What is Steatorrhea - Symptoms, Causes and Treatment

Definition: What is Steatorrhea?

Steatorrhea (pronunciation: stē′ətərē′ə) came from the Greek words “stear” meaning “ fat,” and “rhoia” meaning “flow” [1]. Steatorrhea refers to elimination of fat in the stool basically because the intestines cannot absorb it well. It is further described as foul-smelling, pale, pasty, spongy, and bulky. This is the third most common cause of chronic diarrhea [2, 3, 4].

 

Pictures: What does Steatorrhea Look Like?

 

                                                            Image Source: steatorrhea.org


                                           Steatorrhea caused by Orlistat (drug for weight loss)
                                                          Image Source: steatorrhea.org

Causes of Steatorrhea

 

Liver Diseases

Hepatitis, Primary Biliary Cirrhosis, Extrahepatic Biliary Obstruction

Conjugated bile salts are needed for digestion of fat. Conjugation happens in the liver. If there is disease of the liver such as those mentioned above, there will be deficient bile salts and fat malabsorption. Eventually, cirrhosis (chronic liver inflammation, cell degeneration, tissue thickening) develops, causing steatorrhea.

 

Short Bowel Syndrome

Short bowel syndrome is mostly associated with surgical removal of the ileum (the third part of small intestine). This also occurs in diseases wherein a large portion of the intestine does not serve its purpose, e.g. Crohn’s disease, radiation enteritis, chemotherapy. Bile acid salts should be reabsorbed in the small intestines but this becomes impaired in short bowel syndrome. This further results to malabsorption of fat [2].

 

Zollinger-Ellison Syndrome

Zollinger-Ellison Syndrome (ZES) is caused by gastrinoma, a tumor in the stomach. In ZES, there is an excess production of acid in the stomach. When pancreatic enzymes are exposed to this, they become inactivated. Lipase is a pancreatic enzyme that digests lipids or fats. If they become inactivated, there will be less absorption of fat, hence the steatorrhea [2, 5].

 

Intestinal Stasis

Stasis or dysmotility of the intestine can be caused by scleroderma or diabetes. If intestinal contents are not properly moved by peristalsis, bacterial overgrowth may develop. Normally, metabolism and deconjugation of bile acids happens in the large intestine but in this case, the bacteria metabolizes the bile acids early in the small intestine [2].

 

Parasitic Infections: Giardiasis, Isosporiasis, Strongyloidiasis

Giardiasis is caused by the parasite Giardia lamblia. The exact pathophysiology on how it induces steatorrhea is unknown but it most probably destroys the intestinal mucosa or deconjugates the bile salts. In every case of unexplained steatorrhea, giardiasis must be considered [5].

Isosporiasis, caused by Isospora belli, is usually seen among immunocompromised patients [6].
Half of patients with strongyloidiasis, most commonly caused by Strongyloides stercoralis, show no signs and symptoms. Acute infections involve the gastrointestinal and pulmonary systems while chronic infections involve integumentary and nervous systems [7].

These parasites damage the brush border of the intestines, inhibiting the absorption of fat and nutrients [8].

 

Foods and Drugs

  • The following are the foods and drugs known to cause steatorrhea:
  • Peanuts
  • Laxatives
  • Bile acid sequestering resins: Cholestyramine and Colestipol
  • Olestra
  • Liquid paraffin
  • Colchicine
  • Para-aminosalicylic acid
  • Antibiotics: Tetracycline and Neomycin [2]

 

Diagnosis of Steatorrhea

The patient comes into the clinic with a history of oily or greasy stools that are malodorous. It often leaves a stain in the toilet bowl. Associated manifestations include weight loss, bloating, and flatulence [2, 3].

Steatorrhea is quantitatively diagnosed by 72-hour collection of fat in the stool. This is the gold standard in identifying steatorrhea. The patient takes in 100 grams of fat per day and stool is collected every 24 hours for three days. Excretion of less than 7 grams per day is considered normal. 7-14 grams per day most likely suggests malabsorption syndrome although it is not definitive because mild to moderate diarrhea and ingestion of mineral oil or castor oil can also produce steatorrhea.

