Dietl's crisis: an under-recognized clinical entity in the pediatric population

It's Not Cyclic Vomiting Syndrome Until Dietl's is Ruled Out: A Case for Point of Care Renal Ultrasound

BACKGROUND

Abdominal pain and vomiting are frequent complaints for pediatric patients presenting to the Emergency Department (ED). When a diagnosis such as chronic abdominal pain, cyclic vomiting, or abdominal migraine has previously been made, it can lead to diagnostic momentum and confirmation bias on behalf of the treating physician. Dietl's crisis is a commonly missed diagnosis in the pediatric population that presents with intermittent episodes of pain and vomiting. It can be readily diagnosed at the bedside by the emergency physician (EP) through the employment of point of care ultrasound (POCUS).

CASE SERIES

We present two cases of pediatric patients with episodic abdominal pain and vomiting who were previously diagnosed with cyclic vomiting syndrome. In both cases, pediatric gastroenterology evaluations had occurred with negative diagnostic testing having been performed. Both patients also presented to their primary pediatrician and the ED multiple times with each encounter resulting in treatment of symptoms and discharge. Each patient eventually presented to the ED when an EP was present who performed a renal POCUS. In each patient, the POCUS revealed severe unilateral hydronephrosis. Subsequent workup confirmed the diagnosis of Dietl's crisis as the etiology of symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In pediatric patients, EPs should be wary of the diagnosis of cyclic vomiting syndrome until ureteral obstruction has been ruled out. A bedside POCUS can rapidly establish this diagnosis and potentially preclude recurrent health care visits, unnecessary diagnostic testing, and permanent loss of renal function.

Are robots the future? A case for robotic pyeloplasty as the gold standard treatment in ureteropelvic junction obstruction

PURPOSE OF REVIEW

Robotic pyeloplasty is still a relatively novel procedure. Clinically, early studies have shown high success rates, decreased complication rates, decreased length of hospital stay, and better cosmetic results. This goal of this article is to argue for the use of robotic pyeloplasty as the gold standard of ureteropelvic junction obstruction (UPJO) treatment. Results of studies that have compared robotic pyeloplasty with other procedures currently used are reviewed.

RECENT FINDINGS

Our study, a comprehensive review of published outcomes of robotic pyeloplasty and alternative therapies, consisted of 666 pediatric patients and 653 adult patients. Our review coincided with the previously established studies that robotic pyeloplasty shows equivalent surgical success rates as previous standard of care treatments. Open pyeloplasty has fallen out of favor as standard of care due to the increased length of hospital stay, increased adverse events, and the undesirable aesthetics.

SUMMARY

The use of robotic pyeloplasty has shown to have clinical outcomes that are consistent with other intervention for UPJO, with a potential decrease in length of stay and morbidity. More work has to be done to develop ways to decrease cost of the robot to help establish it as the gold standard for UPJO treatment.

Dietl crisis: Presentation and imaging findings in a 7-year-old boy

Intermittent ureteropelvic junction obstruction, or Dietl crisis, is a rare entity with sparse reports in published literature. Establishing the diagnosis is challenging given its intermittent nature. We report a case of Dietl crisis, focusing on ultrasound (US) and magnetic resonance urography (MRU) findings in a 7-year-old boy with recurrent episodes of colicky abdominal pain prompting multiple visits to the emergency department. Severe left hydronephrosis was visualized on US during one episode with complete resolution on follow-up US. MRU demonstrated severe left hydronephrosis with delayed calyceal transit time, time-to-peak enhancement, and excretion. There was no aberrant blood vessel. Surgical pyeloplasty provided complete symptomatic resolution. MRU can be a valuable tool in eliciting and dynamically confirming the diagnosis of Dietl crisis.

Point-of-Care Ultrasound Diagnosis of Ureteropelvic Junction Obstruction in a Child With Recurrent Abdominal Pain and Vomiting

A case is described of a 4 year-old girl who presented with chronic episodic abdominal pain with vomiting. Physical examination was unremarkable aside from hypertension. Point-of-care renal ultrasound showed hydronephrosis, leading to a diagnosis of ureteropelvic junction obstruction presenting with Dietl crisis (episodic abdominal pain secondary to urinary tract obstruction). The clinical utility of point-of-care renal ultrasound in the evaluation of abdominal pain and ultrasound findings of ureteropelvic junction obstruction are highlighted.

The clinical manifestations of intermittent hydronephrosis and their relationship with renal function in pediatric patients

BACKGROUND AND OBJECTIVE

Most patients with intermittent hydronephrosis have preserved differential renal function (DRF), while others already have impaired DRF at diagnosis. We summarized the clinical manifestations of intermittent hydronephrosis to elucidate what may be related to DRF loss.

STUDY DESIGN

We retrospectively reviewed patients presenting to our department with unilateral Dietl's Crisis between January 2014 and December 2017. Clinical characteristics were collected, including age of first onset, time of onset, duration of the longest single episodes and whether the patient had prenatally detected hydronephrosis. Ultrasonographic (US) parameters included anteroposterior diameter (APD) during the symptomatic and asymptomatic period. Dynamic renograms (DR) were reviewed to obtain preoperative DRF.

