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Year : 2000  |  Volume : 10  |  Issue : 1  |  Page : 33-34
Case report: Spontaneous intraperitoneal extrusion of vesical calculus


Dept of Radiodiagnosis, Kasturba Medical College, Manipal, Karnataka, India

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Keywords: Urinary Bladder, Calculus, Peritoneum

How to cite this article:
Lakhar BN, Shetty DS. Case report: Spontaneous intraperitoneal extrusion of vesical calculus. Indian J Radiol Imaging 2000;10:33-4

How to cite this URL:
Lakhar BN, Shetty DS. Case report: Spontaneous intraperitoneal extrusion of vesical calculus. Indian J Radiol Imaging [serial online] 2000 [cited 2019 Sep 20];10:33-4. Available from: http://www.ijri.org/text.asp?2000/10/1/33/30630
Vesical calculi vary in number, size and position. They may be situated within the lumen or in diverticula and rarely in a vesicovaginal fistula. We have recently observed a patient with spontaneous intraperitoneal extrusion of a vesical calculus, which was situated, in the right iliac fossa.


   Case Report Top


A 45-years old man with a history of acute retention of urine for two days was examined in the urology outpatient. There was a past history of surgery for a large vesical calculus. There was no history of urinary tract infection, hematuria or loin pain. On examination, the general condition was satisfactory. Per-rectal examination revealed an enlarged prostate. The patient was referred for ultrasound. US revealed an echogenic area, 3.0x2.5cm in size with posterior shadowing and surrounding fluid and septations, in the right iliac fossa. The gall bladder was distended normally and there were no calculi. Both kidneys showed normal morphology and no calculi. The pelvis showed evidence of calculi in the distended urinary bladder. A plain radiograph of the abdomen revealed a solitary opacity in the right iliac fossa and three overlapping opacities in the pelvis in the midline [Figure - 1].

Intravenous urography (IVU) was performed and it showed normally functioning kidneys. The right ureter was medial to the calculus-like opacity in the right iliac fossa. The pelvic opacities were seen to be in the opacified urinary bladder. A barium meal follow-through examination was performed to rule out the possibility of an enterolith in the right iliac fossa. The opacity was seen to lie outside the bowel lumen [Figure - 2].

CT showed a hyperdense lesion in the right iliac fossa (400 HU) with surrounding fluid. On contrast enhanced scans, there was marginal enhancement of the wall of the collection surrounding the opacity [Figure - 3]. Three calculi were seen in the urinary bladder. The appearance and shape of these opacities were similar to the opacity in the right iliac fossa (400 HU).

With the above clinical and imaging findings, the possibility of vesical calculi and intra-abdominal calcification was considered and the patient was taken up for surgery. At surgery the opacity in the right iliac fossa was intraperitoneal in situation and surrounded by purulent material. The gall bladder, small intestine and appendix were intact. Cystolithotomy was performed and three vesical calculi were removed. The urinary bladder wall was intact. The vesical calculi appeared identical to the calculus-like opacity in the right iliac fossa. The triple phosphate composition of the vesical calculi matched that of the opacity in the right iliac fossa suggesting a common origin.


   Discussion Top


Calculi situated outside the urinary bladder are usually located in diverticula and have a dumb-bell shape with one end lodged in the diverticulum and the other projecting into the lumen of the bladder [1]. A common cause of focal calcification in the right lower quadrant is an appendicolith. Appendicolith are oval and laminated [3]. In our case the appendix was normal in position and morphology. The possibility of an extruded enterolith due to obstruction leading to ischemia and perforation of the small bowel [2] was ruled out since the small intestine was normal and the mineral composition of ileal enteroliths is predominantly mineral salts. An ectopic gallstone was ruled out since the gall bladder was normal and most gallstones contain choleic acid.

In conclusion we could not confirm the origin of the right iliac fossa calculus on imaging. It could have been from the gastrointestinal, biliary or urinary tracts. We had to rely on the biochemical nature of the calculus, which matched that of vesical calculi. Extrusion of vesical calculus into the extraperitoneal space is a known entity. However the precise mechanism of intraperitoneal extrusion of vesical calculus is not known and has not been reported in literature.

 
   References Top

1.John L.Emmett, David M.Witten, Clinical Urography. 3rd edn. W.B.Saunders Company, Philadelphia 1971.   Back to cited text no. 1    
2.King P.M, Bird, D.R. and Eremin O. Enterolith obstruction of the small bowel. J.R. Coll.Surg.Edinb. 1985, 4:269-270.   Back to cited text no. 2    
3.Ronald L.Eisenberg. Gastrointestinal Radiology, 2nd edn. J.B.Lippincott Company, Philadelphia 1990.   Back to cited text no. 3    

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Correspondence Address:
Bhushan N Lakhar
Dept of Radiodiagnosis, Kasturba Medical College, Manipal-576 119, Karnataka
India
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Source of Support: None, Conflict of Interest: None


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    Figures

[Figure - 1], [Figure - 2], [Figure - 3]

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