RENAL AND URINARY TRACT COMPLICATIONS

1.Urinary Retention
Etiology
Inpatients undergoing perianal operations and hernia
repair
 Rectal cancer , spinal procedures and may occur after

overly vigorous IV administration of fluid.

 Reversible abnormality
 Benign prostatic hypertrophy and, rarely, a urethral
stricture may also be the cause of urinary retention.
 Presentation and Management
• Dull, constant discomfort in the hypogastrium,
urgency
• Percussion just above the pubis reveals fullness
and tenderness.
• Elderly and patients who have undergone low
anterior resection, must be watched carefully,
• Adequate management of pain,
• Most patients should not go more than 6 to 7
hours without passing some urine,
• Judicious administration of IV fluids during the
procedure and in the immediate postoperative
period,
• General management principles include initial
catheterization, cystoscopy may be required
2. Acute Renal Failure
Etiology
• Acute renal failure (ARF) is characterized by a
sudden reduction in renal output
• Prevalent after major surgical procedures , septic
shock, major blood loss, with transfusion reactions,
diabetics , in life-threatening trauma, with major
burn injuries, and in multiple organ system failure.
• Prerenal, renal, postrenal
 Presentation and Management
• Distinguishing between prerenal and renal azotemia is
complicated.
Careful history taking & Physical examination
Lab. Investigation the u/a
• Postrenal causes of ARF are the most dramatic and
straightforward to diagnose and treat,
• Prevention
 identification of patients with preexisting renal
dysfunction;
 voidance of hypovolemia, and medications that
depress renal function;
• The risk for contrast-induced nephropathy has to be
reduced
PARAMETER PRERENAL RENAL POSTRENAL
Urine osmolality >500 mOsm/L =Plasma Variable

