On a lonely morning when you are sipping coffee ☕and peeking at your tweeps🐦, you get a consult for acidosis
Wanna know what do #GI #Urology #Nephrology have in common?
#nephtwitter #urotwitter #medtwitter #FOAMed #theskeletonKG #NSMCinternship
Read our post @RenalFellowNtwk
Wanna know what do #GI #Urology #Nephrology have in common?
#nephtwitter #urotwitter #medtwitter #FOAMed #theskeletonKG #NSMCinternship
Read our post @RenalFellowNtwk
1/ A 55 year old man👨🏻 with urothelial cancer
✂️transurethral tumor resection, radical cystectomy & neobladder reconstruction 3 mons ago
✂️B/L PCNs & ileostomy - postop (urinary and bowel leak)
✂️transurethral tumor resection, radical cystectomy & neobladder reconstruction 3 mons ago
✂️B/L PCNs & ileostomy - postop (urinary and bowel leak)
2/ He was admitted🏥 6 days ago due to increased ostomy output💩🌊 (>4L/day) & dehydration, and has been receiving NS 💧@ 150mL/h
His BMP is-
His BMP is-
3/ What do you want to do next?
4 / Right, all of the above 👍🏻.
Then, you find the following gynormous yet interesting data📚
Then, you find the following gynormous yet interesting data📚
5/ Now that you have all the information, what do you think is the cause of his acidosis?🤔
6/ Ans: C and D. But, how often do you see a HCO3 of 10🤔
Let's review NAGMA Ddx🙌🏻
What mnemonic do you like?
Let's review NAGMA Ddx🙌🏻
What mnemonic do you like?
7/ My favourite...
8/ What is a neobladder?
💥One of the common urinary diversion procedures performed after radical cystectomy, where bladder is constructed using an intestinal segment, commonly ileum💥
💥One of the common urinary diversion procedures performed after radical cystectomy, where bladder is constructed using an intestinal segment, commonly ileum💥
9/ Cool😎.. But,why would it cause acidosis?
Bowel has many exchangers and channels whose sole purpose is absorption is electrolytes and water. You made it a bladder.
#cantteacholddognewtricks
Bowel has many exchangers and channels whose sole purpose is absorption is electrolytes and water. You made it a bladder.
#cantteacholddognewtricks
10/ ⭐Apical Cl/HCO3 exchanger🌟 plays a major role is secretion of HCO3 into Ileal lumen.
🔁Exchange of H & Cl in urine with Na & HCO3 from blood via Cl/HCO3 exchanger ➡️➡️ hyperchloremic hypokalemic metabolic acidosis.
🔁Exchange of H & Cl in urine with Na & HCO3 from blood via Cl/HCO3 exchanger ➡️➡️ hyperchloremic hypokalemic metabolic acidosis.
11/ Quiz time🤪
There is a similar cell in the kidney. Do you remember what it is?
There is a similar cell in the kidney. Do you remember what it is?
12/ You got it right✔
It is the interrelated cells of the collecting duct. Kidneys are😎 beans, eh..
It is the interrelated cells of the collecting duct. Kidneys are😎 beans, eh..
13/
📍Ileal neobladder➡️fatigue, lethargy, dehydration
📍Absorption of creatinine, NH4, urea ➡️increased burden on liver and kidneys
💥neobladder are discouraged in liver and kidney disease patients💥
📍Ileal neobladder➡️fatigue, lethargy, dehydration
📍Absorption of creatinine, NH4, urea ➡️increased burden on liver and kidneys
💥neobladder are discouraged in liver and kidney disease patients💥
14/ Don't worry.. there's a happy ending!
Mucosal atrophy overtime▶️decreases electrolyte imbalances.
Meanwhile, hydration💧helps.
🚫 urinary obstruction & stasis --> worsen and/or prolong acidosis🚫
Mucosal atrophy overtime▶️decreases electrolyte imbalances.
Meanwhile, hydration💧helps.
🚫 urinary obstruction & stasis --> worsen and/or prolong acidosis🚫
15/ Does it matter how much ileum is taken?
16/ Yes it does! Have you heard of Short Bowel Syndrome?
Thankfully, only a maximum of 60 cm of ileum is needed for neobladder construction.
💥Always look at the operative report💥
Thankfully, only a maximum of 60 cm of ileum is needed for neobladder construction.
💥Always look at the operative report💥
17/ Back to our number 🔢📈world!
What do you think of his UAG of 4?
What do you think of his UAG of 4?
18/ Ans: Both the above.
Electrolyte shifts🔄via Ileal mucosa into blood stream➡️Urine in neobladder unreliable.
UAG of 4 is not reliable.
➕UAG= 20 to 90
➖UAG= -20 to -50
More details in our prior @RenalFellowNtwk post @TheSkeletonKG @prakashneph
renalfellow.org/2019/10/03/the…
Electrolyte shifts🔄via Ileal mucosa into blood stream➡️Urine in neobladder unreliable.
UAG of 4 is not reliable.
➕UAG= 20 to 90
➖UAG= -20 to -50
More details in our prior @RenalFellowNtwk post @TheSkeletonKG @prakashneph
renalfellow.org/2019/10/03/the…
19/ What happened to our patient?
He received 💉IV NaHCO3 and hydration. He was discharged home on NaHCO3💊 tablets. His BMP at discharge was normal. 😊😊😊
He received 💉IV NaHCO3 and hydration. He was discharged home on NaHCO3💊 tablets. His BMP at discharge was normal. 😊😊😊
20/ Take home points-
📌UAG is not reliable with urinary diversion systems
📌Apical Cl-/HCO3- exchanger in the ileal tissue ➡️ acidosis
📌Bicarbonate therapy is the🗝
📌UAG is not reliable with urinary diversion systems
📌Apical Cl-/HCO3- exchanger in the ileal tissue ➡️ acidosis
📌Bicarbonate therapy is the🗝
