Perirenal Hemorrhage Research Articles

A Case Report of Wünderlich Syndrome Causing Massive Hemorrhage During Hemodialysis.

Wünderlich syndrome (WS) refers to subcapsular, perirenal, or pararenal hemorrhage due to non-traumatic and iatrogenic conditions. Neoplasms, vascular disease, renal etiology, and anticoagulant use are underlying risk factors. We describe a case of WS in a 79-year-old male who was undergoing hemodialysis, which resulted in hemorrhagic shock requiring multiple transfusions and embolization by interventional radiology. Most commonly, patients present with flank pain; a computed tomography with contrast of the abdomen is essential for diagnosis. Surgical intervention is considered in hemodynamically unstable patients. Conservative therapy and intravenous resuscitations with blood products are considered a priority in hemodynamically stable patients.

Wunderlich syndrome as a rare complication of polyarteritis nodosa: a case report.

Spontaneous subcapsular and perirenal hemorrhage, known as Wunderlich syndrome (WS), is a rare clinical manifestation of polyarteritis nodosa (PAN). We report a case of a 48-year-old male with a history of recurrent episodes of leg muscle tenderness and dysesthesia, bilateral flank pain, painful nodular skin lesions in the lower limbs, weight loss, and difficult-to-control arterial hypertension. The abdominopelvic computed tomography angiography showed a large left perirenal hematoma, leading to the patient's admission to the intensive care unit. After the exclusion of infectious or neoplastic foci, the patient was diagnosed with PAN and started intravenous methylprednisolone pulses with a good response. Since WS is a rare initial clinical manifestation of PAN, an early diagnosis and aggressive treatment will significantly improve clinical outcomes.

Wunderlich syndrome secondary to bilateral renal angiomyolipoma

Wunderlich syndrome is understood as spontaneous subcapsular or perirenal renal hemorrhage of non traumatic etiology secondary in 63% of cases to neoplastic ethology.

Management Outcomes of Large Renal Angiomyolipoma Presenting with Wunderlich Syndrome-Experience from a Tertiary Center.

Renal angiomyolipoma is an uncommon, benign-mixed mesenchymal tumor consisting of thick-walled blood vessels, smooth muscles, and mature adipose tissues. Twenty percent of these tumors are associated with tuberous sclerosis. Wunderlich syndrome (WS), an acute nontraumatic spontaneous perirenal hemorrhage, can be a presentation of large angiomyolipoma. This study evaluated the presentation, management, and complications of renal angiomyolipoma with WS in eight patients who presented to the emergency department between January 2019 and December 2021. The presenting symptoms included flank pain, palpable mass, hematuria, and bleeding in the perinephric space on computerized tomography. Demographic data, symptoms at presentation, comorbidities, hemodynamic parameters, the association with tuberous sclerosis, transfusion requirements, need for angioembolization, surgical management, Clavien-Dindo complication, duration of hospital stay, and 30-day readmission rates were evaluated. The mean age of presentation was 38 years. Of the eight patients, five (62.5%) were females and 3(37.5%) were males. Two (25%) patients had tuberous sclerosis with angiomyolipoma, and three (37.5%) patients presented with hypotension. The mean packed cell transfusion was three units, and the mean tumor size was 7.85 cm (3.5-25 cm). Three of them (37.5%) required emergency angioembolization to prevent exsanguination. Embolization was unsuccessful in one patient (33%) who underwent emergency open partial nephrectomy, and one (33%) patient developed post-embolization syndrome. A total of six patients underwent elective surgery-four underwent partial nephrectomy (laparoscopic - 1, robotic - 1, open - 2) and two underwent open nephrectomy. Three patients encountered Clavien-Dindo complications (Grade 1, n = 2 and IIIA, n = 2). WS is a rare, life-threatening complication in patients with large angiomyolipoma. Judicious optimization, angioembolization, and prompt surgical intervention will help deliver better outcomes.