If fecal fat is more than 14 grams per day, there may be maldigestive or malabsorptive disease. Highest yield of steatorrhea is caused by severe pancreatic diseases like chronic pancreatitis or carcinoma of the pancreas. The levels may reach fecal fat of more than 35 g/day.

Qualitatively, steatorrhea can be diagnosed with the use of Sudan black stains. More than 80% of patients with true steatorrhea test positive for this. This is used as a screening test or if 72-hour fecal fat collection cannot be performed. It has the ability to differentiate malabsorption of triglycerides versus free fatty acids. However, it can only be useful if the patient has moderate to severe steatorrhea because it only correlates well with the 72-hour fecal fat collection if the value is more than 15 g/day [3, 5, 9].

 

Treatment of Steatorrhea

 

Restriction of Dietary Fat

In steatorrhea, there is excess fat in the stool, therefore the primary treatment is to lessen what is in excess. But restriction does not mean total cessation of fat intake because our body needs fat in order to function. In patients with pancreatic exocrine insufficiency, limitation to 20g of dietary fat is acceptable.

 

Supplemental Pancreatic Enzymes

If restriction of dietary fat is not possible or not effective, supplemental pancreatic enzymes (SPE) are necessary. To have a well-absorbed fatty meal, pancreatic lipase of 30,000 IU is generally required. The amount may be decreased for snacks. It is important to note that SPE should be taken during meals, not before or after, for maximal absorption.
When eating, secretion of gastric acid is stimulated. SPE is inactivated by gastric acid. Medications that control gastric pH is necessary to ensure effectiveness.

 

Supplementation of Fat-Soluble Vitamins

Fat-soluble vitamins (vitamins A, D, E, and K) are supplemented to all patients with chronic pancreatitis where steatorrhea or maldigestion is noted.

 

Medium-Chain Triglycerides

There are rare cases wherein SPE renders ineffectiveness. If this, plus weight loss and persistent steatorrhea occurs, medium chain triglycerides are given as supplements because they do not need lipase in order to be absorbed in the intestines, thus providing the patient fat-derived calories needed by the body [10].

 

Antibiotics

Antibiotics are given to patients whose steatorrhea is caused by bacterial overgrowth.

 

Bile Acid Sequesters

Cholestyramine is a bile acid sequester given to patients with steatorrhea if the cause is bile acid malabsorption [3].


References
  1. Mosby's Medical Dictionary, 8th edition, 2009. Retrieved from http://medical-dictionary.thefreedictionary.com/steatorrhea
  2. Paulman PM, Paulman AA, Harrison JD. Taylor's 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Lippincott Williams & Wilkins, 2006
  3. Cheifetz AS, et al. Oxford American Handbook of Gastroenterology and Hepatology, Oxford University Press, USA, 2011
  4. Brunzel NA, Fundamentals of Urine and Body Fluid Analysis, Elsevier Health Sciences, 2013
  5. DiMarino AJ & Benjamin SB, Gastrointestinal Disease: An Endoscopic Approach, 2nd edition, SLACK Incorporated, 2002
  6. http://emedicine.medscape.com/article/219776-clinical
  7. http://emedicine.medscape.com/article/229312-clinical
  8. Rose S, Gastrointestinal and Hepatobiliary Pathophysiology, Hayes Barton Press, 2004
  9. Humes HD, Kelley's Essentials of Internal Medicine, Lippincott Williams & Wilkins, 2001
  10. Wilson T, Nutrition Guide for Physicians, Springer Science & Business Media, 2009
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Mucus in Urine

Define Mucus

Mucus is a protein made up of fibers. Grossly, it is a slimy substance that is brought about by glands and mucous membranes. It can be normally present in our urine in very small amounts. However, it can be a sign of an underlying pathology.

