Spontaneous subcapsular hematoma of the kidney

INTRODUCTION: Spontaneous subcapsular hematoma of the liver is usually associated with pregnancy, coagulopathy or liver lesion. We report a rare case of spontaneous subcapsular liver hematoma without any of the above risk factors. CASE DESCRIPTION/METHODS: A 59-year-old lady with a history of hypertension presented with sudden-onset in the right upper abdomen, right chest, shoulder and neck pain. She was otherwise hemodynamically stable other than being mildly hypertensive. Work-up for cardiac ischemia was negative. She was noted to have a low hemoglobin of 10.4 g/dl (prior baseline was 13.7 g/dL) and she had mild hepatocellular injury (ALT 32 IU/L, AST 31 IU/L). She underwent CT scan to rule out pulmonary embolism which incidentally revealed a large subcapsular liver hematoma. MRI abdomen confirmed a large lenticular shaped subscapular collection along the right lobe of the liver measuring approximately 12 × 4 × 16 cm. There was no focal hepatic lesion to explain the cause of bleeding. She did not recall any preceding trauma and there was no obvious trauma on exam. She was not taking any blood thinners. She admitted to inadvertently using oral contraceptives (OCP) for over 30 years for purely birth control purposes. The patient was admitted for observation and remained clinically stable over the next few days. At her 1-month follow-up, an office ultrasound showed that the size of the hematoma had decreased when compared to her prior ultrasound during her hospitalization (thickness from intercostal view decreased from 42 mm to 35 mm). At her 1-year follow-up, an MRI abdomen was repeated that showed a minimal residual hematoma and no discrete underlying lesion. DISCUSSION: Spontaneous subcapsular hematoma of the liver represents an accumulation of blood between the capsule of Glisson and the liver parenchyma, and is frequently located around the right lobe. If it ruptures into the peritoneum, it can be potentially fatal. Our case is unique in that none of the usual risk factors such as pregnancy, trauma, blood thinner use or underlying liver lesion were present. To our knowledge, there are very few similar case reports that describe spontaneous subcapsular hepatic hematoma. OCP use is generally associated with the development of hepatic adenoma, which can in turn cause spontaneous subcapsular hematoma. Theoretically, long-term OCP use in a post-menopausal hypertensive lady (such as in our case) may mimic the pathophysiology of pregnancy and independently lead to spontaneous subcapsular bleeding.Figure 1.: MRI showing large hepatic subcapsular hematoma and no focal lesion.Figure 2.: MRI showing nearly resolved hepatic subcapsular hematoma.

Etiology Of Spontaneous Perirenal Hemorrhage: A Meta-Analysis

Spontaneous subcapsular liver hematoma is a rare condition, and this case report describes the clinical course of an 85-year-old female patient who developed a spontaneous subcapsular hematoma while being followed up for acute cholecystitis. After exacerbation of right upper-quadrant pain, imaging studies revealed hematoma. The patient was managed conservatively, with subsequent imaging showing a reduction in the size of the hematoma, and her hemodynamic stability was maintained. This case highlights the diagnostic, therapeutic, and clinical considerations of spontaneous subcapsular liver hematoma and provides a broader perspective by comparing it with similar cases in the literature.

Spontaneous subcapsular renal hematoma (SSRH) emerged as a complication of acute pyelonephritis (APN) is an extremely rare condition. We showed a patient aged 63 years hospitalized due to languor, febrility, abdominal pain accompanied by nausea and vomiting. Ultrasound (US) examination of the abdomen and multidetector computed tomography (MDCT) showed the presence of subcapsular hematoma of the left kidney with calculus in the initial part of the left ureter. Laboratory tests registered a positive inflammation syndrome, anemia and an increase in nitrogen compounds. Based on laboratory results, clinical presentation and imaging techniques it has been found that it is APN with spontaneous subcapsular hematoma. After application of non-surgical treatment which included antibiotic therapy with percutaneous drainage of hematoma, a good clinical response with regression of subjective symptoms and hematoma was obtained. On repeated US and MDCT after 18 months no pathological changes in the kidneys were registered. Spontaneous subcapsular hematoma extremely rare occurs as a result of APN associated with calculosis. The use of non-surgical treatment, which includes appropriate antibiotic therapy with percutaneous drainage of hematoma would represent a method of first choice.