Spontaneous perirenal hemorrhage (Wunderlich syndrome) in the fetus: a case report

BackgroundSpontaneous perirenal hemorrhage (Wunderlich syndrome) in the fetus is a rare urinary system disease. Prenatal ultrasound diagnosis presents challenges due to the lack of specific clinical features.Case presentationA 27-year-old Chinese woman gravida 2 para 0 found her fetus with the left Wunderlich syndrome accompanying bilateral hydronephroses and bladder dysfunction with an early diagnosis through prenatal ultrasound and postnatal magnetic resonance imaging. After a timely emergency cesarean section, the infant was administrated antimicrobial prophylaxis and an indwelling catheter treatment. Ultrasound follow-up showed his urinary system gradually developed normally.ConclusionA fetus with bilateral hydronephroses accompanying bladder dysfunction should be observed because of the risk of spontaneous renal rupture with hemorrhage formation. Ultrasound and magnetic resonance imaging play a vital role in the diagnosis and follow-up of Wunderlich syndrome. Early diagnosis facilitates better pregnancy planning and appropriate care of newborns.

Suburothelial hemorrhage masquerading as renal neoplasms: a case report of antopol Goldman lesion

Renal cell carcinoma (RCC), which accounts for 2-3% of all adult malignancies, is one of the most lethal urologic cancers. They are sporadic in the majority of cases with 4-6% being familial. They are adenocarcinomas arising from renal tubular epithelial cells. They can present with symptoms of loin pain, palpable mass and haematuria. Another rare presentation is spontaneous perirenal haemorrhage which can be seen in up to 50% of these patients. These patients are also predisposed to increased risk of deep vein thrombosis (DVT) due to prevailing pro-thrombogenic state. Management requires radical nephrectomy for localised disease, targeted therapy and cytoreductive nephrectomy for metastatic RCC. Our patient is adult female who was referred to surgical OPD given her history of gross haematuria and right flank pain for 6 days. She is a known case of DVT on treatment with Warfarin for 4 years. A diagnosis of renal malignancy was made, contrast CT was suggestive of solid mass lesion of the upper pole of calyx likely transitional cell carcinoma (TCC)/papillary RCC. She underwent an urgent radical nephrectomy which showed a hard 5×5 cm lump in the upper pole of the kidney, revealing a clot on the cut section. Post-op HPE showed a large subcapsular hematoma in the upper pole with microscopy showing large areas of haemorrhage surrounded by chronic inflammatory infiltrate, likely Antopol Goldman lesion notorious for its similarity to renal malignancy.

Renal tamponade in a patient with hydronephrosis-related Page kidney.

A 48-year-old woman presented with hyperreninemic hypertension and renal dysfunction and was diagnosed with hydronephrosis-related Page kidney. The pathophysiology was "renal tamponade", in which the kidney was compressed by the renal pelvis and Gerota's fascia, resulting in intrarenal microvascular ischemia. Ureteral stent placement promptly improved the hyperreninemic hypertension and renal dysfunction, and additional perirenal fluid drainage gradually improved these conditions. These observations indicated the following three points. First, renal compression-induced renin-angiotensin-aldosterone system upregulation plays an important role in the pathogenesis of Page kidney. Second, physicians should consider perirenal fluid drainage as a therapeutic option in addition to ureteral stenting in patients with hydronephrosis-related Page kidney. Third, bilateral perirenal subcapsular hematomas in this case could be caused by hydronephrosis. Hydronephrosis-induced intrarenal pressure elevation possibly caused chronic perirenal subcapsular hemorrhage at the vulnerable sites of the renal cortex and peeling of the renal capsule from the cortex, resulting in the bilateral massive subcapsular hematomas and Page kidney.