Urinary sodium <20 mOsm/L >50 mOsm/L >50 mOsm/L

Fractional excretion of <1% >3% Variable

sodium

Urine/plasma creatinine >40 <20 <20

Urine/plasma urea >8 <3 Variable

Urine/plasma osmolality <1.5 >1.5 Variable

• Isotonic fluid is indicated and a Foley catheter
placed ( 30 to 40ml /hr of uo)
• In the presence of CHF, diuretics, fluid restriction,
and appropriate cardiac medications are indicated.
• Most urgent in management of ARF is treating
hyperkalemia and fluid overload. Hyperkalemia
can be managed with a sodium/potassium
exchange resin, insulin plus glucose, ß2-
adrenergic agonist, and calcium gluconate,
hemodialysis
• Hyperphosphatemia with hypercalcemia:
phosphorus binders (calcium carbonate) or
dialysis.
• Hemodialysis.
 ENDOCRINE GLAND DYSFUNCTION
1.Adrenal Insufficiency
Etiology
• Uncommon but potentially lethal condition .
• Primary : autoimmune adrenalitis (Addison's
disease), surgical excision or destruction of the
adrenal gland
• Secondary adrenal insufficiency : long-term
administration of pharmacologic doses of
glucocorticoids , or surgical excision or
destruction (postpartum necrosis) of the pituitary
gland.
 Presentation and Diagnosis
• Fatigue, weakness, anorexia, weight loss,
orthostatic dizziness, abdominal pain, hyper
pigmentation of the skin and mucous membrane,
headaches, visual disturbances
• Laboratory test abnormalities, hyponatremia,
hyperkalemia, acidosis, morning plasma cortisol
concentration <3 mg/dL (83 nmol/L),
• Corticotropin level >100 pg/mL (22 nmol/L), low
aldestron level (primary ds)
• MRI & CT
 Treatment
• Prevention : avoidance of abrupt termination of
the medication, and adequate Perioperative
corticosteroid administration.
• A stress dose (100 mg ofdhydrocortison)
• For major surgical procedures, continued every 8
hours until stable or free of complications .
• For minor surgical procedures, usual maintenance
dose is continued postoperatively.
• Symptomatic patients are treated with
hydrocortisone or cortisone. Fludrocortisone
• Hypovolemia and hyponatremia are corrected with
saline infusion
2. Hyperthyroid Crisis
Etiology
• Thyroid crisis is a medical emergency that occurs
in thyrotoxic patients .
• Mortality :20% to 50%
Presentation and Diagnosis
• Nervousness, fatigue, palpitations, heat
intolerance, weight loss, atrial fibrillation (in the
elderly), and ophthalmopathy .
• The diagnosis of thyrotoxicosis requires
demonstration of elevated T3 &T4 levels and
suppressed TSH levels and identification of the
cause of the thyrotoxicosis.
 Management of Thyroid Crisis
• Identification and treatment of the precipitating
factor
• Supportive care
• Fever: antipyretics and cooling
• Heart failure: digoxin and diuretics
• Atrial fibrillation: intravenous heparin
• β-Blockers: Oral propranolol, 60-80 mg/4 hr (or
diltiazem),
• Propylthiouracil or methimazole, Lugol's solution
• Definitive therapy must be considered to prevent
a second crisis
3. Hypothyroidism
Etiology
• Low systemic levels of thyroid hormone
• May be primary , secondary , or tertiary .
Presentation and Diagnosis
• Asymptomatic or rarely have the severe form
myxedema coma . The majority, however,
demonstrate cold intolerance, constipation, brittle
hair, dry skin, sluggishness, weight gain, and
fatigue.
• The ECG abnormalities.
• Low T3 & T4 levels ,TSH is high in primary & low
in secondary
 Treatment
• Euthyroid patients on replacement hormonal
therapy are instructed to continue taking their
medications.
• In patients with symptomatic chronic
hypothyroidism, surgery is postponed until a
euthyroid state is achieved.
• Patients with myxedema coma or those showing
clinical signs of significant hypothyroidism are
immediately treated with thyroid hormone,
concomitant with the IV administration of
hydrocortisone, to avoid an addisonian crisis.
 4. Syndrome of Inappropriate Antidiuretic Hormone
Secretion
Etiology
• Is the most common cause of chronic
normovolemic hyponatremia.
• Trauma, stroke, antidiuretic hormone–producing
tumors, drugs (ACE inhibitors, dopamine,
NSAIDs),
Presentation
• Anorexia, nausea, vomiting, obtundation, and
lethargy. With more rapid onset, seizures, coma,
and death can result.
• Hyponatremia
• SIADH is diagnosed in any patient who remains
hyponatremic despite all attempts to correct the
imbalance in the presence of persistent
antidiuretic activity from elevated arginine
vasopressin.
 Treatment
• Treat the underlying disease process and removal
of excess water .
• Fluid restriction is the mainstay of management of
chronic SIADH.
• IV administration of normal saline or3% saline is
