1968 Where Did the Problem Stem From? An Unusual Case of Hematemesis and Hematuria

Abstract

INTRODUCTION: Accidental foreign body ingestion is a common problem encountered in emergency departments. Most of the time foreign bodies pass through the GI tract without any sequela; however, perforation can occur in up to 1% of cases. Here we discuss a case of a perforated viscus presenting with hematemesis and hematuria. CASE DESCRIPTION/METHODS: A 61 year old woman with type 2 diabetes presented to the emergency room with new onset abdominal pain, hematemesis and hematuria an hour after eating dinner at home. A CT scan was obtained on admission and was notable for periduodenal lymphadenopathy, thickening of the duodenal wall, and dense material in the right renal calyx. Upper endoscopy showed a clot in the duodenal sweep, which was unroofed to reveal a sharp foreign body that was embedded in the small bowel wall and protruded 1.5 cm into the lumen. The foreign body was removed with a snare and the mucosal defect was closed with an endoclip. On gross examination, the foreign body measured 6 cm in total length and had a dried stem-like appearance. A CT scan was repeated to evaluate for suspected perforation, which demonstrated gas around the first and second portions of the duodenum and right-sided hydroureter. The patient was managed conservatively with antibiotics, with resolution of abdominal pain. However, due to persistent hematuria, patient underwent a renal angiogram, which showed a right renal artery aneurysm for which the patient required angioembolization, cystoscopy for evacuation of clots in the bladder, and right uretral stent placement. The patient did not have any further hematemesis or hematuria, and pathology of the foreign body returned as plant-based material suspected to be a dried stem. DISCUSSION: In cases of GI foreign bodies, the culprit sharp objects are often chicken or fish bones, paper clips, or dental tools. In this patient, we report a case of plant matter causing viscus perforation through the duodenum and into the right kidney, presenting as simultaneous hematemesis and hematuria. Plant matter may not appear on radiographic images and might be missed on preliminary radiographic evaluations. Furthermore, this case highlights the anatomic proximity of the duodenum to the right kidney, specifically the renal calyx. Simultaneous presentation of abdominal and urologic symptoms may suggest a duodenal source. This should cue endoscopists to pay extra attention to the duodenal sweep, which can be overlooked during endoscopy.