The twisted diversion: a paralyzing complication
An 80-year-old gentleman presented to A&E department for general weakness and paralysis of all four limbs. His past medical history includes Type 2 diabetes mellitus, spinal stenosis at the level of L2/L3, L3/L4 and L5/S1. His drug history includes aspirin, simvastatin and omeprazole.\nThe initial diagnosis was thought to be Guillan–Barre syndrome. However, he denied any recent flu-like symptoms or dysphagia. He said that he had become unwell since his cystectomy operation 4 months prior to his attendance at A&E. He also denied any loin pain. On examination, his abdomen was soft, a draining ileal conduit stoma was observed, sensation and reflex at all limbs were intact, but motor power of all limbs was diminished.\nHis initial blood test shows the potassium level of 9.1 mEq/l, serum urea of 20.1 mM/l, creatinine of 521 µM/l. He was immediately treated with calcium gluconate 10%, insulin-sliding scale and salbutamol nebulisers. An ultrasound scan of the renal tracts was carried out and subsequently shows bilateral hydronephrosis. Computed topography of the head revealed no intracranial bleed or infarct for the cause of paralysis. Due to his worsened renal function, a loopogram was performed and showed a stricture 4 cm proximal to the skin opening of the ileal conduit (see Fig. ).\nThe patient was treated conservatively with 2 weeks of intravenous Ciprofloxacin antibiotics and nephrostomy tubes were inserted as a diversion. He underwent a laparatomy and revision of ileal conduit 2 months later. The surgical exploration revealed a small fibrous tissue band of mesenteric origin 4 cm proximal to the skin opening of the ileal conduit. The patient recovered uneventfully, his renal function improved remarkably and he was discharged back to community care after a stormy hospital stay.