Forniceal ruptures after acute pyelonephritis are relatively common. Bilateral spontaneous subcapsular haematoma (SSCH) is an uncommon sequela to pyelonephritis. We report a case of SSCH where the underlying cause of...

Spontaneous perinephric hematoma secondary to renal tumor

A gravida 3, para 2 woman in her mid-30s with a history of preeclampsia presented at 23 weeks' gestation with severe right upper quadrant pain. On arrival, she suffered seizures and cardiac arrest and was successfully resuscitated. A computed tomographic scan revealed a 16.8-cm, heterogeneous attenuation involving the medial and inferior portion of the liver, consistent with a subcapsular liver hematoma (arrow, Figure 1). Exploratory laparotomy revealed a ruptured subcapsular hematoma of the liver and lacerations predominantly involving the right lobe. Approximately 2.5 L of clotted blood was evacuated from the hematoma. The hepatic artery was clamped for 20 minutes, and the liver was packed to achieve hemostasis. During surgery and in the immediate postoperative period, the patient received 16 units of packed red cells, 18 units of platelets, 10 units of cryoprecipitate, and 14 units of fresh frozen plasma. However, the patient developed anuric renal failure. Despite continued hemodynamic and ventilatory support, her condition did not improve. It was determined that the patient had suffered severe anoxic brain damage as a result of the cardiac arrest. Ventilatory support was withdrawn by family request on the fourth day after admission.Autopsy revealed a large subcapsular liver hematoma dissecting the Glisson capsule from the surface of the entire right lobe, with laceration of the hepatic parenchyma and capsule rupture (arrows indicate subcapsular hematoma, Figure 2). Microscopic examination of the liver showed microvesicular steatosis and periportal hepatocellular coagulative necrosis, features consistent with toxemia of pregnancy (Figure 3, hematoxylin-eosin, original magnification ×200).Spontaneous subcapsular liver hematoma is an extremely rare but potentially life-threatening complication of pregnancy, with a quoted incidence of approximately 1 per 45 000 live births.1 There is an almost exclusive association with severe preeclampsia or with HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets), as more than 80% of cases occur in patients with preeclampsia/eclampsia and/or HELLP syndrome.2 Conversely, spontaneous hematoma occurs in approximately 1% to 2% of patients with preeclampsia.2 The clinical presentation of subcapsular hematoma is not characteristic; most patients present with right upper quadrant pain.1 However, due to the rarity of this entity and its variable presentation, most cases are missed and diagnosed only at laparotomy.The pathogenesis of subcapsular liver hematoma and subsequent rupture is unclear. Fibrin deposition in the hepatic sinusoids is speculated to be the initiating event.3 Fibrin deposition may lead to platelet activation, thrombus formation, occlusion of capillaries, and subsequent hepatic hemorrhage and necrosis. Coalescence of these hemorrhagic areas leads to dissection of the Glisson capsule from the liver surface. Concurrent consumptive coagulopathy occurring in preeclamptic patients often aggravates the condition. It is therefore reasonable to conclude that achieving adequate hemostasis would not only control blood loss in the event of a rupture, but may prevent the formation or expansion of the subcapsular hematoma. A tense subcapsular hematoma may rupture spontaneously or secondary to trivial trauma during labor or convulsions, leading to catastrophic life-threatening hemorrhage. Awareness of this entity and its early recognition is important in reducing the morbidity and mortality associated with a ruptured liver hematoma.

