Subcapsular Hematoma Research Articles

Biliopleural fistula after penetrating thoracoabdominal injury: A case report.

IntroductionBiliopleural fistula is a rare complication of thoraco-abdominal injury. Due to its rarity, the experience of any one surgeon is minimal, there is a paucity of literature regarding optimal treatment. This case report can be an addition to the existing reports to guide surgeons in better understanding and management of such cases.Case presentationA 30 yrs old male patient presented 2 weeks after he sustained gunshot injury over the right posterior chest. He was referred to our hospital because there was bilious chest tube output. Thoracotomy was done and finding was 10 cm right diaphragmatic defect with lacerated liver oozing bile and subcapsular hematoma that herniated into chest. Clotted blood had trapped the lung with pleural peel. Clot evacuation, decortication, biliary leak and liver laceration repair was done. The diaphragmatic defect was then closed. Patient had smooth postoperative course.DiscussionPatients with BPF after thoracoabdominal injury can present with shortness of breath, bile output through chest tube and pleural effusion. Since bile has corrosive effect on lung with subsequent complications like empyema and bronchobiliary fistula, early diagnosis and treatment are imperative. BPF after thoracoabdominal injury can be effectively managed with thoracotomy, decortication and closure of diaphragmatic defect.ConclusionBiliopleural fistula is uncommon after penetrating thoraco-abdominal injury and high index of suspicion and early diagnosis are of paramount importance to prevent complication. Surgery is best treatment option to stop biliary leak, close the diaphragmatic defect, manage further injuries in the chest and release trapped lung.

Atraumatic Bilateral Renal Subcapsular Urinomas in a Young, Healthy Female

BackgroundUrinomas are rare and generally result from trauma to any part of the urinary collecting system. Appropriate imaging is crucial in the timely diagnosis and management of urinomas and for ruling out other etiologies such as subcapsular renal hematomas and perinephric abscesses. Case ReportA 31-year-old woman with no past medical history or known trauma presented to the Emergency Department (ED) with a week of right flank pain, abdominal pain, and intermittent fevers. On point-of-care ultrasound (POCUS), she was found to have a complex right perinephric collection, later confirmed with computed tomography (CT) imaging. She was treated with intravenous (IV) antibiotics and discharged after a 3-day hospital admission with instructions to follow up with Urology. A day later, she was readmitted with worsening bilateral flank pain and persistent fevers. Image-guided percutaneous aspirations of her bilateral perinephric fluid collections revealed both urine and blood. A right ureteral stent was then placed with ultimate resolution of her symptoms.Why Should an Emergency Physician Be Aware of This? Urinomas without history of trauma are rare and should be on the differential for patients presenting with flank pain and infectious symptoms. Urinomas or other expanding perinephric fluid collections can result in superimposed infection, rupture, secondary hypertension, and renal failure. Here, we present an atypical case of atraumatic bilateral renal subcapsular urinomas with hemorrhagic components in a young and healthy woman. Our case further outlines the utility of POCUS in the ED for the timely diagnosis and management of this disease process.

Robotic assistance for percutaneous needle insertion in the kidney: preclinical proof on a swine animal model

BackgroundWe evaluated the accuracy, safety, and feasibility of a computed tomography (CT)-guided robotic assistance system for percutaneous needle placement in the kidney.MethodsFiducials surgically implanted into the kidneys of two pigs were used as targets for subsequent robotically-assisted needle insertion. Robotically-assisted needle insertions and CT acquisitions were coordinated using respiratory monitoring. An initial scan volume data set was used for needle insertion planning defining skin entry and target point. Then, needle insertion was performed according to robot positioning. The accuracy of needle placement was evaluated upon the distance between the needle tip and the predefined target on a post needle insertion scan. A delayed contrast-enhanced CT scan was acquired to assess safety.ResultsEight needle trajectories were performed with a median procedural time measured from turning on the robotic system to post needle insertion CT scan of 21 min (interquartile range 15.5−26.5 min). Blind review of needle placement accuracy was 2.3 ± 1.2 mm (mean ± standard deviation) in lateral deviation, 0.7 ± 1.7 mm in depth deviation, and 2.8 ± 1.3 mm in three-dimensional Euclidian deviation. All needles were inserted on the first attempt, which determined 100% feasibility, without needle readjustment. The angulation and length of the trajectory did not impact on the needle placement accuracy. Two minor procedure-related complications were encountered: 2 subcapsular haematomas (13 × 6 mm and 35 × 6 mm) in the same animal.ConclusionsRobotically-assisted needle insertion was shown feasible, safe and accurate in a swine kidney model. Further larger studies are needed.

