal tenderness and a mass in the area of left lower quadrant. The pertinent laboratory tests were: erythrocyte sedi-
From the Departments of Internal Medicine C (HB, DMB, YE), Gastroenterology (AL), Urology (vo), and Diagnostic Radiology (DF), Rambam Medical Center and Faculty ofMedicine, Technion, Israel Institute of Technology, Haifa, Israel. Submitted October 27, 1999; accepted April 20, 2000. Correspondence: Haim Ben-Ami, M.D., Department of Internal Medicine C, Rambam Medical Center, P.O.B. 9602, Haifa-31096, Israel (E-mail: [email protected]).
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It is important for urologists to be aware of Crohn disease. The urologic complications include renal calculi, fistulae to the urinary bladder, and the nephrotic syndrome secondary to renal amyloidosis.f In addition, hydronephrosis caused by the ureteral obstruction occurs more frequently than has been recognized. The incidence of ureteral obstruction as a complication of Crohn disease varies between 0.3 and 25%.9,10 Ureteral obstruction predominantly occurs on the right and has been attributed to the inflammatory process that primarily involves the ileocolic portion of the intestine in Crohn disease. Intestinal microperforations or retroperitoneal fistulae resulting in local abscess or phlegmon may result in ureteral October 2000 Volume 320 Number 4
Ben-Ami et 01
intraabdominal sepsis can result from fistula or abscess, formation and can be masked by these agents.P In this report, 24 patients with Crohn disease and a palpable abdominal mass were treated with high-dose steroids. Fourteen of 24 patients eventually required resection for persistence or recurrence of Crohn disease activity with or without the abdominal mass, but in all patients, the operation was performed electively. Eight patients (33.3%) never required resection during a mean follow-up period of 40 months. No complications ascribed to steroid therapy were seen in either the operative or nonoperative group. Successful conservative treatment of obstructive uropathy was reported also by Hyams-" in pediatric patients. In summary, the question whether obstruction of the ureter is itself an indication for surgery remains unanswered. We believe that clinicians should not fear using corticosteroids to treat severe Crohn disease with an abdominal mass and ureteral obstruction. It may be both safe and effective. It should be considered before surgery. References 1. Hyams JA, Weinburg SR, Alley JL. Chronic ileitis with
2. 3.
Figure 1. CT scan of the abdomen. Top, moderate left hydronephrosis with preserved kidney parenchyma. Bottom, a large tissue mass located in the left peritoneum, thickened bowel wall with infiltration of the mesenteric fat.
compression and obstruction. The left ureter is obstructed in patients with severe granulomatous colitis of the sigmoid colon. However, Goldman and Glickman" described a patient with obstruction of the left ureter caused by regional enteritis alone in whom the retroperitoneal inflammatory reaction extended to the left side of the abdomen. Management of ureteral obstruction is controversial, with Block- strongly advocating ureterolysis and Siminovitch-! recommending resection only. A review of the literature revealed very few recent articles regarding obstruction of the urinary tract caused by Crohn disease. Most of these patients underwent surgical treatment. However, today, with newer therapeutic options (institution of intravenous corticosteroids, percutaneous nephrostomy, and/or ureteral stent insertion), nonsurgical management is sometimes feasible. Steroid therapy is often avoided in Crohn disease patients with a palpable abdominal mass, because
THE AMERICAN JOURNAL OF THE MEDICALSCIENCES
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5.
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9. 10. 11.
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concomitant ureteritis. Case report. Am J Surg 1943;61:11720. Ginzburg L, Oppenheimer GD. Urologic complications of regional enteritis. J Urol 1948;59:948-52. Goldman HJ, Glickman SI. Ureteral obstruction in regional ileitis. J Urol 1962;88:616-20. Block GE, Enker WE, Kirsner JB. Significance and treatment of occult obstructive uropathy complicating Crohn's disease. Ann Surg 1973;178:322-32. Present DH, Rabinowitz JG, Banks PA, et ale Obstructive hydronephrosis: A frequent but seldom recognized complication of granulomatous disease of the bowel. N Engl J Med 1969;280:523-8. Fleckenstein P, Knudson L, Pedersen EB, et ale Obstructive uropathy in inflammatory bowel disease. Scand J Gastroenterol 1977;12:519-23. Pardi DS, Tremaine WJ, Sandborn WJ, et ale Renal and urologic complications of inflammatory bowel disease. Am J Gastroenterol 1998;93:505-14. Wether JL, Schapira A, Rubinstein 0, et ale Amyloidosis in regional enteritis: report of five cases. Am J Med 1960;29: 416-23. Schofield PF, StaffWG, Moore Te. Ureteral involvement in regional ileitis (Crohn's disease) J Urol 1968;99:412-6. Steigmann F. Urinary tract complications in regional enteritis. Am J Gastroenterol 1973;59:389-96. Siminovitch JMP, Fazio VW. Ureteral obstruction secondary to Crohn's disease: A need for ureterolysis? Am J Surg 1980; 139:95- 8. Felder JB, Adler DJ, Korelitz BI. The safety of corticosteroid therapy in Crohn's disease with an abdominal mass. Am J Gastroenterol 1991;86:1450-5. Hyams JS. Extraintestinal manifestations of inflammatory bowel disease in children. J Pediatr Gastroenterol Nutr 1994; 19:7-21.
