A 26-year-old unemployed man presented with abdominal pain.
He also complained of chills and rigor for one day, and subjectively scanty urine output for 3 days. On examination, abdomen was soft with normal active bowel sound, and bladder was not palpable. There was no loin tenderness. With a clinical diagnosis of urinary tract infection, he was admitted to medical ward. Bediside USG showed mild bilateral hydronephrosis and hydroureter. For unknown reason, he refused foley insertion. Blood test showed Hb 14, creat 500, urea 36, K 6.7, pH 7.2 with BE -16. Plain CT abdomen was done and a striking feature was shown.
An ICU physician asked one question to confirm his clinical suspicion. After discussion about the diagnosis, he agreed for foley insertion.
With the help of the image, what will you suspect?
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The CT shows grossly thickened bladder wall with diminished urine volume. The gas bubble in wall is rather non-specific and may represent recent instrumentation. On direct questioning, he admiited history of ketamine abuse since teenage. He had been admitted into medical ward of another hospital one day before, but he requested DAMA because he disliked the foley.
After foley insertion, he ran into post-obstructive diuresis, and renal replacement therapy was not required. He was taken over to the urology ward after stabilization.
In the past 2 months, the author had managed three patients of late-twenties who presented as acute renal failure related to Ketamine abuse. They all demonstarted grossly abnormal urinary bladder and variable involvement of the upper urinary tract. Clinicians are reminded of the upsurge in frequency of ketamine-related urological manifestations in Hong Kong.
Suggested reading
1. Chu PSK, Ma WK, Wong SCW, et al. The destruction of the lower urinary tract by ketamine abuse: a new syndrome? BJU International 2008; 102: 1616-1622.
2. Chu PSK, Kwok SC, Lam KM, et al. "Street Ketamine" – associated bladder dysfunction: a report of ten cases. Hong Kong Med J 2007; 13(4): 311-313.