Spontaneous perirenal hemorrhage in a pregnant woman due to the rupture of a simple renal cyst

Renal cysts are diagnosed by ultrasonography, computerized tomography (CT), or urography. A 36-year-old pregnant woman (G2, Ab1, within the gestational age of 38 weeks) with upper abdominal pain starting from two hours ago, vomiting, and nausea was referred to the emergency department. Although abdominal examinations revealed costovertebral angle tenderness, there were no signs of peritoneal irritation, and all vital signs of the patient were in a normal range. Initial investigation results including blood count (Hb: 11.4), BUN/Cr, Na/K, and UA were normal. She underwent a cesarean section (c/s) due to reduced fetal heart rate (FHR). After C/S,the CT scan showed a large left retroperitoneal hematoma with an anterosuperior displacement of the kidney and active bleeding in the cystic lesion of the upper pole of the kidney. Pathological examinations also confirmed a simple cyst. Overall, simple renal cysts should be considered as a rare cause of spontaneous perinatal hemorrhage (SPH) in pregnancy. The diagnosis and treatment of SPH in pregnancy are also critical challenges.

A CASE OF HEMMORRHAGIC SHOCK CAUSED BY WÜNDERLICH SYNDROME

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Wünderlich syndrome (WS) is a rare condition caused by acute renal hemorrhage and characterized by flank pain, flank mass and hypovolemic shock. We report a complex case of WS in an elderly gentleman with left flank pain and nausea. CASE PRESENTATION: An 81-year-old man with diabetes mellitus type 2, end-stage renal disease on hemodialysis, chronic atrial fibrillation on apixaban and coronary artery disease with history of percutaneous coronary intervention on clopidogrel who presented to a tertiary care center with acute onset left flank pain and nausea for six hours. Upon arrival, the patient was found to have a blood pressure of 78/54 mmHg and a ventricular paced rhythm at 70 bpm. His physical examination was significant for tenderness to palpation over the left flank, as well as a palpable flank mass. His hemoglobin at presentation was 12.1 gm/dL but a repeat value resulted 6.6 gm/dL. Computed tomography (CT) of the abdomen and pelvis revealed multiple renal cysts and a 25 x 11 cm hemorrhagic left kidney concerning for a ruptured cyst with extravasation of blood extending to the retroperitoneum along the psoas muscle. The patient was emergently transfused packed red blood cells, four-factor prothrombin complex concentrate and fresh frozen plasma to reverse the effect of his chronic anticoagulation and antiplatelet therapy. A multidisciplinary decision was reached that an urgent nephrectomy would be associated with a prohibitively high perioperative risk, as releasing the hematoma into the retroperitoneum may result in a complex, uncontrollable hemorrhage. The patient subsequently underwent a renal arteriogram and interventional radiology-guided selective embolization of left inferior pole artery. Repeat CT with contrast showed a stable left renal, perinephric and retroperitoneal hematoma. The patient recovered from hypovolemic shock and was successfully weaned off vasopressor support. DISCUSSION: Wünderlich syndrome is a potentially life-threatening condition that requires prompt recognition and management. The most common etiologies are malignant neoplasms (61%) followed by angiomyolipomas (29.1%). Hemorrhagic ruptured cysts are a rare cause of WS, and rupture into the perinephric space is among the rarest presentations. Emergent angioembolization may be effective. Follow-up often includes exploratory laparotomy or laparoscopy. However, if malignancy is not clearly identified on CT imaging, conservative management with repeat imaging is a reasonable alternative. CONCLUSIONS: Although rare, Wünderlich syndrome is a rapidly progressing condition with high mortality that requires time-sensitive diagnosis and emergent management. REFERENCE #1: 1. G Albi, L del Campo, D Tagarro, Wünderlich's Syndrome: Causes, Diagnosis and Radiological Management, Clinical Radiology, Volume 57, Issue 9, 2002, Pages 840-845, ISSN 0009-9260, https://doi.org/10.1053/crad.2002.0981 REFERENCE #2: Zhang JQ, Fielding JR, Zou KH. Etiology of spontaneous perirenal hemorrhage: a meta-analysis. J Urol. 2002;167(4):1593-1596. doi:10.1097/00005392-200204000-00006 REFERENCE #3: Medda M, Picozzi SC, Bozzini G, Carmignani L. Wunderlich's syndrome and hemorrhagic shock. J Emerg Trauma Shock. 2009;2(3):203-205. doi:10.4103/0974-2700.55346 DISCLOSURES: No relevant relationships by Ana de Diego Diaz, source=Web Response No relevant relationships by Jeany Villamizar, source=Web Response No relevant relationships by Ann Vu, source=Web Response