Spontaneous subcapsular hematoma of the liver is an extremely rare but potentially life-threatening condition. We report a case of subcapsular hematoma of the liver without any apparent lesion and in the absence of coagulopathy or trauma. A CT scan of the abdomen demonstrated a huge subcapsular hematoma around the liver. The patient was treated conservatively and was discharged home after one week. Up to our knowledge, this is one of the very few reported cases of a spontaneous subcapsular hepatic hematoma.

We report the rare case of a patient presenting with a spontaneous hepatic subcapsular haematoma after playing golf. The patient had no underlying predisposing conditions. A CT scan of the...

Hepatic artery pseudoaneurysm (HAP) is a rare complication of liver trauma and liver transplant, and spontaneous subcapsular liver hematoma is not frequently encountered outside the setting of preeclampsia and hemolysis, elevated liver enzyme and low platelet (HELLP) syndrome. We report a rare case of spontaneous subcapsular liver hematoma with hepatic artery pseudoaneurysm without any apparent liver trauma or recent interventional procedures of the hepatobiliary system. Although subcapsular hepatic hematoma and HAP are uncommon diagnoses, clinicians should be aware of these diagnoses to promptly diagnose and effectively treat them. Clinicians should also not forget these diseases could be masked by other common etiologies, such as gastritis.

Spontaneous subcapsular hematoma in an ectopic kidney

Spontaneous subcapsular hemorrhage in the liver is an uncommon condition associated with a poor prognosis. We report a case of a renal transplant recipient developing a spontaneous subcapsular hematoma of the liver. A 63-year-old female with end stage renal failure due to interstitial nephritis had an uneventful live unrelated preemptive renal transplant from her husband. Preoperatively, she had normal clotting [international normalized ratio (INR) 0.91 (0.90–1.10); activated partial thromboplastin time (APTT) 1.02 (0.85–1.16); platelets 177×109/L (150–400×109/L)] and liver function tests [alkaline phosphatase 79 U/L (31–116 U/L); total bilirubin 9 μmol/L (0-22 μmol/L); alanine transaminase (ALT) 21 U/L (0–55 U/L); gamma-glutamyl-transferase (GGT) (16–72 U/L)] and was normotensive on medication. She was started on aspirin preoperatively and this was continued after the operation as prophylaxis against vascular thrombosis. She had a routine renal transplant operation through a Rutherford-Morrison type incision. Her blood pressure was stable throughout the procedure and the graft functioned immediately. On the first postoperative day, she developed a headache and was noted to be hypertensive. She was therefore started on labetalol. The following day, she continued to have a severe headache and was still hypertensive, so a glyceryl trinitrate infusion was started. Her hemoglobin was noted to have dropped slightly to 9.4 g/dL (12.0–15.0 g/dL) and her platelet count had fallen to 71×109/L (150–400×109/L). Her coagulation screen was, however, normal [INR 1.06 (0.90–1.10), APTT 0.88 (0.85–1.16)]. On the third postoperative day, her headache worsened, she developed nausea and vomiting, and suddenly became unresponsive. Her hemoglobin dropped to 6.9 g/dL (12.0–15.0 g/dL) and her coagulation was mildly deranged [INR 1.23 (0.90–1.10), APTT 0.90 (0.85–1.16), platelets 66×109/L (150–400×109/L)]. After resuscitation, she was re-explored but no bleeding from the transplanted kidney was found. On abdominal exploration, she was found to have a very large subcapsular hematoma of the liver. A liver surgeon was called, who incised the liver capsule stripped by the hematoma and with considerable difficulty, managed to achieve hemostasis with packs. The patient was transferred to the regional liver unit where two days later the packs were removed. The transplanted kidney subsequently infarcted due to vascular thrombosis and required nephrectomy. Her native renal function also deteriorated further, rendering her dialysis dependent. She required prolonged respiratory support and made a slow recovery. To our knowledge, this is the first reported case of a spontaneous subcapsular hematoma of the liver following a renal transplant. Spontaneous subcapsular hematoma of the liver has been reported in preeclampsia and pregnancy-induced hypertension and is associated with a significant maternal and fetal mortality (1,2). Other reported causes include hepatocellular carcinoma and focal hemorrhagic necrosis of the liver (3). Our patient did not have any underlying liver disease and her preoperative liver function tests were normal. She did not have any known coagulopathy and her routine coagulation screen prior to her transplant was normal. Therefore, we assume that the spontaneous subcapsular hematoma of the liver was a consequence of thrombocytopenia and the administration of aspirin possibly in association with poorly controlled hypertension. The management of subcapsular hematoma of the liver should be to incise the capsule and drain the hematoma. Argon coagulation can then usually achieve hemostasis, and any underlying coagulopathy should be corrected and platelets given if needed. Fibrin glue may be used if necessary, or in severe cases the liver can be packed. Liver resection is not indicated and should not be attempted (1). Ligation of the hepatic artery may be useful, if other methods of controlling hemorrhage are unsuccessful (2). Spontaneous subcapsular hemorrhage in the liver is extremely rare, but this case highlights the importance of platelet dysfunction and hypertension following renal transplantation, as they can have catastrophic consequences. Colin W.M. Cutting Mohammad S. Khan Nizam Mamode Geoff Koffman Department of Nephrology, Transplantation and Urology, Guy’s Hospital, London, UK Nigel Heaton Institute of Liver Studies, King’s College Hospital, London, UK