Acute Kidney Injury Revealed by Massive Spontaneous Renal Subcapsular Hematoma in a 58-Year-Old Male

Acute Kidney Injury Revealed by Massive Spontaneous Renal Subcapsular Hematoma in a 58-Year-Old Male

Renal Subcapsular Hematoma after Transurethral Ureterolithotripsy

Subcapsular renal hematoma is a complication of extracorporeal shock wave lithotripsy or percutaneous nephrolithotripsy. Although it can occur after transurethral ureterolithotripsy (TUL), there is no consensus on the risk factors, outcomes, and its management. This study aimed to elucidate the clinical courses of patients with subcapsular hematoma after TUL. We retrospectively investigated 1,235 patients who underwent TUL from October 2011 to December 2020 at our hospital and identified cases with subcapsular hematoma diagnosed after surgery. Subcapsular hematoma was diagnosed in 5 of the 1,235 (0.40%) patients, whose median age was 63 (49-69) years. The median operation time, hematoma diameter, and hemoglobin decrease were 66 (35-115) min, 8.2 (5.4-10.5) cm, and 1.6 (0.7-2.6) g/dl, respectively. All patients were conservatively managed without invasive interventions (eg, embolization), although one patient required blood transfusion. In conclusion, this study presented five cases with renal subcapsular hematoma after TUL that could be conservatively managed. It is important not to miss the timing of therapeutic intervention while observing the progress after diagnosis.

Ultrasonographic features of atraumatic‐pathological subcapsular splenic haematomas in two dogs with confirmed lymphoma

AbstractThis report describes the ultrasonographic features of splenic subcapsular haematoma in two dogs with lymphoma. One dog presented for suspicion of pancreatitis and the other for persistent lethargy; both dogs had peripheral lymphadenomegaly. Abdominal ultrasound showed an avascular, subcapsular, hypoechoic region along the parietal surface of the spleen. Both dogs underwent exploratory laparotomy, during which a splenectomy and biopsies of the liver and lymph nodes were performed. Lymphoma was diagnosed via histopathology in both dogs. Atraumatic‐pathological splenic subcapsular haematomas have been reported in humans with lymphoma, but this is the first known report in veterinary medicine in patients with lymphoma.

The clinical outcomes of flexible ureteroscopy and laser lithotripsy (FURSL) for treatment of the upper urinary tract calculi

To evaluate efficacy and safety of flexible ureteroscopy and laser lithotripsy (FURSL) for treatment of the upper urinary tract calculi. We retrospectively analyzed 784 patients who underwent FURSL between January 2015 and October 2020 in our unit. All patients were preoperatively evaluated with urine analysis, serum biochemistry, urinary ultrasonography, non-contrast computed tomography and intravenous urography. The procedure was considered as successful in patients with complete stone disappearance or fragments < 4 mm on B ultrasound or computed tomography. The operative parameters, postoperative outcomes and complications were recorded and analyzed respectively. The average operative time and postoperative hospital stay were 46.9±15.8 min and 1.2±1.1 days, respectively, among 784 patients. In addition, 746 patients were followed up and 38 patients were lost. In these patients, 700 (93.8%) cases met the stone removal criteria and 46 cases (6.2%) did not meet the stone removal criteria who need further treatment. The stone free rate (SFR) is 92.5%after 1-3 months and SFR of middle and upper calyceal calculi was higher than that of lower calyceal calculi significantly. The most common complications were fever (58/784, 7.4%), gross hematuria (540/784, 68.9%) and lpsilateral low back pain (47/784, 6.0%). The incidence rate of serious complication was 1.28%(10/784), including 5 cases of septic shock and 5 cases of subcapsular hematoma, which were cured after active treatment. FURSL is a reliable treatment for small and medium calculi patients of upper urinary tract. The curative effect of stone removal is clear. The complications are few and the safety is high. However, there are certain limitations to the efficacy in treating larger stone and lower calyceal calculi.