Spontaneous perirenal hemorrhage in systemic lupus erythematosus: a rare case report and literature review

BackgroundSpontaneous perirenal hemorrhage is relatively uncommon but may be life-threatening. There are some challenges in early diagnosis due to the lack of specific presentations.Case presentationWe report a case of spontaneous perirenal hemorrhage in a newly diagnosed systemic lupus erythematosus patient who initially presented with non-specific flank pain. Weakness and unstable vital signs were noted on admission. Abdominal ultrasonography and computed tomography revealed a sizable perirenal hematoma over the left retroperitoneal cavity. Renal arteriography identified active extravasation of contrast media from a distant branch of the left renal artery, and selective embolization effectively obliterated the bleeding spot. After cessation of bleeding, the patient received intensive immunosuppressive therapy for acute kidney injury and encephalopathy due to lupus. Her mental status recovered successfully, and she was withdrawn from short-term hemodialysis.ConclusionsSpontaneous perirenal hemorrhage in the condition of systemic lupus erythematosus was a rare clinical entity with life-threatening potential. Early accurate diagnosis of spontaneous renal hemorrhage requires both detailed clinical examination and radiologic studies. Interventional embolization is essential and effective for both diagnosis and treatment. A high index of suspicion is necessary to avoid missing this potentially fatal syndrome, especially in patients with an increased risk of bleeding.

Acute perirenal hemorrhage after lower limb digital subtraction angiography in one patient with diabetic foot

患者女性，44岁。行下肢动脉造影后2h出现心悸、全身不适，3h出现剧烈腰痛伴烦躁不安及大汗，4h右肾区叩痛明显，右侧腰背部可触及一个大而软的肿块，血压降至88/57 mmHg（1 mmHg=0.133 kPa），急诊彩色超声显示右肾周见约9.9 cm×5.6 cm弱回声团，提示右肾肾周血肿，立即给予止血、输血及扩容，并行急诊右肾动脉造影术，显示右肾下极靠近包膜处可见一血管畸形，造影剂外溢，给予弹簧圈栓塞治疗。术后继续对症处理，病情稳定出院，出院随访10个月，未见任何不适。.

A rare case of spontaneous perirenal hemorrhage - Wunderlich syndrome

Introduction. Spontaneous perirenal hemorrhage or Wunderlich syndrome represents a rare entity in urological settings. The vast majority of the causes are represented by angiomyolipoma and renal cell carcinoma. In other cases, vascular abnormalities, polycystic kidneys, polyarthritis nodosa, or pyelonephritis could represent the cause of perirenal bleeding. The treatment depends on the clinical parameters at the presentation as well as on the possible presence of renal malignancies. Our goal was to present a rare case of a healthy men who presented the idiopathic Wunderlich syndrome. Case outline. We present a case of a 50-year-old patient with spontaneous perirenal hemorrhage that was not due to any defined cause even after a six-months follow-up. Conclusion. In some rare cases of perirenal bleeding, the cause cannot be defined at the presentation, even with today?s advanced radiological imaging methods. Thus, it is important to be aware of the fact that in those cases, a longer follow-up is needed, knowing that the presence of perirenal hematoma can always obscure the real diagnosis. Sometimes, even in cases where the proper follow-up has been done, the real cause of the bleeding remains unknown.

Comparing thoracoabdominal injuries of manual versus load-distributing band cardiopulmonary resuscitation.

