十二指腸被誤認為是萎縮的腎臟併積水的個案報告

黃英哲¹ 、鄭元佐¹

¹高雄長庚紀念醫院外科部泌尿科

A case of adhesion duodenum mimicking an atrophic kidney with hydronephrosis

Ying-Che, Huang¹、Yuan-Tso Chang¹

¹Divisions of Urology, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital

Case description:

A 42-year-old male presented to our urologic outpatient department with a chief complaint of the recurrent right retroperitoneal abscess. The patient’s medical history is significant for 1) right renal trauma with poor function and urinoma, post right kidney surgery 15 years ago 2) recurrent retroperitoneal abscess with Pseudomonas aeruginosa infection, post pigtail drainage on 2019/11 and 2020/09. Physical examination did not find a palpable kidney, lower extremity edema, or right costovertebral angle tenderness. The latest computed tomography (CT) favored 1) right chronic kidney disease with hydronephrosis 2) right flank perirenal enhancing cystic lesion (2.4cm), which was drained by percutaneous nephrostomy (PCN) catheters during the last admission. After discussing with the patient, he decided to undergo the robotic-assisted nephrectomy to prevent recurrent infection.

Under successful general anesthesia, the ascending colon was free from peritoneal reflection under the robotic scope. However, when we further dissected along the previous adhesive bowel segment, we found the large cyst-like lesion was adhesive duodenum, not the hydronephrosis of residual kidney, which is confirmed by the GS surgeon. The infected sinus actually originated from duodenum adhesion. Robotic duodenum dissection until the whole 2nd and 3rd portion were free from adhesion, followed by duodenal wall repair with 3-0 Vicryl even no overt bowel rupture and cover with Surgicel. Abscess in muscle was identified and wide open after resection of inflammatory tissue. A JP drain was implanted. The skin was sutured with 3-0 Vicryl in a subcuticular manner. The pathology was 1) congestion with focal chronic inflammation right ureter 2) acute and chronic inflammation retroperitoneum. There was no active oozing, bleeding, ecchymosis, or hematoma formation thereafter. Under the stabilization of the general condition, the patient was discharged and arranged further clinical follow-up.

Discussion:

First, tracing back to this patient’s history, he had right renal trauma 15 years ago. Neither the patient nor his healthcare providers are sure whether he underwent the total nephrectomy at that time. The only thing we knew was that his peritoneal integrity or normal organ position might be changed after the procedure.  Second, fluid-density material within the small cavity on the image was misdiagnosed as an atrophic kidney with hydronephrosis. The true medical condition was found in robotic surgery. Adhesion duodenum mimics an atrophic kidney with hydronephrosis is relatively rare, therefore, it can be a pitfall in clinical practice.

Conclusions:

Abnormal anatomic variations can lead to diagnostic challenges in clinical practice. Adhesion duodenum should be considered when the history, symptoms, image studies, or organ appearance mismatch.