Idiopathic non-traumatic spontaneous renal hemorrhage/laceration: a case report and review of the literature.
Though uncommon, non-traumatic spontaneous renal hemorrhage is well reported in the literature. Nearly all isolated case reports and case series including metanalysis; report renal neoplasm as the most common etiology for the spontaneous renal/perirenal hemorrhage. (1,2) Both benign and malignant renal neoplasms are included as a source of bleeding with the majority being either angiomyolipomas or renal cell carcinomas respectively. Meta-analysis of these case series with renal hemorrhage infrequently report patients with an unknown idiopathic etiology (2.6 to 6.7%). (1,2) We report a case of a previously healthy middle aged female with spontaneous idiopathic non traumatic renal laceration with renal and perirenal hemorrhage and review of literature.
A 57 year old female was referred to us via an outside Emergency Department following the finding of a renal laceration with perirenal hematoma detected on CT scan. On further evaluation, the patient was in otherwise good health and only felt unwell one day prior to presentation. Symptoms included persistent back pain, fatigue and associated with nausea. The patient denied history of fever. On further evaluation in the form of abdomino-pelvic CT scan with and without contrast, the patient was determined to have a grade IV renal laceration involving the inferior pole of the right kidney with a large perirenal hematoma (Figure 1). Detailed review of the radiologic images revealed a normal left kidney with no evidence of any incidental masses on either side.
The patient denied any recent or remote history of any obvious or trivial trauma in any form. The patient denied any medical co morbidities in the form of diabetes, hypertension, systemic vascular disorder or any vasculopathies. On presentation the patient denied any long term use of steroids or blood thinning medications.
On presentation to our emergency department; the patient was admitted to the intensive care unit with serial hemoglobin and hematocrit monitoring. Throughout the hospital course the patient remained stable and was reimaged with a CT angiogram (in 48 hrs) to delineate the renal anatomy and to identify the source of bleeding. The CT angiogram confirmed a grade IV laceration of the right renal midzone and inferior pole. A normal single renal artery was demonstrated bilaterally and the right side demonstrated a nonperfused inferior pole without any evidence of masses (Figure 2). The patient was managed conservatively and was discharged home.
Non-traumatic spontaneous renal hemorrhage is a distinct entity described in the literature.2 It presents in the absence of any obvious renal trauma, either external or iatrogenic. A majority of these cases are attributed to renal neoplasms, both benign and malignant.2 A large meta-analysis (47 published manuscripts) revealed that the vast majority of patients (85%) were adults and presented with acute flank pain. Of these 165 patients 61.5% were reported to have benign (31.5%) and malignant (29.7%) etiology. Angiomyolipoma and renal cell carcinoma were the most common etiology, respectively, with size ranging from 1-20 cm. A majority of patients (68.4%) were treated with nephrectomy, whereas about 10% patients were treated conservatively.
Diverse etiological factors such as infection, nephritis, blood dyscrasias, coumadin anticoagulation, calculus disease, and dialysis have been attributed to spontaneous non-traumatic renal hemorrhage. (1-3)
Idiopathic non-traumatic spontaneous renal bleeding is extremely rare. Only two published meta-analysis mention it being factored as the etiology for non traumatic spontaneous renal bleeding. The first largest meta-analysis of spontaneous renal parenchymal rupture was reported in 1975 by McDougal et al. The cohort had 78 patients with the majority (58%) of renal ruptures being secondary to renal neoplasms. The author also reported two patients for whom the source of the bleeding was undetermined. (1)
Recently, another metaanalysis with a large cohort of patients reported almost identical results. Of these 165 reported patients, 154 had determined etiology, whereas 11 (6.7%) had no etiological basis for bleeding. (2)
Based on these two well documented large meta-analyses and our literature search, only 13 cases have been reported where the etiological basis of the spontaneous renal hemorrhage remained undetermined.
Though it is well recognized that most cases of spontaneous renal hemorrhage are secondary to renal mass, in incidental cases where the source of bleeding is nonexistent, idiopathic, and non traumatic, etiologies should be taken into account. Due to the ease of availability and minimal time required for CT scanning almost all patients with abdominal pain presenting to the emergency department are imaged on presentation. It is at this point that many patients with retroperitoneal and or perirenal bleeding can be identified and classified based on the etiology. A careful evaluation of the radiological images with a radiologist is of utmost importance to discover a possible source of bleeding.
If no cause is determined the patient can be managed conservatively. In our patient, after discussing the initial imaging with the radiologist we elected to manage the patient in this manner. We further evaluated the source of bleeding with a CT angiogram which confirmed the initial finding of normal renal anatomy.
Non-traumatic idiopathic spontaneous renal hemorrhage with renal laceration is a rare entity. Though very few cases are reported, a significant number of cases may be unreported. Occasional patients may present with insignificant symptoms, a high index of suspicion is vital to avoid misdiagnosis. This case emphasizes that a thorough evaluation of patients presenting to the Emergency Department is of paramount importance.
Diagnosis is confirmed after careful evaluation with selective angiographic imaging. Most patients should be managed conservatively unless life threatening hemorrhage is the initial presentation.
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(1.) McDougal WS, Kursh ED, Persky L. Spontaneous rupture of the kidney with perirenal hematoma. J Urol. 1975; 114(2):181-184.
(2.) Zhang JQ, Fielding JR, Zou KH. Etiology of spontaneous perirenal hemorrhage: a meta-analysis. J Urol. 2002; 167(4):15931596.
(3.) Malek-Marin T, Arenas D, Gil T, Moledous A, Okubo M, Arenas JJ, et al.
(4.) Spontaneous retroperitoneal hemorrhage in dialysis: a presentation of 5 cases and review of the literature. Clin Nephrol. 2010; 74(3):229-244.
Pankaj Dangle MD, MCh
Lopa Pandya, MS-III
Michael Chehval, MD
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|Title Annotation:||Scientific Article|
|Author:||Dangle, Pankaj; Pandya, Lopa; Chehval, Michael|
|Publication:||West Virginia Medical Journal|
|Article Type:||Case study|
|Date:||Nov 1, 2012|
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