Traumatic kidney devascularisation and bowel/mesenteric injuries

Case contributed by RMH Core Conditions

Presentation

High speed MVA.

Patient Data

Age: 20
Gender: Female

There is non-enhancement of left kidney. There is abrupt non-enhancement of the left renal artery approximately 8mm from its origin - ? transection or dissection. There is contrast extravasation within the left anterior pararenal space, likely from a mesenteric artery. There is haematoma within the anterior pararenal and posterior pararenal spaces. There is a small amount of free fluid within the pelvis and in the right paracolic gutter. No gross bowel abnormality demonstrated. The liver, spleen, pancreas, adrenal glands and right kidney are unremarkable. Previous cholecystectomy noted. There is a oblique horizontal fracture through the right pedicle of L2, which extends into the right lamina and spinous process and anteriorly to involve the right posteroinferior corner of the L2 vertebral body. Subcutaneous fat stranding noted in the left flank region. 

Conclusion Left renal artery devascularisation, secondary to either dissection or transection of the left renal artery. Active bleeding in the left anterior pararenal space - bleeding vessel unclear from CT (likely mesenteric artery). T12 and L2 vertebral fractures.

Angiography confirms occlusion of the left renal artery just beyond its origin. It is unclear whether this represents dissection or transection though given the relatively small haematoma in the vicinity of the left renal artery, a dissection is favoured.

Inferior mesenteric angiography demonstrates a discontinuous segment in the mid descending colon (marginal artery fails to fill over a distance of 7cm). This is in close proximity to the anterior pararenal bleeding. The possibility of mesenteric artery tear with subsequent occlusion is raised.

The left renal artery stump was coiled using 4 mm x 15 cm and a 3 mm x 12 cm Interlock detachable microcoils. 

Patient proceeded for trauma laparotomy, nephrectomy and bowel resection. 

Histopathologically confirmed injuries:

1. Left kidney: Haemorrhagic infarction and renal arterial thrombus.

2. Proximal jejunum: Traumatic perforation and peritonitis.

3. Large bowel: Focal ischaemic mucosal changes. Arterial and venous mesenteric recent thrombi.

4. Splenunculus: Congested but otherwise unremarkable spleen.

Case Discussion

Injuries sustained: 

  • devascuarlised left kidney
  • mesenteric and bowel injury to descending colon and proximal jejunum
  • multiple fractures

 

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Case information

rID: 28445
Case created: 26th Mar 2014
Last edited: 14th Mar 2016
Inclusion in quiz mode: Included

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