The Tangential Extraperitoneal Retrorenal Approach in Kidney Transplant Biopsy: An Observational Study to Assess Complication and Adequacy Rates.

Introduction: Ultrasound-guided percutaneous kidney allograft biopsy is the gold-standard for pathology work-up. Recent studies postulate better safety and efficacy for tangential approaches, however, there is no recommendation regarding biopsy needle path. In this context, we previously described the unified tangential extraperitoneal retrorenal (TER) approach for standard allograft biopsy. Methods: A single-center retrospective observational study evaluated safety and efficacy of the TER biopsy approach among 250 patients that underwent 330 ultrasound-guided kidney transplant biopsies between January 2011 and May 2020. Results: The overall major complication rate was 0.56% per biopsy attempt (1.21% per biopsy) including blood transfusion, arterial embolization and bladder catheterization for gross hematuria in 0.28, 0.14 and 0.14% of biopsy attempts, respectively (0.61, 0.30 and 0.30% of biopsies, respectively). Minor complications included subcapsular and/or perinephric hematoma, superficial bleeding, arteriovenous fistula and gross hematuria in 12.6, 3.0, 2.5 and 1.4% of biopsy attempts, respectively (27.0, 6.4, 5.5 and 3.0% of biopsies, respectively). Sample adequacy rate was 86.7%, ranging from 82.2 to 94.1% if one or ≥two cores were analyzed, respectively. Residents and consultants yielded similar complication and adequacy rates. Conclusion: According to current literature, ultrasound-guided TER kidney transplant biopsy is a safe and efficient approach eligible for nephrology training.

Right Anterior Sectionectomy for a Subcapsular Hepatic Hematoma Causing Disseminated Intravascular Coagulation Following an Endoscopic Retrograde Cholangiopancreatography

A 29-year-old female diagnosed with an acute cholecystitis and choledocholithiasis in a different medical center, was treated by an ERCP with sphincterotomy, being discharged 4 days later due to pain in the right hypochondrium radiated to the right cervical region and the diagnosis of hospital acquired pneumonia. 11 days after the initial procedure she came to our Emergency Department due to persistent pain in the right hypochondrium. She was hemodynamically stable with 99/62 blood pressure, heart rate of 70 bpm and a temperature of 36 C. The computed tomography scan on admission showed a liver dependent heterogeneous collection, predominantly hypodense with hyperdense material that formed a liquid - liquid level, measuring 157 x 188 x 96 mm with a volume of 1,481 cc that created a mass effect on liver parenchyma, compatible with subcapsular hematoma. A conservative management was proposed but in the fourth day of inpatient stay the hemoglobin levels dropped from 8.6 g/dL to 8.0 g/dL and the platelets dropped from 397 K/mL to 44.4 K/mL in the daily controls. A diagnosis of Disseminated Intravascular Coagulation was made and an urgent exploratory laparotomy was proposed. A big subcapsular hematoma involving segments V – VIII with 1,500 cc of clotted material was found. Drainage and rinsing of the hematoma were made and a right anterior sectionectomy was performed. On postoperative, patient showed no signs of complications. A control CT scan showed a small subphrenic collection with a well-placed drain. The patient was discharged after 7 days with no further complications.

Endoscopic Retrograde Cholangiography-Induced Subcapsular Hepatic Hematoma

Endoscopic retrograde cholangiography (ERC)-induced subcapsular hepatic hematoma is a rare but potentially fatal complication. Right hypochondrial pain is the most common symptom and diagnosis is based on imaging after procedure. Majority can be managed successfully with conservative measures. Angioembolization and surgery may be required in hemodynamically unstable patients. We report a case of ERC-induced subcapsular hepatic hematoma detected laparoscopically following endoscopic stone extraction and managed conservatively.

