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Q: For Crabcakes-ga Only ( Answered 5 out of 5 stars,   1 Comment )
Subject: For Crabcakes-ga Only
Category: Health > Conditions and Diseases
Asked by: nancylynn-ga
List Price: $2.00
Posted: 19 Sep 2006 13:02 PDT
Expires: 19 Oct 2006 13:02 PDT
Question ID: 766684
Hello crabcakes!

What could be the possible source of off-and-on pain (pain, "not
cramping") in the lower left abdomen of a dialysis patient?

The patient is not running a fever and is able to pass urine (no pain
during urination), so this doesn't seem to be the onset of peritonitis
or kidney stone -- then again, maybe it is?

Any possible causes you could list would be appreciated.

Clarification of Question by nancylynn-ga on 19 Sep 2006 13:11 PDT
Oops, to clarify: the pain began in the lower left back then moved to
lower left ab.

The patient isn't vomiting or having diahharea; so no overwhelming
signs of appendicitis or a gallbladder problem. His potassium levels
tested high a week ago, and so he has cut back on potassium intake.

Request for Question Clarification by crabcakes-ga on 19 Sep 2006 17:05 PDT
Hello Nancylynn,

   I've seen your question and appreciate your patience. I will be
away from my desk for a few hours, but after that will devote my
attention to your question!

  Sincerely, Crabcakes

Clarification of Question by nancylynn-ga on 19 Sep 2006 18:27 PDT
Please don't rush, no need.

He isn't in constant pain; it comes and goes. (I assure you, if things
seemed dire, we would have gone to ER by now :)

Thanks again,
Subject: Re: For Crabcakes-ga Only
Answered By: crabcakes-ga on 20 Sep 2006 22:27 PDT
Rated:5 out of 5 stars
Hello Nancylynn,

   Actually, this does sound like it could be a kidney stone; one that
is passing from the kidney through the ureters. Kidney stones can be
present in one ureter and not the other, hence the patient can urinate
without pain in the urethra.  Since a dialysis patient is already on
restricted fluids, the kidneys produce a more concentrated urine.
Concentrated urine contains higher levels of salts, such as uric acid
and calcium oxalate. When the salts can no longer de dissolved in the
urine, they produce crystals, commonly called kidney stones. Some
patients pass very small salt crystals, that look like sand or grit,
but can cause an inflammatory type pain as the pass through the
urinary tract.

   ?It is estimated that between 5 and 13% of all dialysis patients
will develop symptomatic renal calculi and many more asymptomatic
calculi. Many of the stone-forming dialysis patients will have
recurring stone disease with one study finding an 83.3% recurrence
rate. Conclusions: Since dialysis patients have a wide range of urine
output, the clinician should be alert to the possibility of stone
formation. We recommend yearly ultrasound examinations on all dialysis
patients as well as citrate and magnesium supplements with careful
follow-up of laboratory results and urine electrolytes. We also
recommend careful follow-up of all patients on aluminum-hydroxide
phosphate binders as they are predisposed to form Al-Mg-urate stones.
For those dialysis patients that form renal calculi, watchful waiting
and symptomatic treatment is recommended since almost all patients
will spontaneously pass their stones.?

   ?A kidney stone develops when substances in urine form crystals
that stick together and grow in size. In most cases, these crystals
are removed from the body by the flow of urine, but they sometimes
stick to the lining of the kidney or settle in places where the urine
flow fails to carry them away. These crystals may gather and grow into
a stone, ranging in size from a grain of sand to a golf ball.

Most stones start in the kidney. Some may travel to other parts of the
urinary system, such as the ureter (the tube leading from the kidney
to the bladder) or bladder, and grow there. The most common types of
kidney stones are calcium stones, uric acid stones, struvite stones
and cystine stones.?

   "Symptoms of kidney stones can present as ?severe pain, which
usually starts suddenly and may last from minutes to hours, followed
by long periods of relief. Kidney stone pain usually starts in the
kidney or lower abdomen and later may move to the groin.?

?Medical interventions include: 

For calcium stones, the doctor may prescribe thiazide diuretics or
phosphate-containing preparations. Additionally, in hyperparathyroid
patients, removal of all or part of the parathyroid glands located in
the neck helps prevent further stone development.

For uric stones, the doctor may prescribe allopurinol and a medicine
to keep the urine alkaline.

For struvite stones, the doctor will monitor the urine for bacteria on
a regular basis. Additionally, if struvite stones cannot be removed,
the doctor may prescribe acetohydroamic acid (AHA). AHA is used with
long-term antibiotics to prevent the infection that leads to stone

For cystine stones, the doctor may prescribe Thiola. This medication
helps reduce the amount of cystine in the urine.?

 ?A kidney stone may be as small as a grain of sand or as large as a
pearl, and some are as big as golf balls. They may be smooth or
jagged, and are usually yellow or brown.?

   ?Diet - it is thought in patients predisposed to stone formation,
that low fluid intake, or more specifically, production of
concentrated urine is more likely to result in stone formation.
Specific excesses of animal fat may predispose to uric acid stones,
and leafy vegetables possibly to oxylate stones.?

?This pain usually results from a calculus that has impacted in the
ureter, and is therefore obstructing the urine flow from the kidney,
resulting in back pressure and swelling of the affected kidney.
The pain may be colicky and intermittent. Stones in the kidney may be
associated with a similar pain, but less severe in nature than with
stones in the ureter.
Ureteral stones that lodge near the distal end of the ureter, i.e. in
the ureter as it is passing into the bladder wall may cause severe
urinary frequency and urgency in addition to "renal colic".

Patients may also experience microscopic or macroscopic haematuria
(blood in urine).

If infection is present with or without obstruction, there may be
fever in addition to the pain.?

