A Large Bladder Stone in a Young Individual

Figure 1: Impression of X-ray was VESICAL CALCULUS WITH SMALL ATROPHIC LEFT KIDNEY

Investigations

The patient had undergone complete blood count in which all the parameters were normal. He has undergone pancreatic function tests in which blood glucose came out to be normal. He has undergone the screening for HIV ABS, HCV ABS, and HBSAg, which came out to be negative.

He has also undergone renal function tests in which blood urea and creatinine was done which came out to be under normal range.

The patient has undergone XRay in which there is presence of radio opaque calculus in the pelvic cavity in the midline measuring 30 mm into 20 mm in size.

The right kidney was faintly opacified with normal nephrographic phase with prompt excretion of contrast in PCS.

The right pelvicalceal system was normal.

The left kidney was not opacified. And on ultrasound correlation it came out to be small atrophic left kidney. Left ureter was also not opacified.

Normal filling and evacuation of urinary bladder is seen.

Impression of X-ray was VESICAL CALCULUS WITH SMALL ATROPHIC LEFT KIDNEY.

The patient has also undergone ultrasound which states liver was normal in size and outline, it shows normal homogenous echo texture. The ultra scan done for other abdominal visceral does not show any deviation from normal morphology in any of the visceral except kidney.

Right kidney came out to be normal in size and position. Cortical outline, echogenecity and corticomedullary differentiation were normal. Though tiny concretions were seen in the middle and lower calyces. No evidence of any right hydronephrosis seen.

Left kidney was relatively small in size but normal in position. Corticomedullary differentiation Was partially lost. A calculus measuring 4 mm was seen in middle calyx along with few concretions. Mild hydroureteronephrosis changes were seen with parenchymal thinning. Distal ureter was obscured by excessive bowel gases.

No evidence of abdominal lymphadenopathy or ascitis was seen. Few internal echoes were noted suggesting hypertrophy of mucosal layer of bladder indicating cystitis. Patient also undergone urine examination which showed presence of pus cells, also culture was done which showed presence of E. coli indicating urinary tract infection.

Gross Physical Examination

Physical examination of the stone revealed that it was 30 mm x 20 mm in size ,25 gms In weight, black in color, and oval in shape. The stones surface was rough and irregular with visible crystal formations. The stone was crushed in mortar and was used further for biochemical examination to identify its constituents.

Biochemical Examination

The presence of uric acid in the stone was confirmed using a biochemical test where a sample of stone was crushed and treated with potassium hydroxide (KOH) and phosphotungstic acid (PTA). The addition of phosphotunstic acid resulted in appearance of blue color that confirmed that uric acid was the main constituent of this stone. This test is commonly used to detect the presence of uric acid in kidney stones. while all other tests including carbonate, calcium, magnesium, oxalate and cysteine were negative.

Provisional Diagnosis

The provisional diagnosis in this case is primarily urinary bladder stone which occurred mainly due to dietary factors and which also lead to backflow of urine leading to urinary tract infection and further hydronephrosis of left kidney leading to atrophy and shrunken left kidney which became non functional. Further biochemical examination lead to the conclusion that it was a uric acid bladder stone.

Differential Diagnosis

Primary gout was ruled out because there was no family history.

Renal abscess was ruled out as no abscess was seen in imaging.

Renal artery aneurysm will have flank pain but also along with pulsatile mass which was not present in this case.

Appendicitis causes pain in lower abdomen but the pain is usually in lower quadrant which was not in this case.

Pancreatitis, cholecystitis, mesentric ischaemia causes pain in upper abdomen along with nausea and vomiting which was not present in this case so ruled out.

Renal Cell Carcinoma: Can cause flank pain and hematuria, but imaging will show a mass. Renal Vein Thrombosis: Can cause flank pain and hematuria, but imaging will show a thrombus.

Splenic Abscess: Can cause left upper abdominal pain, but imaging will show an abscess. Symptomatic Abdominal Aortic Aneurysm (AAA): Can cause abdominal pain, but pain is typically associated with a pulsatile mass.

Renal Artery Embolus: Can cause flank pain and hematuria, but imaging will show a thrombus.

Gastrointestinal Foreign Bodies: Can cause abdominal pain, but pain is typically localized to the area of the obstruction.

Ileus: Can cause abdominal pain, but pain is typically associated with nausea and vomiting.