Severe Retroperitoneal Hemorrhage Research Articles

A Giant Renal Angiomyolipoma: A Case Report

Background: The most common solid benign renal tumors are angiomyolipomas (AMLs). They are highly vascularized and contain smooth muscle and adipose tissues. Perivascular epithelioid differentiation is characteristic for AML. Radiological imaging plays an important role for diagnosis of these tumors which usually are found incidentally, but sometimes symptoms like flank pain, gross hematuria, or severe retroperitoneal hemorrhage may also exist. Case Details: In this study, we will present a 20-year-old male patient who came to the emergency department with right sided abdominal pain for one day duration of sudden onset, associated with generalized weakness, vomiting and dysuria. The patient was diagnosed to have a huge right renal angiomyolipoma (sized 18 x 13.5 x 32 cm), compressing the liver, crossing the midline, and reaching below right iliac crest. The management was by right nephrectomy in our Prince Hussien Urology Center. The follow-up period was for 6 weeks in our urology clinics. Conclusion: In our case report the angiomyolipoma was larger than 30 cm. So, awaring about the presentation of huge angiomyolipoma and its complications is mandatory due to the rarity of these cases (> 20 cm). Therefore, in the future we can deal with them in a good manner.

Massive retroperitoneal haemorrhage after retrograde pyelogram in end-stage kidneys: A case report

Severe retroperitoneal haemorrhage after retrograde pyelogram (RPG) is rare and has not been reported in the literature. One of the few indications for performing RPG in end-stage kidneys is evaluation of the upper urinary tract for malignancy. We present a rare case of massive retroperitoneal haemorrhage in a 58-year-old man, with a history of deceased donor kidney transplantation for end-stage kidney disease (ESKD), following bilateral RPG for the evaluation of urothelial cancer. The bleeding was successfully stopped with renal artery angioembolisation. This case demonstrates the importance of exercising extra caution when performing endoscopic procedures in patients with ESKD and keeping the intrarenal pressure as low as possible.

Acute Retroperitoneal Hemorrhage Induced by Giant Adrenal Myelolipoma Mimicking Renal Colic Pain: A Case Report

Retroperitoneal hemorrhage is a life-threatening clinical entity which is difficult to diagnose due to numerous etiology and unspecific symptoms. Spontaneous severe retroperitoneal hemorrhage, known as Wunderlich’s syndrome presented with Lenk’s triad, includes acute flank pain, flank mass, and hypovolemic shock. Giant adrenal myelolipoma causing Wunderlich’s syndrome is rare. Here, we presented a 59-year-old woman with spontaneous acute onset persistent left flank pain. The kidney, ureter, and bladder (KUB) study revealed left renal stones. The abnormal D-dimer level and progressive symptoms alerted emergency physicians to intervene timely. The computed tomography (CT) scan revealed a giant adrenal mass with retroperitoneal hemorrhage. After hemodynamically controlled and surgical intervention, she recovered and was followed up at the outpatient department (OPD). In this article, we highlight that myelolipoma-induced spontaneous retroperitoneal hemorrhage may cause Wunderlich’s syndrome and lead to hypovolemic shock. It is important for emergency physicians to intervene timely. Early diagnosis and management lead to a better outcome.

Severe retroperitoneal haemorrhage in the first trimester of a multiple pregnancy after spontaneous rupture of renal angiomyolipoma

Tuberous sclerosis (TS) is a neurocutaneous hereditary disease with typical growth of benign tumours called hamartomas in different anatomical locations. Potentially, TS can affect every tissue in the body. Most frequent manifestations are hamartomas in the skin, brain, kidneys, heart, etc. [1, 2]. It is a rare disease with a prevalence in the population 1:10000 and incidence 1:6000, occurring almost identically in all races, ethnic groups and both genders. It can vary from ‘‘only’’ cosmetic skin defects to severe organ damage [3, 4]. The most important diagnostic criteria are cerebral lesions causing epileptic seizures, mental retardation, psychiatric disorders and skin lesions, cardiac rhabdomyomas and renal angiomyolipomas [5, 6]. Final diagnosis is based on DNA analysis. The life-threatening complication associated with haemodynamic changes in the pregnancy is rupture of renal angiomyolipoma [7, 8]. In our case, a 30-year-old patient, primigravida, primary observed for TS, was referred to the hospital in the 9th week of gestation. The patient complained of left lumbosacral pain. Tenderness of the abdomen was present, the colour of the patient’s skin was pale, tapotement was positive. Other clinical signs were hypotension, tachycardia and subfebrility. Ultrasonography of the pelvis described an intact multiple pregnancy—biamniotic bichorionic twins in the 9th week of gestation, the cul de sac and vesicouterine excavation were full of fluid (Fig. 1). Ultrasonography of the kidneys showed left renal mass. Laboratory tests identified severe acute anaemia. Because of haemodynamic instability of the patient, unsuccessful aggressive intravenous volumotherapy and progressive worsening of the blood count, it was not possible to extend the diagnostics to MRI or CT scan. The patient was indicated for an urgent laparotomy. By the revision of the whole peritoneal cavity sanguinolent fluid, intact peritoneum and giant violet retroperitoneal mass (30 cm) in the area of the left kidney was found. By the revision of the retroperitoneal space a giant profusely bleeding tumour surrounded with blood clots was confirmed. The total intraoperative blood loss was more than 5,000 ml, the patient was adequately substituted. Haemostasis was finally achieved by left nephrectomy with ‘‘in toto’’ extirpation of the tumour mass. The histopathological finding of the tumour (21 9 12 9 8 cm) was multiplicite angiomyolipoma (Figs. 2, 3). The subsequent ultrasound examination after the operation confirmed an intact pregnancy. Because of the severity and early onset of the complications, it was not possible to continue in the pregnancy and a therapeutic abortion was indicated. In the retrospective studies of renal tuberous sclerosis and their complications 89.1 % of cases were complicated in average gestational age at 27th week. These situations were usually described in singleton pregnancy [9]. In the report, we present this complication as a very early onset during the multiple pregnancy. Gimeno et al. refer the mode of the surgical management in case of the ruptured angiomyolipomas—total nephrectomy was indicated in 79 % of cases, polar nephrectomy, selective arterial embolisation or conservative management were performed rarely [10]. In reported V. Ferianec M. Gabor (&) P. Papcun K. Holomaň 2nd Department of Obstetrics and Gynaecology, University Hospital Bratislava, Comenius University, Ružinovska 6, Bratislava, Slovak Republic e-mail: martingabormd@gmail.com