Moreover, the mucus can give the urine a cloudy appearance wherein the degree of turbidity depends on the amount of the mucus and other factors that may be causing this opacity. Normal urine is supposed to be clear which can be amber or straw-colored.


Picture 1: Normal urine is clear which can be amber or straw-colored.



Picture 2: Mucus threads in the urine give off this cloudy appearance. What could this mean?
Image Source: healthtap.com

Mucus in Laboratory Urinalysis

Picture 3: Mucus Thread in the Urine
Image Source: medical-labs.net

Two forms of mucus appear in the urine: mucus threads and mucus corpuscles.
Mucus threads are groups of mucus fibers bundled together forming a pale, irregular, longitudinal fragments that are narrowed on one end. If there is too much mucus, mucus casts will be formed.

The second form of mucus in the urine is called mucus corpuscles which is similar with pus cells in appearance. This is because mucus corpuscles are the crooked version of mucus cells [1].

Reporting of the presence of mucus in the urine is based on its number. It is written as “rare,” “few,” “moderate,” or “many” in the urinalysis laboratory result. It can also be stated according to the power field, i.e. “per low power field (LPF)” or “per high power field (HPF)” [2].


Picture 4: Sample of Urinalysis Laboratory Result
Image Source: s58.photobucket.com

Sources of Mucus in Urine

Picture 5: The Genitourinary Tract of Female and Male
 Image Source: webmd.com

Most of the mucus in our urine comes from the linings of urinary bladder and urethra. The linings are made up of epithelial cells. These epithelial cells, in turn, make up the mucous membrane that secretes mucus for protection [2].

When a person urinates, a part of mucus comes along with urine and flows from the bladder to the urethra and out of your body. The mucus in the urine is not always visible by the naked eye because the refractive power of mucus and urine are almost the same [3].

Another source of mucus in urine is the source of the urine itself, the kidneys. Mucus contains a protein called Tamm-Horsfall protein or uromodulin. This protein is produced by the kidneys and it goes down with the urine through the ureter towards the urinary bladder into the urethra and out of the body [4].

For females, ovulation can also be a factor for you to see mucus threads in your urine. During ovulation, there is increased cervical and vaginal secretions that may flow together with the urine.

Picture 6: Cervical Mucus in the Urine
Image Source: wikihow.com

During menstruation, you may also notice that along with blood and endometrial fragments are mucus threads in the urine. This is normal.

Pathologic Causes of Mucus in Urine

Picture 7: Common Causes of Mucus in Urine
Image Source: buzzle.com

A. Urinary Tract Infection (UTI)

UTI is a common disease wherein foreign bacteria invade your genitourinary tract. More often than not, the bacteria love multiplying in the bladder because this is where the urine is stored. This gives you cystitis. If left untreated and becomes severe, it can advance up to the kidneys, resulting to pyelonephritis.

The bacteria disrupt the epithelium of the linings of your genitourinary organs, causing epithelial cells to shed off, hence the presence of mucus in the urine.

Because of this, the person suffering from UTI experiences pain upon urination, urinary frequency, urinary urgency, dribbling of urine, hypogastric pain, and/or lower back pain.

UTI predisposes women in pregnancy because the uterus compresses the bladder, giving less room for extra urine. The bladder becomes filled easily and the epithelium becomes more irritated. Moreover, pregnant women have more active secretions on their reproductive tract so the mucus comes along with the urine.

B. Sexually Transmitted Diseases (STD) or Sexually Transmitted Infections (STI)

STD/STI associated with the presence of mucus in the urine most commonly involves Gonorrhea and Chlamydia. Gonorrhea gives off a yellowish genital discharge while Chlamydia expresses a rather whitish discharge. Either ways, both make you shed off mucus in the urine.

Gonorrhea, Chlamydia, and other STDs/STIs are acquired if one does not practice safe sex. One simple way to prevent this is to wear condoms, or better yet, sexual abstinence is the key, especially if you do not know your sexual partner very well.