Splenic cyst following trauma, the intraoperative decision on definitive management

Introduction. Posttraumatic splenic cysts are most commonly the result of blunt force trauma to the abdomen. They usually develop from subcapsular or intraparenchymal hematomas and are typically asymptomatic. Diagnostics includes clinical history and radiological imaging procedures. Surgical treatment is the only curative modality of treatment. Case outline. A 43-year-old female patient, without comorbidities, was admitted to the health institution for additional diagnostics and surgical treatment. Laboratory test results were within the reference ranges, while serological test results for hydatid disease were negative. An abdominal CT examination was subsequently performed confirming a splenic cyst positioned in the central part of the spleen. After a laparoscopic partial pericystectomy of the cyst, we identified another smaller cyst of the spleen. According to the estimation of the surgical team, the intraoperative appearance of the remaining tissue of the spleen was less than a third of the entire spleen. The decision was taken to perform a splenectomy in the best interests of the patient, bearing in mind the possibility of complications Conclusion. Accurate diagnosis of posttraumatic splenic cysts remains a challenge, despite state-of-the-art radiological imaging procedures that are applied. In addition to the well-known modalities of treatment, the laparoscopic surgical approach, i.e., minimally invasive treatment, should be the one of choice, if the situation allows it. The laparoscopic approach is a diagnostic and therapeutic method whose effect can especially be observed when the intraoperative finding differs from the preoperative radiological finding.

Spontaneous subcapsular renal hematoma in a patient with pauci-immune glomerulonephritis

Spontaneous subcapsular renal hematoma is a rare occurrence. We report a 42-year-old male with rapidly progressive glomerulonephritis who developed sudden-onset right flank pain. Imaging showed a large subcapsular collection in the right kidney, for which urgent nephrectomy was done due to hemodynamic instability. Histopathology from the nephrectomy specimen was suggestive of pauci-immune glomerulonephritis with crescents. The patient received pulse methylprednisolone followed by injectable cyclophosphamide.

Sub-Capsular Hematoma of the Liver Complicating Preeclampsia

Subcapsular hematoma of the liver Subcapsular hematoma of the liver (SCLH) is defined as an anatomical-clinical entity corresponding to the appearance of a hematic collection located between the intact GLISSON capsule and the hepatic parenchyma. It is a rare complication of pregnancy with a high maternal-fetal mortality, occurring most often in the context of pre-eclampsia or HELLP syndrome (Hemolysis, Elevated Liver Enzymes, and Low Platelets Syndrome). We report the case of a 25-year-old parturient, primiparous woman, with no previous history, admitted to the emergency room for shock in a 29-week amenorrhea pregnancy. Ultrasound examination revealed a ruptured sub capsular hematoma of the liver. An urgent surgical exploration was required, during which a rupture of the subcapsular hematoma of the liver was revealed, accompanied by a state of hemorrhagic shock. The management consisted in a polytransfusion with suture of the hepatic lesion without paking. The evolution was favorable with clinico-biological normalization and the patient was declared discharged at D10 of her hospitalization.

Hepatic subcapsular hematoma post-endoscopic retrograde cholangiopancreatography requiring embolization.

Endoscopic retrograde cholangiopancreatography (ERCP) placement of biliary stents is the procedure of choice for bile duct strictures. Complications of endoscopic retrograde cholangiopancreatography have a low incidence. Hepatic subcapsular hematoma is uncommon but potentially serious. It is caused by laceration of the bile duct with guidewire or biliary traction during the procedure. Initial management is conservative with supportive measures. In case of hemodynamic instability or superinfection, embolization of the affected branch or even surgery could be performed.

Liver laceration and hemoperitoneum in a premature neonate: a rare case of perinatal trauma

