Spontaneous intraperitoneal rupture of a neurogenic bladder; the importance of ascitic fluid urea and electrolytes in diagnosis

Abstract

Summary: Spontaneous intraperitoneal bladder rupture in a 38 year old man with a spastic paraparesis since infancy is described. Delayed diagnosis resulted in peritoneal autodialysis so providing an opportunity for documentation ofbiochemical abnormalities. Surgery resulted in a successful outcome. The literature on this rare condition is outlined and difficulties in diagnosis are discussed. The diagnostic value of urea and electrolyte levels in ascitic fluid is emphasized.

Ascitic fluid with ammonia odor as a symptom of bladder rupture

“…This clinical condition, in the absence of a decrease in the glomerular filtration rate, is known as pseudorenal failure. Hence, examination of the urea and creatinine levels in the ascitic fluid, cystography, and cystoscopy are useful tests to establish the diagnosis; however, these are rarely indicated in the absence of a diagnostic suspicion. Moreover, ascitic fluid sediment and the urinary appearance of mesothelial cells have been recently reported as indicators of bladder rupture.…”

Non‐traumatic bladder rupture showing less than 10 Hounsfield units of ascites

“…In addition, values less than 10 HU were also identified in cases with transudative ascites associated with conditions other than bladder rupture; these conditions included closed‐loop obstruction and malnutrition with serous ascites, peptic ulcer associated with liver cirrhosis, sigmoid diverticulitis in a patient in congestive heart failure with pleural effusions, and small intestinal perforation in a patient on dialysis. The attenuation value of ascites alone was not useful for distinguishing bladder rupture from these 4 cases; however, these exceptional cases had massive ascites that were easily punctured, such that ascites color, odor, and creatinine concentration as obtained by abdominocentesis would have been helpful in the differential diagnosis.…”

“…In these cases, bladder rupture is usually not considered in the differential diagnosis because of its rare incidence . High ascitic urea and ascitic creatinine levels, cystoscopy and fluoroscopic retrograde cystography, as well as computed tomography (CT) with retrograde cystography can be used to confirm the diagnosis of bladder rupture. Clinically, however, these examinations are not indicated for patients presenting with acute abdominal pain unless there are clear indications to suspect a rupture of the bladder .…”

Ascitis y falla renal: no olvidar el uroperitoneo

“…Cuando es espontánea se presenta en general en una vejiga enferma, o bien en casos de obstrucción del tracto urinario. Entre las causas descritas destacan obstrucción del tracto urinario, divertículos, material de sutura, ingesta de grandes cantidades de alcohol, neoplasias, litiasis, candidiasis, tuberculosis y esquistosomiasis vesical, vejiga neurogénica y en el postparto 1,5,[8][9][10] . Su forma de presentación es variable.…”

“…A veces debuta como un cuadro de abdomen agudo, en cuyo caso es frecuente que el diagnóstico se haga en pabellón alcanzando una mortalidad de hasta 25%, o bien presentarse como un cuadro de insuficiencia renal oligúrica 2,3,[12][13][14] . En este caso el diagnóstico se sospecha por oliguria, azotemia, acidosis, la presencia de creatinina, urea y nitrógeno aumentado en el líquido peritoneal, rápida caída de la creatinina sérica y aumento del volumen urinario al drenar el líquido ascítico e instalar una sonda vesical 4,10 . El aumento de la creatinina sérica estaría dado por su reabsorción desde el peritoneo a la sangre, de ahí que se produzca un rápido descenso en la creatininemia al drenar el líquido y al favorecer la salida de la orina por la vejiga descomprimiendo el sistema con una sonda vesical (cuando no hay estallido, sino más bien un orificio), teniendo estos casos mejor pronóstico que los que se presentan con abdomen agudo.…”