used only in significantly symptomatic patients .
Correction must occur at a rate of 0.5 mmol/L/hr
until the serum sodium concentration is 125 mg/dL
or higher.
• Diuretics such as furosemide occasionally help
correct the imbalance.
 GASTROINTESTINAL COMPLICATIONS
1. Ileus and Early Postoperative Bowel
Obstruction
Etiology
• Early postoperative bowel obstruction denotes
obstruction occurring within 30 days after surgery.
• The obstruction may be functional (i.e., ileus), or
mechanical .
• Two types of Ileus:
primary or postoperative ileus.
secondary or adynamic or paralytic ileus.
 Causes of Intestinal Paralytic Ileus
•  Pancreatitis , Intra-abdominal infection
•  Retroperitoneal hemorrhage and inflammation
•  Electrolyte abnormalities
•  Lengthy surgical procedure
•  Medications
•  Pneumonia
•  Inflamed viscera
• Mechanical obstruction: adhesions (92%),
abscess, internal hernia, intestinal ischemia, or
intussusceptions
 Presentation
• Abdominal distention, pain, nausea and vomiting,
and obstipation.
• Adynamic ileus patients have diffuse discomfort ,
distended abdomen, hypoactive bowel sounds ,X-
ray reveal diffusely dilated bowel throughout the
intestinal tract with air in the colon and rectum
• With mechanical obstruction, sharp colicky pain,
hyperactive sounds ,there is small bowel dilation
with air-fluid levels and thickened valvulae
conniventes.
• A CT scan is more accurate. barium follow through
is indicated in some pts.
 Treatment
• Preventive measures
Minimize injury to the bowels.
Avoid prolonged exposure to air
In the postoperative period, electrolytes are
monitored .
Alternative analgesia to narcotics,
• Postoperative obstruction is suspected or
diagnosed:
resuscitation, investigation, and surgical
intervention.
• Conservative treatment: Adynamic ileus , Partial
mechanical small bowel obstruction
• Emergency relaparotomy
2. Acute Abdominal Compartment Syndrome
Etiology
• Consistently increased intra-abdominal pressure
greater than 12 mm Hg associated with rising peak
airway pressure, and oliguria or anuria that
improve with decompression.
• Most commonly encountered in the multiple
trauma and major abdominal surgery
• Lungs: increase in peak airway pressure,.
• Heart: decreased CO.
• Kidneys: decrease in the glomerular filtration rate
and urine output.
• GI: decrease in splanchnic perfusion, .
• CNS: increase in intracerebral pressure.
 Treatment
• Prevention of Abdominal Compartment Syndrome
- Patients at risk have to be identified (major
trauma, complex abdominal procedure)
- Organ function is monitored and assessed:
Lungs, Heart, Kidneys, Central nervous system,
abdomen distention: Computed tomography
scan
– measures to lower intra-abdominal
hypertension:
 Drainage of intra-abdominal fluid collections
 Muscle relaxation
 Avoid primary closure of the incision
3. Postoperative Gastrointestinal Bleeding
Etiology
• peptic ulcer disease, stress erosion, a Mallory-
Weiss tear, varices, arteriovenous
malformations, bleeding from anastomosis &
diverticulosis.
Presentation and Diagnosis
• previous history is important in assessing the
patient.
• Bright red blood or melanotic stools. Bleeding
from the anastomosis may be a slow ooze or a
rapid hemorrhage that can lead to hypotension.
 Treatment
• Receive aggressive fluid resuscitation to improve
oxygen delivery and prophylaxis that neutralizes
or reduces gastric acid,
• The basic principles of management .
1.Fluid resuscitation and restoration of intravascular
volume
2.Checking and monitoring clotting parameters and
correcting abnormalities as needed
3.Identification and treatment of aggravating factors
4.Transfusion of blood products
5.Identification and treatment of the source of the
bleeding ( Endoscopic control of bleeding ,
Visceral angiography, Laparotomy)
4. Stomal Complications
Etiology
• Stomas are widely used in the treatment of
colorectal, intestinal, and urologic diseases. An
intestinal stoma can be an ileostomy, colostomy,
• Stomal complications are the result of several
factors but technical factors are most important
 Stoma
• Poor location, Prolapse, Retraction, Stenosis,
Ischemic necrosis, Parastomal hernia, Fistula
formation, Opening wrong end
Peristomal skin
• Excoriation , Parastomal varices , Dermatitis,
Cancer, Skin manifestations of inflammatory
bowel disease
 Treatment
• To prevent the majority of Stomal complications,
adherence to sound surgical technique is important.
• Ischemia may be mucosal or full thickness,
expectant
immediate revision of the stoma.
• Repair of Stomal retraction often require laparotomy.