We present a case of a premature very low birth weight neonate who developed abdominal distension and acute anemia on his 2nd day of life, in which a liver laceration was diagnosed. Neonatal hepatic injury is rare but frequently fatal. It usually happens due to perinatal trauma in complicated labor or delivery or when resuscitation maneuvers take place. It can result in a subcapsular hematoma of the liver but can also translate as a simple laceration. When the hepatic capsule ruptures, a hemoperitoneum usually develops. Umbilical vein catheterization, hepatic congestion and an increased bleeding tendency have also been associated with liver injury and hemorrhaging in the neonate. Clinical presentation can vary from abdominal distension to acute anemia or even hemorrhagic shock. Unspecific signs such as lethargy, tachypnea, feeding intolerance, jaundice and laboratory findings of thrombocytopenia, coagulation disturbances and hyperbilirubinemia can occur. Diagnosis may be difficult, and imaging methods are essential. A conservative approach to treatment is usually preferred, even in the case of a hemoperitoneum. In the case described, there was a history of a difficult extraction and need for resuscitation maneuvers at birth. The abdominal radiograph showed a large liver, and ultrasound revealed a hepatic laceration and a hemoperitoneum. Treatment was supportive, consisting of blood components, expectant observation and strict avoidance of abdominal manipulation. Follow-up of the lesion through serial ultrasounds was performed, and the infant survived, recovering well. This case is one of the few in recent literature describing a good outcome in neonatal liver injury. Awareness of the possibility of its occurrence is important, especially in premature neonates, who are at particular risk.

Renal subcapsular hematoma with abscess in severe COVID-19.

Renal subcapsular hematoma with abscess in severe COVID-19.

İdrar Taşı Olan Yaşlı Hastalarda Şok Dalgası Litotripsi Sonrası Taşsızlık Oranını Etkileyen Faktörlerin Araştırılması

Aim: Urinary stone disease is an important disease seen in all age groups, including elderly patients. It can cause kidney failure and urinary infection problems. Shock wave therapy, which is the minimal invasive among the different treatment alternatives, is preferred for kidney and proximal ureteral stones smaller than 2 cm. Studies on the efficacy and safety of this treatment in elderly patients are limited. This study aimed to investigate the factors affecting the stone-free rate (SFR) in elderly patients with urinary stones after shock wave lithotripsy. Material and Methods: The data of 120 patients in the Urology department of Duzce University Faculty of Medicine between 2010 and 2018 over 65 years old who underwent extracorporeal shock wave lithotripsy (ESWL) for urinary system stone disease were evaluated retrospectively. The data obtained from these patients included sex, age, location of the stone (upper, middle, or lower calyx, renal pelvis, ureter), number of shock waves, stone size, and the need for the auxiliary procedure were analyzed. Results: Of the 120 patients, 82 (68.3%) were male and 38 (31.7%) were female. Comorbidity was present in 49 patients. An overall SFR of 65.8% (n=79) was found. The highest SFR was found in middle calyx stones with 79.3% (23 of the 29 patients). Post-ESWL auxiliary procedures were needed in 36 (30%) patients. Two patients developed subcapsular renal hematoma and pyelonephritis. Conclusion: ESWL is an appropriate even the first option for elder male with favorable stone size. Furthermore, ESWL caused acceptable morbidity in older patients.

Treatment of a newborn with birth trauma of the liver with catheter embolization of a vessel

Birth trauma of the liver with the development of subcapsular hematoma and hemoperitoneum is reported extremely rarely. The slow enlargement of the hematoma also results in delayed development of bleeding symptoms. Noticeable clinical manifestations appear simultaneously when the hematoma ruptures into the abdominal cavity. Later, the symptoms develop very quickly that doctors failed to understand the root cause of the bleeding. The diagnosis is established only during autopsy. When conservative therapy is ineffective, open surgery is conducted; however, the surgery is associated with a high risk of unfavorable outcomes. Herein, we present a clinical case demonstrating successful treatment with endovascular embolization of a vessel due to bleeding from a giant subcapsular hematoma of the liver in a newborn.&#x0D; The child was born in a settlement of the Arkhangelsk Region and weighed 3480 grams. A vacuum extractor was used to assist the weak mother during delivery. The child was in a critical condition and suffered from asphyxia. Mechanical ventilation was used. At 10 h after birth, the child was taken to a specialized neonatal center of Arkhangelsk (the helicopter flight took 2.5 h). The intensive therapy continued. Negative dynamics followed. At 25 h after birth, hemodynamic indexes decreased. X-ray and ultrasound investigations of the abdominal cavity revealed a large hematoma in the liver. It occupied the entire area of the right liver lobe. Abdominal bleeding was diagnosed. The child was taken to the X-ray department. The newborn underwent urgent endovascular embolization of the right hepatic artery. The bleeding was stopped, and the childs condition was stable. On follow-up at age 1 year and 5 months, the childs development was in accordance with age, and blood biochemical parameters were within normal limits. Ultrasound data revealed well recovery of the liver structure.&#x0D; With extensive birth trauma of the liver, minimally invasive surgery, i.e., endovascular embolization of vessels, can be considered an alternative option to surgical treatment.