To identify and compare manual and load-distributing band (LDB) cardiopulmonary resuscitation (CPR)-related injuries. Retrospective observational cohort study. Adult, nontraumatic deaths with a postmortem computed tomography scan (PMCT) performed were classified into two groups: deceased after LDB CPR or after manual CPR. PMCT scans were reviewed for thoracoabdominal injuries such as fractures, pneumothorax and hemorrhage. The injuries between groups were compared. LDB CPR (n = 43) showed increased incidences of posterior rib fractures (53 vs 18%, P = 0.006), pneumothorax (23 vs 4%, P = 0.04) and more pericardial fluid (median 12 vs 6 mm, P = 0.002) compared with manual CPR (n = 29). Multivariable regression analysis revealed that LDB CPR was significantly associated with posterior rib fractures [odds ratio (OR) 5.37, 95% confidence interval (CI): 1.44-20.09, P = 0.01). Pneumothorax (OR 6.80, 95% CI: 0.73-62.99, P = 0.09) and the amount of pericardial fluid (OR 3.40, 95% CI: 0.20-56.32) were not significantly associated with LDB CPR. No significant difference was found for anterolateral rib fractures, sternal fractures, vertebral fractures, pleural fluid, hemothorax, hemopericardium, pneumoperitoneum, perihepatic, perisplenic and perirenal hemorrhage. Rib fractures, sternal fractures, hemothorax and hemopericardium are common CPR-related injuries. LDB CPR is significantly associated with more posterior rib fractures and a trend toward more pneumothoraces is observed when compared with manual CPR. This knowledge is important for caretakers in the case of ongoing CPR, as a pneumothorax may attribute to not achieving persistent return of spontaneous circulation, and to improve postresuscitation care of survivors.

Treatment of an Atypical Case of Bilateral Nephrolithiasis in a Canine

Background: Less than 5% of canine uroliths are found in the kidney and ureter. The decision to remove a nephrolith is controversial and should be considered in cases of refractory infection, hematuria, presence of obstructive uropathy and compression of the renal parenchyma. The aim of this report is to describe an unusual presentation of bilateral nephrolithiasis in a dog, occupying almost the entire renal parenchyma, its clinical and imaging findings, in addition to surgical treatment and its evolution.Case: A 10-year-old male Basset Hound was evaluated at the Veterinary Medical Teaching Hospital (HCV) of the Federal University of Rio Grande do Sul (UFRGS), presenting prostration, anorexia, vomiting, diarrhea and severe hematuria for three days. On physical examination the patient was dehydrated, with pale mucous membranes, uremic breath and abdominal pain. Blood tests showed mild anemia and azotemia. In both kidneys, abdominal ultrasonography exhibited a large hyperechoic structure with deep acoustic shadowing. These same structures were observed in abdominal radiographic examination as radiopaque structures, confirming the diagnosis of bilateral nephrolithiasis. Urine culture was positive for coagulase-negative Staphylococcus sp. The patient was stabilized with fluid therapy, antiemetic, analgesics, antibiotics and whole blood transfusion. Unilateral nephrotomy of the right kidney was performed to remove the urolith. After three months, nephrotomy of the left kidney was performed to remove the other urolith. The patient was clinically stable and with no macroscopic hematuria 12 h after surgery. Two days after discharge, the patient returned prostrated in lateral recumbency, however with no alteration of parameters in physical examination. Blood tests showed anemia, thrombocytopenia, hypoalbuminemia, azotemia and hyperphosphatemia. The dog presented a convulsive episode and died shortly, eight hours later. In the necropsy examination, extensive loss of renal parenchyma was seen in both kidneys and the presence of thrombosis and areas of infarction in several organs such as spleen, liver, lungs and central nervous system.Discussion: Complications of nephrotomy include perirenal hemorrhage, hydronephrosis due to obstruction of blood clots or urine leakage to the abdominal cavity. From the necropsy findings, the surgical site did not present these complications, justifying that the surgical procedure was not directly related to death. Correction of dehydration, blood transfusion, and antibiotic therapy based on urine culture and susceptibility testing was important for initial stabilization, before surgery. However, the presence of advanced chronic kidney disease may have contributed to deterioration of the patient's clinical condition and death. The presence of thrombus and hemorrhagic areas, observed during necropsy, associated with acute onset of clinical signs and the presence of severe hypoalbuminemia, may suggest that the patient died due to a thromboembolic event, as a consequence of nephrotic syndrome. Studies show that nephrotomy can be performed with few adverse effects on renal function if the surgical technique and anesthetic management are adequate. In this case, nephrotomy was the best option for the treatment of the patient, since it enabled a rapid intervention, controlled the hematuria and allowed the removal of both uroliths without complications related to surgery.