C. Irritable Bowel Syndrome (IBS)

IBS is an idiopathic (with unknown cause) disease wherein your bowel habits have been deviated from normal for 6 months or more. Aside from changes in the bowel habits, passage of mucus is also a manifestation of this syndrome [5].

The mucus comes from the intestine in this disease, not from any organs in the genitourinary tract.
The mixing of mucus does not occur inside the body because normally, there is no conduit between the genitourinary and gastrointestinal tracts that could make it possible for the mucus in the intestine to go directly into the urinary tract.

There is mucus in urine of IBS patients probably because the excess mucus from the stool gets mixed up with urine as it being passed out, especially if the person urinates and defecates at the same time. Considering the altered bowel habits of the patient, this is possible.

D. Ulcerative Colitis

Ulcerative colitis is an inflammatory bowel disease wherein there are patches of ulcers and erosions in the colon. This is where the excess mucus comes from and the disseminated ulcers cause the hallmark feature of this disease which is bloody diarrhea. Patients experience fecal urgency and pain in the lower quadrants of the abdomen.

There is mucus in urine in patients with ulcerative colitis probably because the excess mucus from the anus gets mixed up with urine as it being passed out, considering the fact that these patients have fecal urgency.

E. Urachal Cancer or Bladder Cancer

Urachal cancer refers to the presence of rapidly multiplying malignant cells in the urinary bladder. Several cases have revealed the presence of mucus in the urine. That is why physicians consider this as a differential diagnosis when there is persistent mucus in the urine.

F. Urinary Stone Disease

Like in urachal cancer, presence of mucus in urine is associated with urinary stone disease, especially nephrolithiasis (kidney stones). Other signs and symptoms include severe abdominal pain, back pain, and dark-colored and malodorous urine [6-10].

Treatment

  • For normal or physiologic causes of the presence of mucus in urine, there is no need to worry unless you have other manifestations that may be due to an underlying condition. If this is the case, it is better if you consult your doctor.
  • For pathologic causes of mucus in the urine, the following treatment and remedies may help you have that clear urine once again.
  • For UTI and STD/STI, have your doctor prescribe you with appropriate antibiotics.
  • For IBS, antispasmodics, antidiarrheals, anticonstipation, psychotropics, serotonin receptor agonists and antagonists, non-absorbable antibiotics, and probiotics may be prescribed by the gastroenterologist.
  • For mild to moderate ulcerative colitis, 5-ASA agents, corticosteroids, immunomodulators, and probiotics can be considered.
  • For severe ulcerative colitis, corticosteroids, anti-TNF therapy, cyclosporines, and surgery are the options for treatment.
  • For urachal cancer, chemotherapy, radiation therapy, or surgery may be necessary to get rid of the cancer.
  • For urinary stone disease, medications that can dissolve the stones will be useful. If this does not help, surgery will be the final option [5].

References
  • Das Gupta B, Urine Analysis, Butterworth
  • http://www.hopkinslupus.org/lupus-tests/screening-laboratory-tests/urinalysis/
  • Berzelius JJ, The Kidneys and Urine, Lea & Blanchard, 1843
  • Brunzel NA, Fundamentals of Urine and Body Fluid Analysis, 3rd edition, Elsevier Health Sciences, 2013
  • Papadakis MA & McPhee SJ, Current Medical Diagnosis and Treatment 2013, McGraw-Hill Lange, 2013
  • http://medicalhub.hubpages.com/hub/Mucus-in-Urine
  • http://www.healthwellnessbook.com/mucus-in-urine/
  • http://symptomstreatment.org/mucus-in-urine/
  • http://www.healthmedicine.co/mucus-in-urine/
  • http://symptomscausestreatment.com/mucus-in-urine-symptoms-causes-treatment.html
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How to get rid of - Dry, Cracked Skin on Feet

Compared to the skin covering the rest of our body, the skin on our feet is normally drier. This is because it lacks the sebaceous glands or oil glands that can keep it moisturized. To compensate for this, the skin on our feet relies on the sweat glands to at least prevent it from becoming extremely dry. However, there are conditions wherein the skin on feet becomes severely dry it becomes cracked [1].