P-O12 Atraumatic Splenic Rupture Secondary to Concurrent Cytomegalovirus and Epstein Barr Virus Infection

Abstract Background Infectious Mononucleosis (IM) is a common viral illness among adolescents and young adults. While most cases are self-limiting, a small number of patient can develop life threatening complications, such as atraumatic splenic rupture (ASR). This is a rare but serious sequelae, and the commonest cause of associated mortality. While Epstein Barr Virus is commonly associated with IM, concurrent infection of cytomegalovirus (CMV) and EBV is rarely reported. Both infections are associated with splenomegaly, however this is usually mild and very rarely results in ASR. Methods We present the case of an immunocompetent nineteen year old male who underwent emergency splenectomy for ASR secondary to concurrent EBV and CMV infection. He presented to the Emergency Department with a five hour history of severe, sudden onset left upper quadrant pain preceded by coughing fit. He reported a one year history of incidental splenomegaly and recent positive monospot test in community. Computerised tomography (CT) of abdomen and pelvis confirmed splenic rupture with large haemo-peritoneum and large sub-capsular haematoma. He was haemodynamically unstable and underwent laparotomy and splenectomy. Results Intraoperative findings included two litres of intraperitoneal blood and large spleen with sub-capsular haematoma; approximately seventeen centimetre diameter and weighed nine hundred and seventy grams. Pathology showed features of non-specific lymphoid hyperplasia. Serum virology confirmed high levels of CMV on polymerase chain reaction with low levels of EBV detected. Virology screening was incidentally repeated post discharge and at this time was consistent acute EBV infection. No alternative cause for splenic rupture or pre-existing splenomegaly has been identified. Conclusions The serology results in this case confirm acute CMV infection with most likely concurrent EBV infection. While we cannot confidently identify which virus caused splenic rupture in this case, ASR is a life threatening condition and an important differential in patients presenting with sudden onset LUQ pain and shock. Splenectomy remains the treatment of choice in haemodynamically unstable patients.

Atraumatic Splenic Rupture is a Rare Complication of Acute Myeloid Leukemia: A Case Report and Literature Review

Introduction: Atraumatic Splenic Rupture (ASR) is a rare but life-threatening clinicopathological phenomenon with limited information on patient features, occurrence, or etiology. Case presentation: A 48-year-old man with no history of the underlying disease presented to the emergency department with abdominal pain. He was admitted with leukocytosis 145x103/µl, hemoglobin 6.4 g/dl, and platelets 15x103/µl, ESR 89mm/h, D-Dimer 1043ng/FEU ml. Sputum test (PCR) ruled out SARS-CoV-2 infection. Due to peripheral blood smear and bone marrow aspiration/biopsy, AML was diagnosed for the patient. On the third day of hospitalization, the patient's abdominal pain intensifies. Ultrasound revealed medium free fluid inside the abdomen and pelvis. The patient was transferred to the operating room to undergo an emergency laparotomy. There was a large hematoma in the spleen with a rupture in its posterior surface. Splenectomy was performed. The histopathological study of the spleen showed leukemic involvement, capsular ruptures, and subcapsular hematomas. Discussion: ASR is an uncommon and lethal complication that is seen in infectious diseases (mainly mononucleosis) and hematological diseases (mainly malignant homeopathies) in more than half of cases. Mortality is approximately around 20%. Some deaths occur before the diagnosis is confirmed, while others occur after surgery, as a result of delayed management and poor patient status. Conclusion: ASR can occur for a variety of reasons, including non-traumatic or idiopathic factors. In the absence of significant trauma, emergency physicians should be aware that splenic rupture can occur. ASR is more likely to present with symptoms similar to the underlying disease.