To report the development of a spontaneous subcapsular splenic hematoma following filgrastim administration in a patient undergoing an allogeneic hematopoietic stem cell transplant. A 60-year-old female with myelodysplastic syndrome was admitted for a reduced-intensity allogeneic hematopoietic stem cell transplant from an unrelated donor. She received filgrastim 5 μg/kg starting on day 1 to accelerate neutrophil recovery. On day 5, she began reporting severe left chest-wall pain. Contrast-enhanced computed tomography of the abdomen/pelvis revealed a spontaneous subcapsular splenic hematoma. Upon discontinuation of filgrastim, the pain fully resolved. The patient was subsequently rechallenged with filgrastim, which led to recurrence of the left-sided chest-wall pain. Filgrastim was discontinued and the patient reported resolution of the pain. Filgrastim has been associated with splenic hematoma and splenic rupture, predominantly in healthy donors undergoing mobilization of peripheral blood stem cells. Although splenic rupture attributed to filgrastim in a patient undergoing allogeneic hematopoietic stem cell transplantation has been reported, to our knowledge, this is the first case report to establish causality. Using the Naranjo probability scale, an objective causality assessment revealed that the adverse drug event was highly probable. Although filgrastim-induced splenomegaly, splenic hematomas, and splenic rupture are rare, clinicians working in the bone marrow transplant setting should be cognizant of the potential of growth factors to cause these adverse events.

A spontaneous subcapsular hematoma in an allograft kidney is a rare condition with only a few cases reported in the literature. Common causes of subcapsular hematoma of an allograft include trauma, post-biopsy status, occult malignancy, vascular diseases, and infection. Chronic allograft dysfunction related to spontaneous subcapsular hematoma is extremely rare. We report a case of spontaneous subcapsular hematoma in a patient who underwent a renal transplant 14 years ago in which we could not find an associated condition.

Prior to the development of angiography, a definite diagnosis of spontaneous subcapsular renal hematomaa was not often made preoperatively. The classic triad of blood loss, pain, and mass on the affected side is seldom presented by the patient. The one constant finding on scout film is an enlarged renal shadow, presenting a problem in differential diagnosis. Chief among cause of subcapsular renal hemorrhage are trauma, tumor, infarct, arteritis, and bleeding diathises. Selective renal arteriography gives specific information about the renal vascular supply and the state of the renal parenchyma not available by other means. Diagnosis of subcapsular renal hematom is facilitated by this modality. A correct diagnosis of subcapsular renal hematoma may well spare an otherwise innocent kidney. A review of current literature was undertaken, and three documented cases of spontaneous subcapsular hematoma diagnosed prior to surgery and confirmed at surgery are presented.