Spontaneous bilobar subcapsular hematoma of the liver while undergoing anticoagulation therapy: our experience and review of the literature

We report on a case of bilateral subcapsular hematoma of the liver, occurring during treatment with warfarin. A 64-year-old woman was put on long-term warfarin therapy. After a bout of severe right hypochondriac pain, computed tomography (CT) scan showed subcapsular hematoma of the liver. Subsequent CT scan, conservative policy only, showed regression of the hematoma. The patient was discharged from the hospital on the 23rd day. We conclude that a nonruptured spontaneous liver hematoma should not be surgically removed. A conservative management with close observation is the mainstay therapy. A switch from warfarin therapy to another anticoagulation therapy is strongly suggested.     

经皮肾镜术后肾包膜下巨大血肿的治疗（附16例报告）

目的：探讨经皮穿刺置管引流和尿激酶局部注射治疗经皮肾镜术后肾包膜下巨大血肿的价值。方法：经皮肾镜术后形成肾包膜下巨大血肿16例,出血停止1～3周后,在B超定位下行经皮血肿穿刺置管引流术,引流出陈旧性积血后,每间隔2～3d,通过引流管分别向血肿内注射3万U的尿激酶并保留24h,然后充分引流。结果：经皮穿刺置管引流陈旧性积血后,间断注射尿激酶溶解血块,30~35天后复查CT显示血肿明显减小,仅为治疗前的1／19～1／56。16例患者经1～2年随访,无继发性出血、感染、高血压等并发症。结论：对经皮肾镜术后肾包膜下巨大血肿患者行经皮血肿穿刺置管引流,同时应用尿激酶局部注射溶解血凝块,可有效溶解引流。肾包膜陈旧性出血和血凝块,具有推广价值。     

肾包膜下积液（附10例报告）

报告肾包膜下积液１０例，其中４例包膜下尿液囊肿，６例包膜下血肿。主要特点为影像学检查见肾包膜下有液性区征象，局部或全部包绕肾脏。肾包膜下积液是多种疾病肾脏的一种表现，ＣＴ检查是目前确诊最可靠的方法，应尽可能作出病因诊断，以获得理想的治疗。     

A case report of spontaneous rupture of renal cell carcinoma difficult to be distinguished from angiomyolipoma

A 56-year-old woman was admitted with right flank pain as the chief complaint without any trauma. Abdominal and chest computed tomography (CT scan) demonstrated with low-density area in a retroperitoneal hematoma suspected of spontaneous rupture of angiomyolipoma and hematothorax. Superselective transarterial embolization and drainage of the thoracic cavity were performed. Three months later a right renal tumor in perirenal hematoma was revealed by abdominal CT scan and suspected renal cell carcinoma. Right nephrectomy was performed. Histopathology revealed renal cell carcinoma. Including this case, 31 cases of spontaneous rupture of renal cell carcinoma have been reported in the Japanese literature.     

A case of renal subcapsular hematoma caused by paravertebral muscular injection of local anesthetics

We report a case of left renal subcapsular hematoma caused by paravertebral muscular injection of acetylcholine chloride for the treatment of lumbago in a 42-year-old man. Since the patient suffered from left lumbago after paravertebral muscular injection, he consulted us. Excretory pyelography showed a left poor visualizing kidney and computed tomography demonstrated left renal subcapsular hematoma. Conservative treatment was done. After two weeks, drip intravenous pyelogram was normal and after four months computerized tomographic scan demonstrated no renal subcapsular hematoma. The main causes of renal subcapsular hematoma are renal injury, nephritis, renal tumor and renal biopsy. Renal subcapsular hematoma caused by paravertebral muscular injection is rare and three cases of hematoma including this case have been reported in the Japanese literature.     

Nonoperative management of major blunt renal lacerations with urinary extravasation: report of two cases

Two cases of major blunt renal trauma with urinary extravasation managed by conservative treatment are presented herein. The first case: A 13-year-old girl fell from a bicycle. A computed tomographic (CT) scan showed right renal laceration with retroperitoneal hematoma. Renal arteriography showed evidence of fresh arterial bleeding without visualization of the lower pole. She was treated conservatively with superselective arterial embolization of the lower pole. She developed no urinoma with normal renal function. Renal renin and blood pressures stayed within the normal range in follow up studies. The second case: A 12-year-old boy fell from a tree and hit his right flank. A CT scan showed fragmentation of right renal cortex with retroperitoneal hematoma. He was treated conservatively as his vital signs remained stable, no active arterial bleeding was found no renal arteriography and both renal pelvis and ureters were well visualized by intra venous pyelography. Retroperitoneal hematoma was absorbed without formation of urinoma. Renal function remained within normal limits in follow up studies.     