Causes

  • Prolonged standing, walking, or running
  • Excessive physical activity that involves frequent movement of the feet
  • Back-open shoes that provide no protection to the sides of the feet
  • Improper foot care and hygiene
  • Obesity gives extra bearing to the already exhausted feet.
  • Prolonged water exposure removes the moisture off of your feet.
  • Soaps and cosmetic products containing harsh chemicals cause dryness and leave irritating substances on the skin. You think they help but it is actually the opposite. Gentle mild products are still better.
  • Dry skin is one of the signs of aging. As we age, the outermost layer of the skin called stratum corneum gets thicker, resulting to lessened skin cell turnover. Moreover, fats that serve as a cushion to our toes and heels become thinner, decreasing its protective purpose.
  • Deficiency of vitamin A, vitamin E, and essential fatty acids [omega-3, alpha-linolenic acid (ALA), and gamma-linolenic acid (GLA)] contributes to unhealthy skin.
  • Medical Conditions:
  • Diabetes involves poor wound healing. Moreover, high levels of blood glucose increase the number of microorganisms, making the infection more difficult to cure.
  • Athelete’s Foot (Tinea Pedis) is the most common fungal skin infection. The fungi cause your toes to feel burning and itching sensations. Physically, these fungi deprive your feet of the nutrients that they need to be kept healthy, causing them to dry and crack.


Check for more information on :
  • In Atopic Dermatitis (Eczema), Psoriasis, and other skin diseases, dry cracked skin is an inherent characteristic.
  • Thyroid Disease, in this case Hypothyroidism, contributes to skin dryness and cracking because depressed function of the thyroid gland leads to slow blood circulation. As a result, there are decreased nutrients and fatty acids that reach your feet. Additionally, the skin glands are also deprived of secretions needed to keep your skin hydrated.
  • Neuropathy, also connected with diabetes, is also called nerve damage. One good thing about pain is that it is protective. It tells you that your body is in danger. When you feel it, you find measures on how to avoid it and prevent it from doing further damage. In the case of neuropathy, you cannot feel the pain. When your feet are dried and cracked, you will not notice it until you see it. This might be dangerous because by the time that you notice it, it may be too late especially if the damage is already deep it has already caused severe wound infection. This is not good news to diabetics [2, 3, 4, 5, 6].

Signs and Symptoms 

  • Skin tightness
  • Skin dehydration
  • Shrunken skin
  • Itchiness
  • Appearance of fine lines
  • Formation of flakes
  • Scaling
  • Peeling
  • Redness
  • Bleeding fissures [7]
  •  