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ABSTRACT: We report the case of a 35-year-old man who presented with fever, diarrhea, and a left abdominal mass. Diagnostic studies confirmed Crohn disease and revealed an abdominal massobstructing the left ureter with hydroureter and hydronephrosis. The patient was successfully treated conservatively, with corticosteroids and mesalamine. A review of the literature indicates apredominance of right ureteral involvement in Crohn disease,
O
bst r u ct ive uropathy attributed to Crohn disease was initially described by Hyams! and has since been discussed by many others.s-" The appropriate treatment for ureteral obstruction caused by Crohn disease is still controversial. Some advocate the necessity of formal ureterolysis- and others recommend only resection of involved intestine." However, the difficulty of ureterolysis, whereby the ureter is freed from the surrounding fibroinflammatory tissue," and the high rate of morbidity noted by some" has led to a staged approach to management. Initially, medical treatment is given for inflammatory bowel disease, with subsequent nephrostomy or ureteral stent for significant obstruction. Associated abscess, if present, is drained, and antibiotic therapy is given. Bowel surgery is recommended if conservative treatment fails. If ureteral obstruction progresses or becomes complicated after bowel resection, ureterolysis may be necessary."
associated with a high incidence of ileocecal disease. Most of these patients were treated surgically, with resection of ileocecal lesion and/or ureterolysis. Ureteral obstruction as a complication of Crohn disease is discussed, with emphasis on conservative treatment. KEY INDEXING TERMS: Crohn disease; Obstructive uropathy; Conservative treatment [Am J Med Sci 2000;320(4):286-7.]
mentation rate, 70/hr; hemoglobin, 11.6 g/dL; creatinine, 1.6 mg/dL (reference range, 0.5-1.3 mg/dL). Total protein, albumin, and liver function tests were all normal. On the second hospital day, an abdominal CT showed a large soft tissue mass located in the left peritoneum obstructing the left ureter and thickened bowel wall with infiltration of the mesenteric fat (Fig. 1). Upper and lower GI series demonstrated an inflamed terminal ileum and sigmoid colon. The histology of biopsies taken from the sigmoid colon revealed a focal, transmural inflammation, with presence of noncaseating granuloma; findings consistent with Crohn disease. After institution of "pulse therapy" with corticosteroids (hydrocortisone sodium succinate, 300 mgld during 10 days), mesalamine, 4 gld, percutaneous nephrostomy and ureteral stent insertion, he improved gradually. The hydroureter and hydronephrosis resolved, and the nephrostomy was closed and removed. Corticosteroids were tapered. He was readmitted to the hospital in April 1995 and November 1998 because of exacerbation of Crohn disease with diarrhea, weight loss, and finding of an abdominal mass. He was treated conservatively with steroids and mesalamine. No ureteral obstruction was observed on these 2 occasions. Today, after 8-year follow-up, he is doing well on 3 g of mesalamine daily.
Discussion Case Report A 35-year old man was admitted to the hospital in July 1991 because of fever, diarrhea, and low back pain. On admission, the patient had a temperature of 38.0°C, blood pressure of 120/90 mm Hg, and heart rate 80/min. The physical exam was significant for lower abdominal tenderness and a mass in the area of left lower quadrant. The pertinent laboratory tests were: erythrocyte sedi-
From the Departments of Internal Medicine C (HB, DMB, YE), Gastroenterology (AL), Urology (vo), and Diagnostic Radiology (DF), Rambam Medical Center and Faculty ofMedicine, Technion, Israel Institute of Technology, Haifa, Israel. Submitted October 27, 1999; accepted April 20, 2000. Correspondence: Haim Ben-Ami, M.D., Department of Internal Medicine C, Rambam Medical Center, P.O.B. 9602, Haifa-31096, Israel (E-mail: [email protected]).
