Dietl's Crisis Symptoms, Causes, Radiology, Treatment

 Dietl crisis is not very common. It is defined as a temporary blockage of the ureteropelvic junction (UPJ) that causes intermittent abdominal pain. This is usually caused by an abnormal accessory renal vein. Josef Dietl was the first person to write about it in 1864. He suggested treating it with rest and a belt or corset to support the abdomen. If the pain lasts for a long time, he also suggested putting pressure on the area around the affected kidney from the outside. After that, a surgical procedure known as nephropexy was utilized as a method of rectification from the year 1870 up to the 1960s.

Dietl's Crisis Symptoms

Laparoscopic pyeloplasty has emerged as an effective surgical procedure that, in the majority of instances, results in total remission of the symptoms of this crisis. Some children present at a later period with occurrences of abdominal pain. These episodes may be accompanied by nausea or vomiting, which leads to multiple visits to the emergency department (ED). Because curative surgery resolves all symptoms, accurate and fast diagnosis of individuals with Dietl crisis using imaging testing becomes critical. The other clinical possibilities include psychogenic pain, constipation, an infection of the urinary tract, kidney stones, and appendicitis.

Dietl's Crisis Causes

The majority of the time, a blockage is most commonly caused by narrowing of the renal pelvis. As a result, urine accumulates, harming the kidney. This problem also results from an incorrectly positioned blood artery over the ureter. Some other causes of this condition are:

1. Muscle misalignment at the pelvic-ureter region
2. Collagen collar at the pelvic ureteric junction that is abnormal
3. Injury to the pelvic ureteric junction caused by ischemia
4. The urothelial fold of the ureter
5. Compression or encasement of the external ureter
6. Crossing vessel (at the pelvic ureteric junction)

Dietl's Crisis Radiology

Intravenous urography (IVU) and pyelography (IVP) have traditionally been used to diagnose pelvic ureteric junction blockage. Furosemide administration is utilized to help confirm the diagnosis, especially to rule out a dilated, unobstructed upper collecting system.

The following tests are recommended by the doctors for the diagnosis of this condition:

• BUN ( Blood urea nitrogen)
• Creatinine clearance
• CT scan
• Electrolytes
• Nuclear scan of kidneys
• Voiding cystourethrogram

Doctors must be aware of Dietl's crisis and take a full history of suffering during an incident to accurately diagnose the condition.

Dietl's Crisis Treatment

The treatment of this disease is determined by the underlying cause. A large percentage of congenital instances are harmless, and no treatment is necessary.  UPJ obstruction does not always necessitate surgical intervention; in fact, most instances recover on their own. 

However, if patients experience pain, repeated infections, decreasing function, or increased swelling, they need a procedure known as a pyeloplasty to avoid kidney harm and remove the obstruction. In the past, this procedure was carried out by making an open incision beneath the ribcage; however, the current standard of care in the majority of cases related to children older than 2 years is to carry out this procedure laparoscopically with the assistance of a surgical robot.