Home Remedies for Dry, Cracked Skin on Feet

  • One of the simple and best cures for dried cracked feet is to use moisturizers after taking a bath in order to lock in the moisture. If your feet are extremely dry, you may use oil to decrease water evaporation from your skin. To prevent cracking, you may use creams to soften your skin and prevent forming fissures. Diabetics, however, should watch out in using cosmetics because moisture on enclosed areas (i.e. toes) might lead to infection
  • Epsom salt promotes circulation to your feet. Its magnesium content removes toxins, promoting healthier skin. Put one half cup of Epsom salt into a lukewarm water. Soak your feet for 10 minutes. Rub the affected area with pumice stone. Put it back into the water for another 10 minutes. Pat it dry then apply petroleum jelly. Do this for two to three days.
  • Lemon juice is a weak acid tolerable by the skin if soaked into it. It softens the dry and rough skin so that the affected area is easily scrubbed off when used with a foot brush or loofah. 
  • You may also want to try combining juice from a whole lemon with one teaspoon of Vaseline. Apply all of the mixture to the cracked areas. Cover your feet with wool stocks to preserve the moisturizing effect and prevent your bed sheets from staining. Do this every night before you go to sleep.
  • Pour a cup of apple cider vinegar into a gallon of warm water. This makes a disinfectant wherein you can use to soak your feet for 10 to 15 minutes. It is also said that this is relaxing for tired feet. Moisturize with lanolin products after gently patting it dry with a clean soft cloth.
  • You can also use apple cider vinegar to create a homemade foot scrub. Mix a few tablespoons of apple cider vinegar or honey, a handful of rice flour, and one tablespoon of olive oil. This makes a thick paste which you can use to massage your feet. Rinse with warm water. Do this once or twice a week.
  • After taking a night bath, apply vegetable oil on the affected areas. Cover your feet with clean socks. Do this every night before going to bed.
  • Another natural treatment for dried cracked feet is the coconut oil. Coconut oil has antimicrobial and antifungal properties, not to mention its moisturizing effects. Simply apply it to cracked areas of your feet and cover with socks.
  • To create a homemade moisturizing cream for your cracked heels and toes, shake a combination of one tablespoon of olive oil and a few drops of lavender or lemon oil until thick and milky. Use whenever necessary.
  • You can use an overripe banana to get rid of your dry, cracked skin on feet. Put an overripe banana and a half of avocado (optional) into a blender. This makes a homemade remedy that you can leave on the cracked feet for 15-20 minutes. Alternately wash it with lukewarm and cold water. Do this everyday.
  • Combine one cup of ground oatmeal, one half cup of all-purpose flour, one-fourth cup of honey, and one-fourth cup of olive oil. Before applying the paste, soak your feet first in warm water. Leave the paste into the cracked areas of the feet for 30 minutes then wash it off with lukewarm water. Apply foot cream or moisturizer thereafter. Do this few times a week.
  • Mix a tablespoon of powdered oatmeal and few drops of jojoba oil. This makes a homemade treatment which you can leave on for 30 minutes. Wash with cold water thereafter.
  • Mentholated rub may help. It is also effective in healing toenail fungi.
  • Wrap your foot with wet dressings every night. You may use clean wet socks covered by dry socks. This is done only in the absence of infection. Moisture attracts more microorganisms that could make the infection worse than it already is [1, 2, 8].

When to Consult a Doctor

Many might believe that they should consult a dermatologist when it comes to this matter but in fact, it is better to consult a podiatrist since they are the foot experts. Seek consultation if you have the following:
  • If wounds, ulcers, or infections develop from the affected area
  • If the affected area is expanding and continues to spread
  • If there is a presence of other skin diseases
  • If the condition is persistent despite of home treatment
  • If the condition wakes you up at night and keeps you from sleeping well
  • If the condition interferes with your activities of daily living [7]

How to get rid of Dry, Cracked Skin on Feet

  • Treat the underlying medical condition.
  • Hydrocortisone cream can be used for severe skin itchiness and inflammation.
  • Humectants (with alpha-hydroxy acid) such as glycerin and lactic acid promote moisturization and exfoliation (slaughing off of skin to replace it with newer skin cells).
  • Emollients such as lanolin, urea, and silicon oils keep your skin from becoming severely dry by becoming a moisture barrier [2, 3].

