A 52 year gentleman with no co morbid illness, who was physically active presented with 2 weeks history of abdominal pain and vomiting. He was evaluated at another medical center for the same and given symptomatic treatment. Since his symptoms persisted, he underwent tests which showed that he had acute kidney failure (Creatinine 3.8 mg, CRP 38). He was referred to the Nephrology Department for evaluation of the same.
On Examination: appeared hypovolemic on the first visit, was admitted for fluid hydration. He was considered to have acute pyelonephritis in view of the symptoms, renal failure and high CRP. He was started on antibiotics, antiemetic’s and antacids but his symptoms persisted. He underwent an ultrasound of the abdomen to look for abnormalities but it appeared grossly normal. He underwent tests to assess the etiology of upper GI symptoms including pancreas which were normal. He was seen by the Gastroenterologist and underwent upper GI endoscopy which was also normal. His kidney functions improved gradually with hydration and medications to 1.4 mg. Since, his symptoms persisted and did not correlate with improvement of kidney functions, it was decided to proceed with a CT scan of abdomen with contrast. After explaining the risks of contrast nephropathy to the patient and necessary precautions, he underwent the study. The CT scan revealed the presence of atherosclerotic changes in the abdominal aorta, saccular aneurysm of the celiac artery with an intimal flap. He was referred to the Cardiologist and Surgeon who advised optimal control of Blood pressure by Beta Blockers besides continuing other treatment. He was then referred to vascular surgery for further management and underwent stenting of the lesion with good result. He is well at present and coming for regular checkup.
The sequence of events were worsening bowel ischemia due to the aneurysm leading to vomiting, hypovolemia and acute kidney failure. The learning point from this case was that we need to keep high index of suspicion about patient symptoms. Since his complaints were the only pointer to an internal problem, it was prudent to evaluate the cause. The risk of contrast nephropathy is higher if proper precautions are not taken. In this case the benefits overcame the risk of contrast renal injury and it was possible to avert a major catastrophe.
Aster Hospital, Mankhool