Perirenal hematoma extending to the ipsilateral scrotum region after shock wave lithotripsy treatment

Perirenal hematoma after extracorporeal shock wave lithotripsy (ESWL) is an unusual but underdiagnosed complication. Most hematomas are asymptomatic, but severe complications are possible, which may require intervention such as a blood transfusion. We present the case of a 41-year-old Asian man suffering from a symptomatic huge perirenal/subcapsular hematoma with scrotal hematoma after ESWL; we reviewed the literature and examined the possible risk factors and treatments. This case was a very rare presentation of hematoma extension into the scrotum region from an ipsilateral perirenal hemorrhage caused by shock wave lithotripsy treatment.

Spontaneous perirenal hemorrhage in a patient on an anticoagulant for stroke with severe aortic valve stenosis: Is concern for renal malignancy

Spontaneous perirenal hemorrhage is mainly due to renal malignancy. But its presence in a patient who are on anticoagulant make it challenging for the diagnosis. We report a case of 50-year-old man who presented with brain stroke and started on an anticoagulant. Post anticoagulant treatment he presented with flank fullness. On evaluation, he found to have right perirenal hematoma suspicious of renal malignancy and severely stenosed aortic valve. We did right nephrectomy and aortic valve replacement simultaneous and on histopathologically found to have papillary renal cell carcinoma.

Wünderlich sindrom kao prva manifestacija karcinoma bubrega – prikaz slučaja

Aim: To present a case with spontaneous, non-traumatic, perirenal haemorrhage (Wunderlich syndrome) as a first manifestation of renal cell carcinoma. Case report: A 37-year-old female was admitted to the emergency unit with sudden and severe pain in the left lumbar area of abdomen. She has normal voiding, without macrohaematuria or trauma in her medical history. Because of her generally instable state she was referred to emergency multi-slice computed tomography (MSCT) exam of the abdomen and pelvis which reveals inhomogeneous mass in the upper pole of the left kidney. Radiology report indicated perirenal haemorrhage most likely caused by an angiomyolipoma. The patient was operated on by urologist who performed a partial nephrectomy of the left kidney and evacuation of haematoma. Samples were taken for histopathology and cromophobe renal cell carcinoma which caused the perirenal haemorrhage was diagnosed. Our patient is controlled on regular basis, without signs of tumour recurrence. Conclusion: Wunderlich syndrome as the first manifestation of renal cell carcinoma is a very rare but life-threatening manifestation of renal cancer that warrants urgent surgery. MSCT of the abdomen and pelvis is a method of choice in haemodynamically unstable patients with acute abdominal/lumbar pain.

Specific computed tomography imaging characteristics of congenital mesoblastic nephroma and correlation with ultrasound and pathology

