Cheif Parrish
Well you may remember Cheif Parrish
from last week with the retained abdominal fluid. The strangest
thing was that Cheif's presenting problem was that he had had
a "seizure" and had then "run off" only to
be found a couple of days later semi-comatose and infested with
ticks and fly larva. He was in tough shape when he come in. His
original lab work indicated that he was in renal failure. He had
abdominal pain and was VERY dehydrated. After rehydration it was
obvious that there was an abdominal fluid accumulation. We were
not sure where this fluid was coming from. Analysis of the fluid
indicated a low specific gravity, protein, glucose and relatively
few cells. Our impression was that this probably represented urine
accumlation in the abdoman.
We needed to determine where the
urine may have been leaking from. We injected Cheif with a dye
that shows up white on radiographs and is excreted in the urine.
The dye outlines the kidneys, ureters, bladder and urethra if
everything is intact and functioning well. The Kidneys and ureters
looked OK. However, as the urine filled the bladder there was
obvious leakage from the bladder. We could not explain how a hole
occured in the bladder. We were concerned about whether ther might
be a tumor of the bladder or prostate that may have created a
weakness in the bladder or urethra wall. No cells of this type
were seen in the fluid of the abdoman but many times they are
not visible. Fluid that accumulated in the abdoman was drained
with needles and suction but this was a time consuming and potentially
cantaminating proceedure. I'm sure that it was uncomfortable for
Cheif but he never complained and it allowed us to get through
the weekend for surgery on monday.
At surgery all we found during
our exploratory was a very big hole in the bladder. There was
some necrotic tissue like might occur if some vascular event had
comprimised the blood flow to a portion of the bladder. No indication
of the presence of a tumor was seen. No stones were seen. No evidence
of infection was detected. The necrotic tissue (brown tissue in
this picture) was debrided. The forceps are inserted into the
hole in the bladder.
The bladder is shown here with
a 3 layer closure that is commonly used on the bladder. The health
of the tissue we were suturing looked pretty good.
For addiditional security we added
a flap of abdominal fat was sutured over the closure of the abdoman
to provide an additional "serosal surface" for the closure.
Following surgery a plastic catheter was sutured in place in the
bladder to allow measured and continuous drainage of the bladder
for 24 hours. Since Cheif seemed happy to urinate around the narrow
tube we removed it that night. The next morning Cheif we eating
and drinking more normally. We sent Cheif home on Wednesday and
will recheck his kidney function about 5 days from now. However,
he SEEMS to be doing awfully well. I have no idea how this happened
in the first place.
We saw cheif on 7-19 and repeated lab work. The kidney function
tests were normal and we assume that things are on the mend. I
am fairly amazed at the outcome of this case since it looked to
me like one of those cases that would do poorly then get worse!
Sometimes you get lucky!
Other interesting Cases
Home