Dietl's Crisis: Episodic Flank Pain with Vomiting and UPJ Obstruction

Dietl's crisis is a pain attack that occurs when the narrowing at the kidney's outlet turns, from time to time, into complete blockage. It takes its name from the physician who first described it in the 19th century; in pediatric urology it is used interchangeably with "intermittent UPJ obstruction."

The attack often begins after drinking a lot of water, a fizzy or sugary drink, watery foods like watermelon, intense sports, or sometimes extra fluid taken during a cold. The pain sits in the flank or the upper-side of the abdomen; younger children point around the belly button.

Between attacks the child is completely well, and an ultrasound done at that time may show only very mild kidney swelling, or none at all. Because of this, in a child whose ultrasound is called "normal," the diagnosis can be delayed for months.

Ultrasound taken during an attack shows a markedly widened pelvis and calyces; an ultrasound repeated after the pain has passed, showing the widening has decreased, strengthens the diagnosis. This is why it matters to see your doctor or go to the emergency department during an attack and ask for an ultrasound.

Recurring Dietl's crisis is considered, in guidelines, a surgical indication under the heading of "symptomatic obstruction." Even when kidney function is good, recurring severe pain alone can be enough to justify pyeloplasty; the goal is both to relieve the pain and to protect the kidney.

When the pain starts, do not force your child to drink water; extra fluid can make the picture worse. Do not give any medication other than the pain reliever your doctor has recommended, and seek care without delay in the situations below.

• Severe, unrelenting flank or abdominal pain with vomiting: go to the emergency department or your doctor for an ultrasound while the pain is still present.
• If fever (38°C / 100.4°F or higher) or chills accompany the pain: possible infection in an obstructed kidney; same-day evaluation.
• If the child cannot keep fluids down because of vomiting, has reduced urine output, or is markedly weak.
• If attacks become more frequent in a child already diagnosed with UPJ obstruction: planned but prompt re-evaluation.