Author: Dr. Charles Benson


59 year old male with history of OSA, HLD, DM, HTN, CAD, bradycardia s/p PPM, ESRD s/p pancreas/renal transplant transferred from OSH for acute severe abdominal pain with nausea/vomiting for day. He says the pain started 1 day ago and was located mostly in RLQ. He also endorses multiple episodes of NBNB emesis (10x) and inability to tolerate PO. He has never had pain like this before. It waxes and wanes and is worsened with movement and attempting to use the washroom. No dysuria or hematuria. Last BM 2 days ago was normal. No fevers, chills, chest pain, sob. Denies changes to urine output. 

History (continued)


Family Hx

Social Hx:




Constitutional: Positive for appetite change and diaphoresis. Negative for chills and fatigue. 

HENT: Negative.  

Eyes: Negative.  

Respiratory: Negative.  

Cardiovascular: Negative.  

Gastrointestinal: Positive for abdominal pain, nausea and vomiting. Negative for blood in stool, constipation and diarrhea. 

Endocrine: Negative.  

Genitourinary: Negative for decreased urine volume, difficulty urinating, flank pain and frequency. 

Musculoskeletal: Positive for back pain

Neurological: Negative.  

Hematological: Negative.  

Psychiatric/Behavioral: Negative.  

Physical Exam

General: Acute distress d/t pain

HEENT: Atraumatic, normocephalic, trachea midline 

Respiratory: Non-labored breathing, symmetrical chest extension

CV: Regular rate 

Abdominal: +Distended, soft, significant and diffuse tenderness to palpation despite pain medications, no rebound tenderness or guarding

GU: Deferred

MSK: Spontaneous movements, ROM grossly intact

Extremities: 2+ pitting edema b/l, no cyanosis

Neuro: No focal neurological deficits 

Skin: No rashes, skin warm and dry; ecchymosis on arms

Psych: Cooperative


Lactic acid WNL, CMV and BK virus pending, blood culture pending

Normal chest with no infiltrates or pulmonary edema 

Few dilated loops of small bowel in the upper and mid abdomen. Correlate for partial obstruction or developing ileus. 

US transplant kidney and pancreas with doppler


The transplant pancreas is identified in the right lower quadrant with fairly uniform isoechoic echotexture. No abnormal solid or cystic masses or lesions are seen. No extrahepatic pancreatic fluid collections are demonstrated. 

Patent pancreas vasculature

The transplant kidney is well-identified in the right iliac fossa and is normal in size and echotecture.  The transplant kidney measures 10.3 x 6.2 x 8.0 cm  in its greatest dimensions.  No abnormal solid or cystic masses, lesions or obstructive uropathy.  No extra-renal fluid collections are seen.  Arterial and venous flow are seen.

CT abdomen pelvis with contrast (1)

1.  Appearance of edema in the colon extending from the region of the distal transverse colon to the distal descending colon almost up to the junction with the sigmoid. This was not present on the prior CT study performed at a different institution This could be due to can be seen with colitis which could be from infection, inflammation. Clinical correlation is however recommended to exclude other etiologies such as ischemia also in the appropriate clinical setting. The proximal visualized portions of the superior mesenteric artery, inferior mesenteric artery are grossly patent. Negative for acute diverticulitis. 

2.  Small volume intra-abdominal free fluid, increased from prior same day CT, possibly reactive. 

CT Abdomen Pelvis without contrast (2)

1.  No small or large bowel obstruction. 

2.  Right lower quadrant transplant kidney continues to enhance despite no IV contrast administration for this study. Most recent documented IV contrast administration November 28, 2022. Correlate for renal dysfunction. 

3.  Moderate volume complex free fluid throughout the abdomen, significantly increased from November 28, 2022. This could represent simple free fluid mixed with blood products/proteinaceous content of unknown etiology. If clinically necessary, consider fluid sampling for further evaluation. 

Diagnostic paracentesis

Diagnostic paracentesis

Diagnosis: spontaneous intraperitoneal rupture of the urinary bladder


There are many causes of ascites, the most common in the US being cirrhosis with other common causes being malignancy-related and heart failure.

Signs and symptoms of ascites





Initial Tests

Additional tests



Cell Count and Differential

Total Protein Concentration

Back to our patient...




US of liver with doppler

IR transjugular liver biopsy

So what's the deal?

“Of the various compartments, the urine contains the greatest concentration of creatinine, estimated to be 100 times more concentrated than the serum. Thus, an ascites Cr:serum Cr ratio of over 1 is diagnostic of urinary ascites”

“Reabsorption of peritoneal Cr into the blood via diffusion, a phenomenon known as reverse peritoneal dialysis, increases sCr, resulting in pseudo-renal failure”

Does not improve with HD

FL Cystography

Impression: a SUBTLE small strand of contrast appears extraluminal adjacent to the site of the ureterovesicular anastomosis, suspicious for urine leak. REcommend further evaluation with cystoscopy.

Urinary Bladder Rupture

Nontraumatic Urinary Bladder Rupture


History and Physical