RESULTS

A total of 150 patients met the selective criteria. Of the 128 patients whose mother had regular obstetric ultrasounds during pregnancy, 50 (39.06%) had prenatally detected pelvic dilation. The mean age of the first attack was earlier in the prenatally detected hydronephrosis group than in the postnatally detected group (4.58 vs 5.87, p = 0.002). The mean preoperative DRF was 41.03% in all of the patients. The patients whose DRFs were below 40% had longer durations of single attacks than those over 40%. The former group also had larger APD during the symptomatic periods than the latter group. The risk of DRF < 40% was higher in the patients whose APD at attack was greater than 35 mm (OR=5.111, χ²=12.899, p < 0.001). The attack times, waiting time before the surgery and age of the first onset had no association with preoperative DRF.

DISCUSSION

Our study first found that in patients with Dietl's Crisis, the APD during the symptomatic periods and the longest duration of the attack were associated with DRF loss. But the retrospective nature of our study limited us to understand the relationship between DRF and total duration of all attacks.

CONCLUSION

This study revealed that children with prenatal hydronephrosis could develop Dietl's Crisis at early ages. A longer duration of attack and larger APD during the attack were associated with impaired DRF.

A 7-Year-Old Boy With Recurring Episodes of Abdominal Pain

Recurrent abdominal pain is a relatively common complaint in children who present to the emergency department. The etiology is often thought to be psychogenic, with an underlying organic cause present in less than 10% of patients. Intermittent ureteropelvic junction obstruction is usually not considered in the differential diagnosis of recurrent acute abdominal pain in children, which can cause a significant delay in diagnosis. In this condition, intermittent obstruction of the flow of urine from the renal pelvis to the proximal ureter occurs, which causes intermittent acute colicky abdominal pain and vomiting. This acute event, often referred to as a Dietl's crisis, either subsides after several hours or prompts a visit to the emergency department. Management often focuses on the identification of psychosocial issues or constipation, and routine abdominal imaging is not a common practice. The frequency of these events over time and the duration of each acute event are 2 components that factor into determining the loss of function in the affected kidney. The purpose of this case report is to increase awareness of intermittent ureteropelvic junction obstruction as a cause of recurring episodes of acute abdominal pain in children. Emphasis in this case report is on Dietl's crisis, how it presents, and how it is diagnosed and managed.

Pediatric congenital hydronephrosis (ureteropelvic junction obstruction): Medical management guide

The prevalence of asymptomatic hydronephrosis, now detected by ultrasonography, has increased. However, definitive management guidelines for the management of congenital hydronephrosis have not been established. The Japanese Society of Pediatric Urology created a "medical management guide" based on new findings for physicians practicing pediatric urology. We developed a medical management guide focused on congenital hydronephrosis caused by ureteropelvic junction obstruction. This medical management guide consists of the definition, pathophysiology, epidemiology, diagnosis, classification, treatment using a clinical management algorithm of hydronephrosis and the long-term course of the disease. The aim of hydronephrosis management is to determine whether surgery should be carried out to avoid renal dysfunction, as there is a possibility for improvement without intervention. Ultrasonography is essential to make treatment decisions. Management is determined by a comprehensive assessment, including the degree of hydronephrosis, anterior-posterior diameter of the renal pelvis and, if necessary, a nuclear medicine evaluation of the status of urine drainage and renal function.

Emergency Department Diagnosis of Dietl Crisis in a 7-Year-Old Girl With Abdominal Pain

Children with Dietl crisis often experience a delay in diagnosis, with the clinical entity being underdiagnosed. Pain is caused by compression of an aberrant artery crossing dilated kidney. Pain is often worsened after the consumption of liquids and resolves after fluid reabsorption. There are no clear criteria for evaluating ureter obstruction in childhood abdominal pain in the emergency department setting; however, it has been suggested that ultrasound may aid in the diagnosis. As renal parenchyma is typically preserved, and there is a paucity of associated urological complaints, once properly diagnosed, most patients are well served by a pyeloplasty.

[Intermittent hydronephrosis in childhood]

INTRODUCTION

Intermittent pelviureteric junction obstruction, and its consequence,intermittent hydronephrosis is a difficult condition to identify. The renal collecting system is not dilated between the episodes of abdominal pain attacks and a prompt investigation is hard to carry out during the time of painful crisis. Therefore, most of the patients are initially misdiagnosed.

AIM

The aim of the study was to assess the occurrence and the clinical characteristics of this phenomenon in children operated in the Department of Urological Surgery, Heim Pál Children Hospital, Budapest, Hungary.

PATIENTS AND METHODS

Medical records of children operated for hydronephrosis between 2008 and 2012 were reviewed. The occurrence rate and clinical features of intermittent hydronephrosis were analyzed.

RESULTS

76 children were operated for pelviureteric junction obstruction, of which 10 met the criteria of intermittent hydronephrosis. The average interval between the onset of symptoms and the final diagnosis was 2 years and 4 months. In 7 patients pyeloplasty, and in 3 patients nephrectomy were performed.

CONCLUSIONS

Intermittent hydronephrosis represents a well-defined proportion among cases operated for hydronephrosis. The delay in diagnosis led to the loss of the kidney in one third of the patients, and this finding urges for the awareness of health professionals for this phenomenon. In case of recurrent abdominal pain of unknown etiology one must suspect a urological origin, even if a previous abdominal ultrasound showed normal kidneys.