A case of xanthogranulomatous pyelonephritis probably derived from a renal injury

A 56-year-old women was admitted for examination of glycosuria. She had had a blunt trauma onto the left abdomen 2 years ago that could have caused renal injury. Incidentally a left renal mass was detected by ultrasonography as a low echogenic mass. CT scan revealed a 2.5 X 2.5 cm mass with lower density than the kidney. IVP and renal angiography showed no abnormal findings. Under the diagnosis of renal tumor, left nephrectomy was performed. A 2 X 2 cm butter-yellow tumor, was seen in the renal parenchyma including the renal capsule of the upper and lateral part of the kidney. The renal pelvis was normal and there were no suppurative lesions in the kidney. Histopathological diagnosis was xanthogranuloma of the kidney partly containing a subcapsular hematoma. The previous blunt trauma, presence of hematoma and no evidence of suppurative lesions suggested that the etiology of xanthogranuloma in this case was related to renal injury.     

An unusual presentation of a Page kidney 24 days after transplantation: case report

The Page kidney phenomenon is a well recognized entity where an extrinsically compressed kidney results in hypertension and loss of function. This compression is usually caused by a subcapsular hematoma secondary to blunt abdominal trauma or an invasive procedure such as a renal biopsy. We describe an unusual case involving the spontaneous development of a Page kidney 24 days after renal transplantation without any history of preceding trauma. The subcapsular hematoma was detected by a computerized tomographic scan performed as part of the work-up for acute allograft dysfunction. Prompt recognition and early intervention are essential if renal function is to be restored before irreversible damage occurs.     

Page kidney following renal allograft biopsy - early recognition and treatment

Ultrasound- guided percutaneous allograft renal biopsy is commonly done to evaluate graft dysfunction. Complications of renal biopsy are usually minor, and major complications occur only in less than 1% cases. We report a case of allograft renal biopsy which caused a subcapsular hematoma, Page kidney and deterioration of graft function. This was diagnosed by computed tomography (CT) scan, and early surgical intervention led to complete recovery.     

Spontaneous subcapsular hematoma of the kidney]

A case of spontaneous subcapsular hematoma of the kidney is reported. CT scan findings and etiologies are examined in the light of previously published data. An etiology-specific therapeutic strategy for subcapsular hematoma of the kidney is proposed.     

Nontraumatic subcapsular renal hematoma: report of a case

A case of nontraumatic subcapsular renal hematoma was reported. The patient was a 41-year-old woman. She complained of right flank colic pain. Her excretory pyelography showed right hydronephrosis and ureteral stone, and demonstrated a large mass involving the right kidney and medial displacement of its collecting system. Ultrasonic examination and computed tomography revealed right subcapsular renal hematoma. Since we found no malignancy, we made a puncture and drained the lesion. A bloody aliquot was gained and its cytological examination was negative. Her clinical course was uneventful. After 6 months the hematoma was absorbed clearly. A review was made of 38 cases of nontraumatic subcapsular renal hematoma, including our own case. Of these, the cause was unidentified in 17 cases. Hydronephrosis, mostly associated with calculi, renal infarcts, nephritis and renal cell carcinoma followed. Of 38 cases, 2 (5.3%) were of malignant tumor.     

Traumatic renal artery thrombosis with renovascular hypertension

A 15-year-old boy, who tumbled from a fourth-floor window, was transported to our hospital. Enhanced computed tomography (CT) 1.5 h after the injury showed a non-contrasted right kidney, and a repeat CT 6 h after the injury showed a growing retroperitoneal hematoma. The angiography showed complete obstruction of the right renal artery and bleeding from the subcapsular artery, which was successfully embolized. Renovascular hypertension developed on the second day after the injury; therefore, simple nephrectomy was performed.     