Prevention

  • Hydrate yourself with plenty of water.
  • Avoid staying in very hot or very cold weathers.
  • Avoid steam baths and saunas.
  • Avoid harsh soaps that could cause dryness of the skin. Simply use gentle soaps with moisturizers.
  • Wear socks that are non-irritating to the skin, i.e. cotton.
  • Wear comfortable shoes. Let your feet breathe. Never allow excessive sweating for your feet.
  • Use a room humidifier if you stay in a place with low humidity. A hot, dry environment robs your skin of the proper moisture that it needs. Humidity prevents itchiness and flaking of your skin.
  • Avoid caffeine and alcohol which are thought to worsen the itchy sensation.
  • Foods rich in omega-3, ALA, and GLA include halibut, salmon, sardines, and walnuts. Oils of safflower, flaxseed, canola, baroage, and evening primrose are also rich in these essential fatty acids. All of these help to lock in the moisture into your skin.
  • Foods rich in vitamins A and E such as carrots, kale, olive oil, anchovies, and almonds keep your skin healthy [1, 2, 3, 7].
References:
  • http://www.footvitals.com/skin/dry-feet.html
  • http://www.wikihow.com/Heal-Cracked-Skin
  • http://foothealth.about.com/od/beautifulfeet/a/Dryskin.htm
  • http://www.diabetes.org/living-with-diabetes/complications/foot-complications/
  • http://www.webmd.com/skin-problems-and-treatments/tc/athletes-foot-topic-overview
  • http://www.lowthyroiddiet.com/low-thyroid-symptoms.htm
  • http://www.drscholls.ca/en/foot-health-center/rough-dry-cracked-skin
  • http://www.top10homeremedies.com/how-to/how-to-heal-cracked-feet.html/3

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Anuria - Definition, Causes, Symptoms and Treatment

Anuria Definition


From the word itself, you can derive its definition. The prefix “a-“ or “an-“ means absence. Uria refers to urine. So by the context of the word, anuria or anuresis means no urination.

But in the clinical setting, this is actually not the case. Medically, anuria means having a urine output of less than 100 mL per day. The kidneys do not totally stop producing urine. If the kidneys stop functioning, the person dies.

The term anuria was coined in order to denote that the urine output is dangerously low. If untreated, it can be a cause of death.

Anuria is almost always associated with the term oliguria. Oliguria means having a urine output of less than 500 mL per day. It is an early sign of kidney problems. Anuria comes in late, when the disease progresses and if it is in its advanced state. Obviously, anuria is worse than oliguria.

Anuria Causes

Prerenal Causes

Prerenal causes of anuria refer to problems of the structures “before the kidneys,” i.e. the blood vessels that supply the kidneys.

The kidneys are very vascular organs, especially its medullary part. If the blood supply to the kidneys is low, it means other organs are in dire need of blood and oxygen supply, hence, the kidney which is an organ of elimination, receives less.

Decreased renal perfusion or mean systemic arterial pressure decreases renal output via autoregulatory mechanisms and neurohumoral pathways.

The following are the prerenal causes of anuria for adults and children [1, 2, 3]:

1. Hypovolemia
  • Hemorrhage
  • Diarrhea
  • Vomiting
  • Burns
  • Pulmonary edema
  • Diuretics
  • Intraoperative fluid loss
  • Fluid loss related to use of drains
2. Low systemic vascular resistance
  • Sepsis
  • Shock
  • Antihypertensive drugs
  • Side effects of drugs
3. Heart Failure
  • Decreased cardiac output
  • Arrhythmia
  • Myocardial infarction
  • Cardiomyopathy
  • Cardiac tamponade
4. Others
  • Increased intra-abdominal pressure
  • Direct compression of the renal vein
  • Compression of the inferior vena cava
  • Anaphylaxis
  • Pancreatitis
  • Diabetes mellitus
  • Diabetes insipidus
In neonates, additional prerenal causes are the following [3]:
  1. Respiratory distress syndrome
  2. Perinatal asphyxia
  3. Congenital heart disease
  4. Indomethacin
  5. NSAIDs or ACE inhibitors used by the mother

Renal Causes

Renal causes of anuria refer to the problems of the “kidney itself.” A very low urine output is due to diseases of the glomerulus and renal tubules.

In the presence of glomerular and tubular diseases, the renal parenchyma will not be able to effectively and efficiently filter the urine. As a result, there will be less urine output.