How Does Dialysis Work?
?With kidney failure, the body?s electrolytes get disturbed (some too
high and some too low). This can be very bad for the heart and other
others. With dialysis, we add some electrolytes and remove others and
in the end we hope to balance everything out. In order to do this, we
have to make sure the dialysate has the right concentrations of
electrolytes. When the blood goes through the dialyzer, the
electrolytes will go back and forth until they roughly the same

How Does Hemodialysis Treat High Blood Pressure and Swelling?
With kidney failure, the body cannot get rid of extra salt and fluids.
This can make your blood pressure rise and your body swell (called
edema). Dialysis helps correct by removing that extra salt and fluid
(typically 5-10 pounds worth at time).

The dialyzer machine applies pressure to the blood forcing the salt
and water out of it while leaving the red blood cells and other large
stuff behind. This squeezed fluid is then added to the dialysate and
thrown out. With the extra fluid gone, the blood pressure can

Other lesser possibilities:

Bowel Obstruction:
   ?The presentation of intestinal obstruction varies depending on the
stage and location of obstruction. Generally speaking, the higher up
the obstruction, the more severe the symptoms. Vomiting is an almost
universal symptom, though in lower bowel obstruction patients may have
only anorexia and nausea. The pain from obstruction is usually severe
at onset, caused by intestinal peristaltic waves attempting to
overcome the blockage. Patients will show worsening signs of reduced
intestinal peristalsis: decreased flatulence, increased cramping, and
abdominal distention. Plain radiographs will reveal dilated loops of
bowel. Common causes of obstruction are adhesions, incarcerated
hernias, intussusception, volvulus, and colonic carcinoma.
Strangulation of the bowel can occur with obstruction due to vessel
occlusion and lead to gangrene.?

Left Abdominal Pain
?Left lower quadrant (LLQ) pain indicates diverticulitis in 70% of
patients with this condition in the Western world.19 Patients with
this pancolonic process present very similarly to those with
appendicitis?with a few noteworthy exceptions, such as more pronounced
changes in bowel habits. Fever and leukocytosis ar e more prominent in
diverticulitis, while one often sees anorexia, vomiting, and nausea in
appendicitis. Initial pain with diverticulitis is usually hypogastric
rather than epigastric and radiates to the left iliac crest or
suprapubic area. Patients suffering from an acute attack of
diverticulitis probably have experienced this type of pain before; if
elicited in the history, this information can thus give a good
diagnostic clue.

   Because of the bilateral nature of the renal and reproductive
systems, pain arising from disease pathology of these systems may
manifest on either side or as general abdominal pain. Kidney stones
usually become symptomatic as they exit the kidney and enter the
ureter; patients will complain of severe, paroxysmal pain, the
location and radiation of which depend on where the stone is at
presentation. Renal colic pain commonly refers to the groin, and
patients will most likely writhe around on the bed, finding it almost
impossible to lie still. The majority of patients will present with
hematuria as the main laboratory value of diagnostic importance.
Although simple radiographs may show some stones, CT is the gold
standard for diagnosis."

   You have ruled out peritonitis, and it certainly does not sound
like it from the following symptoms:
?Peritonitis may cause a patient to try to lie strictly immobile,
often with knees bent. Pain from peritonitis becomes more diffuse as
the infection spreads away from the originating organ. Patients will
generally be febrile, tachycardic, and hypotensive, and abdominal
examination will reveal a diffusely tender abdomen, even with gentle

   You say the pain is not a cramping pain, and the patient has no
diarrhea or nausea, so it probably is not gastroenteritis.
?Gastroenteritis can cause abdominal pain, especially cramping, along
with diarrhea, nausea, and vomiting. Knowledge of recent exposure and
illnesses within close contacts or the community can help lead to this
diagnosis. Most cases are self-limiting, but special concern and
treatment may be necessary for immunocompromised and elderly

Other Possibilities for Left Lower Quadrant Pain
?Testicles, inguinal hernias, prostate?
?Sigmoid colon - constipation, obstruction, gas, volvulus (a twisted bowel)
 Left ureter - stone, infection?

Very Rare: Psoas Abcess
?Most commonly, a psoas abscess results from a tuberculous abscess of
the lumbar vertebra that tracks from the spine inside the sheath of
the psoas muscle. Other causes include extension of renal sepsis and
posterior perforation of the bowel.
Patients present with a tender swelling below the inguinal ligament.
They are usually apyrexial. The condition may be confused with a
femoral hernia or enlarged inguinal lymph nodes.? ?Apyrexial? means
there is no fever.


Ethylene oxide reaction

  Since this patient would have different symptoms, It's unlikely this
is the problem, but found it interesting.
?A 45-year-old woman on hemodialysis without significant problems for
6 years developed acute onset of anxiety, shortness of breath, and
abdominal pain within minutes of initiating her hemodialysis
treatment. Her blood pressure was stable throughout the episode. The
treatment was discontinued and she was admitted to the hospital.
Routine blood chemistries were unremarkable except for mild
eosinophilia (5%). An ethylene oxide reaction was suspected.?

I hope this has helped you! Please don't hesitate to ask for
clarifications, if I have missed the  mark!  :-)

SIncerely, Crabcakes

Search Terms
LLQ + intermittent pain
LLQ + pain + differential diagnosis
Renal calculi + dialysis
Kidney stones + dialysis patients
ethylene oxide reaction + dialysis
nancylynn-ga rated this answer:5 out of 5 stars and gave an additional tip of: $15.00
Great work! Very helpful - thank you!

Subject: Re: For Crabcakes-ga Only
From: crabcakes-ga on 21 Sep 2006 10:17 PDT
Thank you for the stars and very generous tip!
Sincerely, Crabcakes

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