肾包膜下积尿的发生原因与处理

目的探讨肾包膜下积尿的病因与处理方法。方法报告12例肾包膜下积尿患者的临床资料。均经影像学诊断,7例为梗阻性积尿,3例为漏尿性,2例病因不明。首先均行经皮肾穿刺引流术。放弃治疗1例;单纯穿刺引流2例;留置双J管内引流2例,1例改行肾裂口修补术;体外冲击波碎石术3例;肾盂输尿管成形术2例;肾输尿管切除术和大网膜包裹肾脏内引流术各1例。结果10例痊愈出院,2例死于肾外恶性肿瘤。结论肾包膜下积尿病因以梗阻性为多见。CT检查有助于确定积尿范围及作病因诊断。及时行肾包膜下穿刺引流为首要的治疗选择,同时针对病因作进一步治疗。     

Subcapsular hematoma of the liver after laparoscopic cholecystectomy

Two female patients underwent an uneventful laparoscopic chloecystectomy (LC) for cholelithiasis. Their past medical history was insignificant. The first patient had diclofenac sodium for her postoperative pain relief. Both patients returned in the early postoperative period with pain in the right hypochondrium. Laboratory investigations revealed elevated leucocytes, C reactive protein (CRP), and deranged liver function tests. A computed tomography (CT) scan showed subcapsular haematoma of liver. CT-guided aspiration of hematoma was done in one case. Both patients improved over a period of time and a follow-up radiological scan showed resolving hematoma. The presentation, diagnostic evaluation, treatment, and possible causes are discussed.     

Bleeding renal angiomyolipoma presenting as duodenal obstruction

We report a case of a 60-year-old woman who had a delayed presentation of duodenal obstruction as a result of a bleeding right renal angiomyolipoma (AML) with retroperitoneal hematoma. Her duodenal obstruction did not improve upon conservative management, and a computed tomography (CT)-guided drainage of the retroperitoneal hematoma was subsequently performed. Post-intervention, CT scan confirmed hematoma resolution, and she was able to resume normal diet afterwards. We present this first reported case of a bleeding renal AML with retroperitoneal hematoma causing duodenal obstruction and discuss on the management of such condition.     

Novel technique for the treatment of large subcapsular renal hematoma: combined use of percutaneous drainage and urokinase injection

Purpose

To evaluate the efficacy and safety of combined use of percutaneous drainage and urokinase injection to treat patients with large subcapsular renal hematoma.

Methods

We retrospectively analyzed the data of 20 patients with large subcapsular renal hematoma who were treated with percutaneous drainage and urokinase at our institutes between 2002 and 2010. Percutaneous drainage of the hematoma was performed after bleeding stopped. Then, urokinase was injected into the hematoma cavity per our protocol every 3 days. During the treatment and follow-up period, the diameter of hematoma was assessed by ultrasonography and enhanced computed tomography (CT) in all cases. Complete blood count, serum creatinine and blood pressure were evaluated as well. Follow-up periods ranged from 12 to 60 months (mean 24.1 ± 11.5 months).

Results

Percutaneous renal hematoma drainage combined with urokinase injection was successfully performed in all the patients. After sufficient drainage, all of the patients were free from their symptoms. The average time to pain relief was 10.8 ± 2.1 days after percutaneous drainage, and the total duration of drainage was 28 ± 5.1 days. Relative to baseline, there was reduction in the diameter of hematoma evaluated by the enhanced CT scan after treatment (from 11.7 ± 3.1 to 2.8 ± 1.0 cm). During long-term follow-up, active bleeding, hypertension, renal function impairment or infectious complications were not found.

Conclusions

This study revealed that combined use of percutaneous drainage and urokinase injection was a safe and effective treatment for patient with large subcapsular renal hematoma.     