The following are the renal causes of anuria for all age groups [1, 2, 3]:
  1. Nephrotoxic drugs: aminoglycoside, amphotericin B, diuretics, NSAID, cephalosporin, penicillin, angiotensin-converting enzyme (ACE) inhibitor, cisplatinum, cyclosporine, tacrolimus, radiological contrast
  2. Endogenous toxins: uric acid, haemoglobin, myoglobin
  3. Glomerulonephritis
  4. Autoimmune diseases
  5. Systemic diseases
  6. Vascular diseases: haemolytic uremic syndrome, renal artery or vein thrombosis, vasculitis
  7. Congenital kidney diseases
  8. Family history of renal diseases
  9. Muscle trauma
  10. Hematuria

Postrenal Causes

Postrenal causes of anuria refer to the problems of the structures “after the kidney,” i.e. obstruction of urine flow.

There is no problem with renal perfusion and there is no noted renal disease. The problem most likely lies on urinary obstruction. The urine cannot pass through structures as it should be so there will be less urine output.

The following are the postrenal causes of anuria [1, 2]:
  1. Lower urinary tract symptoms (LUTS): frequency, weak stream, dribbling
  2. Benign prostatic hypertrophy
  3. Calculi
  4. Mass in the neck of the urinary bladder
  5. Retroperitoneal fibrosis
  6. Kinks in the catheter (if the patient uses one)

In children and neonates, the following are the postrenal causes of anuria [3]:
  1. Stenosis of urinary meatus
  2. Posterior urethral valves
  3. Bilateral ureteral obstruction
  4. Neurogenic bladder

Treatment for Anuria

Cardiopulmonary Resuscitation

Fluid resuscitation of 250-500 mL aliquots may be the key in order to increase urine output and stabilize heart rate and blood pressure. The goal is for the patient to have a urine output of at least 0.5 mL/kg/hr.

Central venous pressure is maintained at 8-12 mmHg via central venous catheter. Blood pressure is very accurately measured through an arterial line. If fluid challenge fails, inotropes come to the rescue.

Nephrotoxic drugs

If the patient is taking drugs that are toxic to the kidneys (as noted above), discontinue these medications. It is also important to release the obstruction, decrease intra-abdominal pressure, and treat underlying infection.

Hyperkalemia


Picture 1 ECG shows hyperkalemia in its early state.
Image Source: http://nswhealth.moodle.com.au

Picture 2: ECG shows progressing hyperkalemia.
Image Source: http://nswhealth.moodle.com.au


Picture 3: ECG shows hyperkalemia in its late state.
Image Source: http://nswhealth.moodle.com.au

Hyperkalemia is a medical emergency wherein potassium level reaches >6.5 mmol/L and ECG shows peaked T waves and widened QRS complexes. It may also be accompanied by ventricular arrhythmias and asystole.

In the presence of hyperkalemia, BLS/ALS is initiated above all. Discontinue medications and infusions that contain potassium.

Administer 10 mL of calcium gluconate 10%; 50 mL of glucose 50%; and 10 units of rapid-acting insulin. 100 mmols of sodium bicarbonate 8.4% and inhaled beta-2 agonist are also given. These will shift the potassium into the cells. However, potassium still leaks out of the cells therefore these are not permanent treatment for hyperkalemia. Excess potassium need to be excreted from the body in order to eradicate its signs and symptoms.

For a less severe case of hyperkalemia, i.e., potassium levels of 5.5-6.5 mmol/L, potassium is restricted and resonium 15-30 g should be administered [1].

Treatment for Anuria in Children

Neonates and children are more prone to dehydration than adults so this is one of the things the health care providers should watch out for.

Dehydration in children is treated by 20 mL/kg fluid bolus of normal saline solution or lactated Ringer’s solution. In cases of fluid overload, fluid restriction and furosemide (diuretics) therapy is ordered. If the cause is postrenal (obstruction or stenosis), perform urinary catheterization [3].

References:

  1. Jacques T et al, 5 Causes of Anuria: DETECT 2nd edition, 2009
  2. Glabowski N, Diagnosis in the Anuric/Oliguric Patient /N%20Grabowski%204%20May%202011%20diagnosis%20of%20renal%20failure.pdf
  3. Jain A & Mattoo TK, AAP Textbook of Pediatric Care, Anuria and Oliguria
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