Congenital mesoblastic nephroma (CMN) is a common solid renal tumor in the neonate. Congenital mesoblastic nephroma can be divided into classic, cellular, and mixed types. The prognosis of CMN is very optimistic. But CMN can easily be misdiagnosed as the other malignant renal tumors by radiology. However, no studies have described the computed tomography (CT) imaging appearance of CNM in detail. The objective of this study is retrospective analyses of the multislice CT characteristics of CMN and their corresponding ultrasound findings and pathology. This retrospective study reviewed the enhanced CT images of the CMNs and other renal tumors in children younger than 1 year in the past 10 years from the First Affiliated Hospital of Sun Yat-sen University. Two radiologists had noted the CT imaging characteristics of these images. t-test and Fisher's exact test were used in the comparison of imaging characteristics between the CMNs and other renal tumors. Compared with other malignant renal tumors, the CMNs tend to appear as smaller round masses without clear coverage or clear boundary with the kidney in CT images (P<0.01). The intratumor pelvis and the double-layer sign are the specific characteristics of CMNs (P<0.01). The gender, quality of tumor (solid or solid-cystic), character of enhancement (homogeneous or heterogeneous enhancement), peri-renal hemorrhage, or peripheral lymph node enlargement showed no statistical significance (P>0.05) between CMNs and other renal tumors. The appearances of CMN with classic components in the CT images are relevant to the pathological findings. The intratumor pelvis is caused by the classic components of CMN growing to encapsulate the pelvis. The double-layer sign in CT image correlates with the specific hypoechoic ring in ultrasound, which is caused by the slow blood flow and delay contrast agent filling in the blood sinus located in the peripheral part of the tumor. The differential diagnosis of CMN should include the other solitary renal tumors such as Wilms' tumor, clear-cell sarcoma of the kidney, and rhabdoid tumor of the kidney. The unclear coverage and unclear boundary with the kidney, the intratumor pelvis, and double-layer sign after contrast were specific CT imaging characteristics of CMN.

Nephron-sparing management of Xanthogranulomatous pyelonephritis presenting as spontaneous renal hemorrhage: a case report and literature review

BackgroundXanthogranulomatous pyelonephritis (XGP) is an uncommon infectious disease of the kidney known to mimic other renal maladies. A rare presentation of this uncommon disease is spontaneous renal hemorrhage (SRH).Case presentationWe report a case of XGP in a 58 year old woman who presented with abdominal pain, hematuria, and radiating left flank pain. CT scan was felt to be consistent with perirenal hemorrhage abutting a fat-containing renal mass. The patient was eventually taken to surgery for left partial nephrectomy. Pathology report returned as XGP, and the patient has no complications from this disease process at 8 month follow up.ConclusionOur search of the literature shows XGP presenting as SRH to be a rare clinical entity. Furthermore, this is the first such case managed with a nephron-sparing approach. The “great imitator” XGP should be added to the differential for patients presenting with spontaneous renal hemorrhage.

A preliminary study on classification and therapeutic strategies for spontaneous perirenal hemorrhage

BackgroundThe aim of our study was to report our experience in the classification and therapeutic management strategies for spontaneous perirenal hemorrhage (SPH). MethodsFrom September 2005 to April 2015, 20 patients with SPH were newly diagnosed in our hospital. Their clinical features, image findings, identification of underlying causes, and therapeutic management were retrospectively analyzed, and relevant literature was reviewed. In this study, patients were classified according to the degree of severity of the disease or emergency imaging diagnosis of underlying causes. On the basis of the former, patients were classified as critical and noncritical, and on the basis of the latter, patients were classified as renal cell carcinoma (RCC), undefined solid neoplasm, angioleiomyolipoma (AML), and unknown cause. ResultsIn the acute stage, contrast-enhanced computed tomography (CT) was superior to ultrasonography for both diagnostic accuracy of SPH (p = 0.02) and etiology discovery power (p = 0.004). The results of contrast-enhanced magnetic resonance imaging (MRI) were identical to those of contrast-enhanced CT. We summarized a flowchart in the whole classification and therapeutic strategies of SPH. According to the imaging diagnosis of underlying causes, all the patients with undefined solid neoplasm or RCC underwent emergency operation. Patients with AML or unknown cause underwent selective arterial embolization (SAE) or conservative management according to the critical degree. Acute hemorrhage was controlled in 19 cases, of which 14 were cured by the operation and only one critical patient with severe shock died shortly despite rescue efforts. ConclusionsContrast-enhanced CT or MRI is the first choice of imaging examination, which could not only accurately diagnose SPH but also detect the underlying causes. Choice of therapeutic strategies for SPH should vary according to the identification of critical patients and imaging diagnosis of underlying cause.