• Stenosis can be
repaired locally or laparotomy.
• End-stoma Prolapse
local repair
Laparotomy (recurrent Prolapse and , a
Parastomal hernia)
• Loop-stoma Prolapse :local revision to an end-stoma.
• Peristomal fistula needs resection
• Treatment of chemical dermatitis : cleaning the damaged
skin, the use of barriers, and a properly fitting stoma
management system.
5. Clostridium difficile Colitis
Etiology
• C. difficile colitis is an inflammatory bowel disease
• 90% have received antibiotic therapy and .
Intensive care ands; impaired host immune
defense .
Presentation and Diagnosis
• Watery diarrhea , abdominal cramps and anorexia,
abdominal tenderness, dehydration, tachycardia,
and a raised leukocyte
• Pseudomembranous develops in 40% of patients
who are significantly symptomatic.
• ELISA for detection of toxin A or B in stool .
Endoscopy .
• Toxic megacolon may develop. Sigmoidoscopy
shows pseudomembranes in 90% cases.
 Treatment
• Prevention : Judicious use of antibiotics, use of
disposable gloves and single-use disposable
thermometers,
• Medical treatment
Some patients respond to discontinuation of
antibiotics .
Vancomycin is given orally or as an enema, or
Metronidazole is given orally or IV for 2 weeks.
• Surgical intervention in colonic perforation and
toxic megacolon, Failure of medical therapy, the
presence of systemic toxicity, adynamic ileus,
and an immunocompromised state . The
procedure of choice is total abdominal colectomy
and ileostomy.
6. Anastomotic Leak
Etiology
• Numerous factors can cause or are associated
with an increased risk for anastomotic leak.
• The level of the anastomosis in the GI tract .
• Adequate microcirculation at the resection margin
• Construction of a water-tight and airtight
anastomosis is essential.
• Local sepsis, Emergency bowel surgery, Obesity,
Steroids
 Presentation and Diagnosis
• The early warning signs of anastomotic leak are
tachycardia, malaise, fever, abdominal pain, ileus,
localized erythema around the surgical incision,
and leukocytosis ,bowel obstruction ,
pneumaturia, fecaluria, and pyuria.
• Sepsis is a prominent feature of anastomotic
leakage and results from diffuse peritonitis or
localized abscess, abdominal wall infection, or
contamination of a sterile site with intestinal
contents.
 Treatment
• prevention : In emergencies,
immunocompromised, and nutritionally depleted
patients and in the presence of fecal peritonitis,
significant bowel dilation, and edema, an
anastomosis is best avoided .
• Mechanical and chemical bowel preparations
• Construction of an anastomosis requires :
1.Adequate exposure, gentle handling of tissues,
aseptic precautions,
 2.Adequate mobilization
  3.Correct technical placement of sutures or staples
  4.Matching of the lumens of the two organs
  5.Preservation of blood supply to the ends
• Once an anastomotic leak is suspected or
diagnosed:
• resuscitation is started immediately
• Oral intake is stopped and NG tube is placed .
• Infected surgical wounds are opened, and any
abdominal wall abscesses are incised and drained.
Reoperation is indicated if there is diffuse
peritonitis, intra-abdominal hemorrhage,
suspected intestinal ischemia, major wound
disruption, or evisceration.
• Abscesses
7. Intestinal Fistula
Etiology
• GI fistulas are most commonly iatrogenic.
Presentation and Diagnosis
• leakage of intestinal contents .
• Anatomically, the fistula may originate from the
stomach, duodenum, small bowel (proximal or
distal), or large bowel.
internal fistula,
external fistula.
• Physiologically:
low output (<200 mL/24 hr),
moderate output (200-500 mL/24 hr),
and high output (>500 mL/24 hr).
• The ileum is the site of the fistula in 50% of high-
output fistulas.
• Sepsis is a prominent feature of postoperative
intestinal fistulas and is present in 25% to 75% of
cases.
• hypovolemia and dehydration, electrolyte and
acid-base imbalance, loss of protein and trace
elements, and malnutrition.
• Skin manifestation.
 Treatment
1. Conservative management
• Intravascular volume is restored and the
electrolyte imbalance is corrected.
• Oral intake is stopped & TPN must be started
• Broad-spectrum IV antibiotic therapy is started.
• Accurate measurement of output .
• Fistulogram, contrast enema, Cystoscopy, GI
endoscopy, CT
• 60% to 90% of will close spontaneously .
2. Definitive surgical intervention.
 References
 Schwartz: Principles of Surgery 8th ed
 Sabiston: Textbook of Surgery, 18th ed
 ACS Surgery: Principles & Practice, 6th ed
 UpToDate 16.3
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