Active renal extravasation with large subcapsular and retroperitoneal hemorrhage

Case contributed by Michael P Hartung


Sudden onset of severe left flank pain.

Patient Data

Age: 75 years
Gender: Female

Left renal active extravasation with massive subcapsular hemorrhage. Bleeding appears to originate from the left interpolar cortex. Blood products extend into and throughout the retroperitoneum. Mass effect and deformity of the kidney and abdominal organs.

Small area of hypodensity in the posterior gastric body which does not change on arterial and portal venous phase images, likely ingested material. Few areas of strandy enhancement along the leftward aspect of the gastroesophageal junction seen only on portal venous phase images, favoring a varix based on appearance on the coronal and sagittal reformats, less likely small venous bleed.

Subtle, nodular contour of the liver with a small number of perihepatic ascites. Trace pleural effusions with basilar atelectasis.

Case Discussion

This patient was hemodynamically unstable, required multiple blood transfusions and pressors, and was immediately transferred to the angiographic suite and underwent embolization coiling of the left posterior branch of the renal artery (images unfortunately not available).

Renal hemorrhage can happen as a result of trauma, in the setting of vasculopathy (such as polyarteritis nodosa), or from a neoplasm (most commonly AML or RCC).

This patient was not anticoagulated. However, some degree of coagulopathy may be present given the subtle findings of cirrhosis and history of substance abuse (positive for cocaine and amphetamines). There was also report of possible falls. 

Given the size of the hemorrhage, it would be appropriate to perform follow-up imaging to ensure no underlying mass. It would not be advisable to do further evaluation with MRI or ultrasound urgently, as most subtle findings would be obscured by the large amount of blood products, greatly limiting the sensitivity of these examinations. Additionally, a negative MRI or ultrasound at the time of presentation would not obviate the need for follow-up.

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