286
It is important for urologists to be aware of Crohn disease. The urologic complications include renal calculi, fistulae to the urinary bladder, and the nephrotic syndrome secondary to renal amyloidosis.f In addition, hydronephrosis caused by the ureteral obstruction occurs more frequently than has been recognized. The incidence of ureteral obstruction as a complication of Crohn disease varies between 0.3 and 25%.9,10 Ureteral obstruction predominantly occurs on the right and has been attributed to the inflammatory process that primarily involves the ileocolic portion of the intestine in Crohn disease. Intestinal microperforations or retroperitoneal fistulae resulting in local abscess or phlegmon may result in ureteral October 2000 Volume 320 Number 4
Ben-Ami et 01
intraabdominal sepsis can result from fistula or abscess, formation and can be masked by these agents.P In this report, 24 patients with Crohn disease and a palpable abdominal mass were treated with high-dose steroids. Fourteen of 24 patients eventually required resection for persistence or recurrence of Crohn disease activity with or without the abdominal mass, but in all patients, the operation was performed electively. Eight patients (33.3%) never required resection during a mean follow-up period of 40 months. No complications ascribed to steroid therapy were seen in either the operative or nonoperative group. Successful conservative treatment of obstructive uropathy was reported also by Hyams-" in pediatric patients. In summary, the question whether obstruction of the ureter is itself an indication for surgery remains unanswered. We believe that clinicians should not fear using corticosteroids to treat severe Crohn disease with an abdominal mass and ureteral obstruction. It may be both safe and effective. It should be considered before surgery. References 1. Hyams JA, Weinburg SR, Alley JL. Chronic ileitis with
2. 3.
Figure 1. CT scan of the abdomen. Top, moderate left hydronephrosis with preserved kidney parenchyma. Bottom, a large tissue mass located in the left peritoneum, thickened bowel wall with infiltration of the mesenteric fat.
compression and obstruction. The left ureter is obstructed in patients with severe granulomatous colitis of the sigmoid colon. However, Goldman and Glickman" described a patient with obstruction of the left ureter caused by regional enteritis alone in whom the retroperitoneal inflammatory reaction extended to the left side of the abdomen. Management of ureteral obstruction is controversial, with Block- strongly advocating ureterolysis and Siminovitch-! recommending resection only. A review of the literature revealed very few recent articles regarding obstruction of the urinary tract caused by Crohn disease. Most of these patients underwent surgical treatment. However, today, with newer therapeutic options (institution of intravenous corticosteroids, percutaneous nephrostomy, and/or ureteral stent insertion), nonsurgical management is sometimes feasible. Steroid therapy is often avoided in Crohn disease patients with a palpable abdominal mass, because
THE AMERICAN JOURNAL OF THE MEDICALSCIENCES
4.
5.
6.
7.
8.
9. 10. 11.
12.
13.
concomitant ureteritis. Case report. Am J Surg 1943;61:11720. Ginzburg L, Oppenheimer GD. Urologic complications of regional enteritis. J Urol 1948;59:948-52. Goldman HJ, Glickman SI. Ureteral obstruction in regional ileitis. J Urol 1962;88:616-20. Block GE, Enker WE, Kirsner JB. Significance and treatment of occult obstructive uropathy complicating Crohn's disease. Ann Surg 1973;178:322-32. Present DH, Rabinowitz JG, Banks PA, et ale Obstructive hydronephrosis: A frequent but seldom recognized complication of granulomatous disease of the bowel. N Engl J Med 1969;280:523-8. Fleckenstein P, Knudson L, Pedersen EB, et ale Obstructive uropathy in inflammatory bowel disease. Scand J Gastroenterol 1977;12:519-23. Pardi DS, Tremaine WJ, Sandborn WJ, et ale Renal and urologic complications of inflammatory bowel disease. Am J Gastroenterol 1998;93:505-14. Wether JL, Schapira A, Rubinstein 0, et ale Amyloidosis in regional enteritis: report of five cases. Am J Med 1960;29: 416-23. Schofield PF, StaffWG, Moore Te. Ureteral involvement in regional ileitis (Crohn's disease) J Urol 1968;99:412-6. Steigmann F. Urinary tract complications in regional enteritis. Am J Gastroenterol 1973;59:389-96. Siminovitch JMP, Fazio VW. Ureteral obstruction secondary to Crohn's disease: A need for ureterolysis? Am J Surg 1980; 139:95- 8. Felder JB, Adler DJ, Korelitz BI. The safety of corticosteroid therapy in Crohn's disease with an abdominal mass. Am J Gastroenterol 1991;86:1450-5. Hyams JS. Extraintestinal manifestations of inflammatory bowel disease in children. J Pediatr Gastroenterol Nutr 1994; 19:7-21.
287