Ruptured subcapsular hematoma after laparoscopic cholecystectomy attributed to ketorolac-induced coagulopathy

Ketorolac is the first injectable nonsteroidal antiinflammatory drug used as an analgesic in the perioperative period. However, gastrointestinal bleeding is a risk associated with its perioperative administration. A 23-year-old woman was admitted for elective laparoscopic cholecystectomy. Her medical history was unremarkable except for a complaint of intermittent right upper quadrant pain for several months. The operative procedure was uneventful. Thirty milligrams of ketorolac were given intravenously just prior to termination of surgery. Eighteen hours after surgery, the patient developed right upper quadrant pain associated with tachycardia and hypotension. Abdominal computed tomography (CT) scan demonstrated a large subcapsular hematoma of the liver. A few hours later, the hemodynamic condition worsened, and the patient was taken to the operating room. Laparoscopic exploration showed a ruptured subcapsular hematoma with active bleeding. No evidence of parenchymal injury of the gallbladder bed was found. The hematoma was evacuated and hemostasis was performed laparoscopically. Ketorolac has a strong antiplatelet activity and further acts by the inhibition of platelet function, which may last as long as 24 h after the last administration. Surgeons and anesthesiologists should be aware that ketorolac may cause or aggravate bleeding.     

Three cases of non-traumatic acute subdural hematoma]

The authors present three cases of non-traumatic acute subdural hematoma showing interesting clinical features and operative findings. Case 1: A-50-year-old male was admitted because of sudden headache and epileptic seizure. Computed tomographic (CT) scan showed a right thin subdural hematoma, but cerebral angiography demonstrated no pathological findings, that might cause acute subdural hematoma on the follow-up CT scans. The hematoma changed to a chronic one within only 15 days, which was proved by the operation. Case 2: A 52-year-old male was hospitalized because of loss of consciousness. CT scan revealed a right subdural hematoma without subarachnoid hemorrhage and cerebral angiography demonstrated a right middle cerebral artery aneurysm. The hematoma was surgically proved to be due to rupture of the aneurysm. Case 3: A 52-year-old male was admitted because of headache, vomiting and left motor weakness. CT scan showed a thick right subdural hematoma and right carotid angiography revealed two internal carotid artery aneurysms. It was surgically certified that the subdural hematoma was caused by a tear in a cortical artery attached to the dura, not by the rupture of the aneurysms. Clinical cause and pathogenesis of so-called "non-traumatic" or "spontaneous" acute subdural hematomas were discussed, and the importance of emergency angiography for this condition is stressed.     

Posterior fossa subdural hematoma in neonates: report of two cases and review of the literature

Posterior fossa subdural hematoma in neonates caused by birth trauma is rare; only 30 clinical cases can be found in the literature so far. Here we experience two similar cases and review that literature. Case #1 is that of a full-term female born in the pelvic position. At 21 hours after birth she developed convulsions and a CT scan revealed a high-density area, mainly in the right posterior fossa. On the fourth day, a right suboccipital craniectomy was performed and about 15 ml of hematoma was removed. At present her mental and somatic development is appropriate for her age (5 months), despite the fact that moderate brain atrophy was seen in the CT scan taken at 4 months. Case #2 is that of a full-term female also born in the pelvic position. At 38 hours she became convulsive and opisthotonic; a CT scan revealed a high-density area in the posterior fossa. No neurological abnormality was seen thereafter, however, and she was treated conservatively. On the 18th day, the high-density area in the CT scan had almost disappeared. In the CT scan taken at 6 months moderate brain atrophy was seen, but at the present age of two she evidences quite normal development both mentally and somatically. These cases lead us to emphasize the importance of prompt diagnosis followed by removal of hematoma, and the usefulness of CT scan as a diagnostic method in clinical manifestations of this sort.     

Renal cell carcinoma in acquired cystic disease of the kidney manifested by spontaneous renal hemorrhage

Acquired cystic disease of the kidney (ACDK) is a common phenomenon in long-term adult dialysis patients with end-stage renal disease. Renal hemorrhage and neoplastic transformation of the cyst are two major complications of this entity and these two can occur independently. Here we describe a 65-year-old man with a history of hemodialysis-dependent end-stage renal failure for 12 years presented with macroscopic hematuria and right flank pain. Investigations revealed right massive perirenal and subcapsular hematoma with ACDK. The hemorrhagic state required nephrectomy of the right kidney. Histological study showed ACDK with massive subcapsular and perinephric hematoma containing minimal clear cell carcinoma region(0.5 cm in diameter). Although a causal relationship between renal hemorrhage and renal cell carcinoma in this patient was unproven, the present case suggests radical surgery can be a recommendable treatment modality of hemorrhagic ACDK.