Spontaneous rupture of adrenal haemangioma mimicking abdominal aortic aneurysm rupture

Serious bleeding from a ruptured adrenal mass limits preoperative diagnostics and can necessitate urgent laparotomy to control blood loss. A 45-year old man underwent an emergency laparotomy due to severe retroperitoneal haemorrhage causing hypovolaemia. Detailed retroperitoneal dissection after splenectomy and clamping of the abdominal aorta revealed bleeding from a ruptured haemangioma of the left adrenal gland. Following a left adrenalectomy, the patient returned to a stable haemodynamic state. Adrenal haemangiomas are rare, but may cause spontaneous life-threatening haemorrhage.

Death during percutaneous transluminal coronary angioplasty (PTCA) and the medicolegal aspects

Coronary embolisation is a very rare complication of the clinically widespread method of percutaneous transluminal coronary angioplasty (PTCA). The well-documented case of a 64-year-old male patient is presented comparing angiographic and morphological findings. The occluded left anterior descending artery (LAD) was successfully dilated during PTCA. Simultaneously the circumflex artery showed acute occlusion. The patient fell into cardiac shock and died after attempted resuscitation and agonal installation of extracorporeal circulation. The autopsy revealed severe residual stenosis of the proximal LAD by parietal thrombosis and occlusion of the proximal circumflex artery by an unattached intraluminal thrombus (0.8×0.3×0.2 cm) which had been dislocated during PTCA. Autopsy thus confirmed the clinical presumption of coronary embolism and, in addition, disclosed a previously unknown perforation of the femoral artery which had occurred during agonal installation of extracorporeal circulation and contributed to death via severe retroperitoneal hemorrhage. The case is discussed under the aspects of clinical quality control by forensic pathological investigations.

Spontaneous rupture of the abdominal aorta without pre-existing aneurysm — Two case reports

Rupture of an abdominal aortic aneurysm is a catastrophic event, with the risk of rupture being largely dependent upon the size of the aneurysm. Rupture may also occur in a non-aneurysmal aorta, generally as the result of one of a limited number of well defined causes, such as abdominal trauma, 1'2 abdominal surgery, 3 interventional radiology, or infection. 45 We report two cases of patients with a rupture of a nonaneurysmal aorta, the first presenting as a false aneurysm, the second as a frank and severe retroperitoneal haemorrhage. In both cases, none of the above ment ioned causes for spontaneous rupture were responsible.

Bone‐marrow biopsy of the iliac bone followed by severe retroperitoneal hemorrhage

Bone‐marrow biopsy of the iliac bone followed by severe retroperitoneal hemorrhage

A CASE OF SEVERE PELVIC FRACTURE WITH CARDIAC TAMPONADE

The present paper reports a case of severe pelvic fracture resulting in hemoperitoneum, hemothorax and cardiac tamponade. A 31-year-old woman was found unconcious after plunging from the third floor of a building in an attempted suicide. She was in shock and her blood pressure was 50 mmHg by palpation on arrival. Since roentgenography revealed pelvic fracture and bilateral leg fracture, and no other traumas were noted, she was diagnosed as having hemorrhagic shock due to pelvic fracture. On the 2nd day exploratory laparotomy was performed for suspected hemoperitoneum because her hemodynamic state was not stabilized by massive blood transfusion. Severe retroperitoneal hemorrhage and small amount of blood in the abdominal cavity, which was presumably exuded from the retroperitoneum, were found. On the 5th day the patient presented elevated CVP and tachycardia. Diagnosis of hemothorax and cardiac tamponade was made by chest roentgenography and echocardiography. Her hemodynamic condition became stable after a massive amount of bloody pleural fluid and bloody pericardial effusion was discharged by drainage of the thoracic cavity and drainage with pericardiotomy. As shown in the present case, patients with pelvic fracture tend to develop not only retroperitoneal hemorrhage but various pathological conditions. Therefore, careful management of their general condition, including respiration and circuration, as well as prompt and appropriate care, are required in addition to treatment of fracture.

LIGATURE OF THE INTERNAL ILIAC ARTERY FOR MASSIVE HAEMORRHAGE COMPLICATING FRACTURE OF THE PELVIS

1. Three cases of severe retroperitoneal haemorrhage complicating fractures of the pelvis are described. In two patients haemorrhage was immediately controlled by ligation of the internal iliac artery. The third patient died before the bleeding could be controlled. 2. Ligature of the internal iliac artery may be a life-saving measure when fracture of the pelvis is complicated by severe haemorrhage.