Indian Journal of Urology
CASE REPORT
Year
: 2001  |  Volume : 18  |  Issue : 1  |  Page : 70--73

Spontaneous retroperitoneal haemorrhage: Diagnostic and therapeutic approach


Arvind Goyal, K Gaitonde, S Nagaonkar, SN Sagade, MH Kamat 
 Department of Urology and Kidney Transplant, P.D. Hinduja National Hospital and Medical Research Centre, Mumbai, India

Correspondence Address:
Arvind Goyal
381/17A, Krishna Nagar, Civil Lines, Ludhiana - 141 001
India

Abstract

Spontaneous retroperitoneal haemorrhage may occur due to variety of causes, but absence of trauma is stressed. In our study often cases, the commonest cause was angiomyolipona (6 cases). Clinical presentation varied, from mild flank pain to shock and oliguria. Ultrasound may be the initial test but CT scan remains the gold standard for diagnosis. Angiography is helpful to look. for vascular defects, and arteriovenous malformations in small renal cell carcinoma. Management varies from conservative approach to radical nephrectomy, depending on etiology.



How to cite this article:
Goyal A, Gaitonde K, Nagaonkar S, Sagade S N, Kamat M H. Spontaneous retroperitoneal haemorrhage: Diagnostic and therapeutic approach.Indian J Urol 2001;18:70-73


How to cite this URL:
Goyal A, Gaitonde K, Nagaonkar S, Sagade S N, Kamat M H. Spontaneous retroperitoneal haemorrhage: Diagnostic and therapeutic approach. Indian J Urol [serial online] 2001 [cited 2019 Aug 24 ];18:70-73
Available from: http://www.indianjurol.com/text.asp?2001/18/1/70/37456


Full Text

 Introduction



Spontaneous retroperitoneal hemorrhage is an uncommon condition that occurs because of bleed either from the kidney or less often from adjacent retroperitoneal structures. The most common renal causes being angiomyolipoma and renal cell carcinoma. Vascular diseases such as polyarteritis nodosa, renal artery aneurysm, infections of kidney such as cortical abscess, pyelonephritis and renal cysts are occasional etiologic factors. Adrenal haemorrhage is seen with severe stress conditions as sepsis. burns or trauma. Patients with pheochoromocytoma, adrenal carcinomas, cortical adenomas also contribute as causes of retroperitoneal haemorrhage. Clinical presentation depends on the amount of bleeding ranging from mild flank pain to shock and oliguria. CT scan is the gold standard for diagnosis in such patients, as it localises the pathology and also demonstrates the extent of bleed.

 Materials and Methods



We treated ten patients with spontaneous retroperitoneal haemorrhage ranging from 24 years to 65 years of age during the years 1987 to 1998. Six of the patients were male. Angiomyolipoma was the commonest diagnosis (6 cases), with most of the patients presenting with shock and flank pain. Renal carcinoma was diagnosed in one patient, while the other patient had adrenal carcinoma with renal artery aneurysm. Of the other two cases one had coagulopathy following septicaemia while the cause could not be ascertained in one patient.

Ultrasonography was done as the initial investigation followed by CT scan to localise the etiology and exact extent of haematoma. Nephron sparing surgery was performed in cases diagnosed to have angiomyolipoma where substantial parenchyma could be spared (4 cases). Nephrectomy was done in the two cases of angiomyolipoma where only a small part of kidney was normal. Radical nephrectomy was performed in case of renal cell carcinoma. Aspiration of haematoma under ultrasound guidance sufficed in case of coagulopathy following septicemia. One patient underwent exploration with drainage of haematoma. On long term follow-up, he is asymptomatic with normal kidneys.

 Discussion



Non traumatic retroperitoneal bleed may be limited to perirenal area or may occupy large retroperitoneal areas. Absence of trauma has been stressed in all cases. In a series of fifteen cases of retroperitoneal haemorrhage, by Machuca et al,[1] six cases had angiomyolipoma, three cases attributed to renal cell carcinoma while pheochromocytoma, cortical adenoma, myelolipoma. ureteral calculi and idiopathic contributed one case each. One case was due to abnormal coagulation profile caused by anti coagulant drugs, while cause could not be determined in one case. Brkovic D et al[2]- have presented a series of eighteen cases, where four were because of angiomyolipoma, two due to renal cell carcinoma, four of polycystic kidney, three of panarteritis nodosa and one each attributed to pyelonephritis, glomerulonephritis, vascular disease, and cortial adenoma.

Clinically, these patients have variable presentation depending on degree and duration of bleed. Mild flank and upper abdominal discomfort in case of minimal bleed to patients presenting in shock with oliguria in case of massive blood loss. Nausea, vomitting, low grade fever and a decreasing haemoglobin are common findings. Urine examination is frequently normal. Subscapsular haematomas do not reach as large a size as when bleeding is into the perinephric space, because of the tamponade effect of the renal capsule. This tamponade effect is not possible with distensible gerota's fascia and hence the perinephric haematoma may attain very large size.[3]

IVP, though used occasionally is non specific, showing poor renal visualization, with ureteral displacement and obliteration of psoas margin. Ultrasound is a rapid non-invasive test to localize the haematoma extent and probably look at primary pathology. CT scan remains the gold standard not only to diagnose the cause of bleed but also to exactly localize the extent of haematoma. CT scan in case of subcapsular haemorrhage will demonstrate the haematoma confined by renal capsule with parenchymal flattening. With haemorrhage into the perinephric space, the CT scan will reveal an abnormal soft tissues density with displacement, compression or obscurity of normal retroperitoneal structures. As the haematoma ages, the density may decrease, while contrast enhancement of a subcapsular or perinephric haematoma does not occur unless active bleeding is taking place.[4]

Selective renal angiography is used to diagnose vascular defects and also to look for arteriovenous malformations in small renal cell carcinoma, in a patient with non conclusive CT scan. Flattened renal parenchyma compressed by haematoma is clearly seen in extracapsular haematomas. Capsular arteries remain close to the capsule in subcapsular haemorrhage. In perinephric haematoma, capsular arteries are displaced away from the capsule.[5],[6]

Nephron sparing surgery is warranted in case of angiomyolipoma as the disease is benign. However, radical surgery is necessary for carcinoma of the kidney or adrenals. In patients with unexplained cause of haemorrhage and normal CT and angiography the possibility of a small renal cell carcinoma is to be kept in mind while planning surgery. Richard Kendall et al[3] strongly support radical nephrectomy in such cases in presence of normal contralateral kidney as more than sixty percent of such patients in their series had renal cell carcinoma on sectioning by the pathologist.

Howalt and Squires[7] have advised conservative management in case diagnostic studies fail to demonstrate significant etiology. Conservative approach has also been supported by Swift and associates[8] if no etiology is found. Chatterjee T et al[9] have advocated interventional radiology as a modality in form of super selective tumour embolization in case of very large angiomyolipomas in view of the risk of bleeding.

 Conclusion



Spontaneous retroperitoneal haemorrhage is an uncommon occurrence and is easily diagnosed by ultrasonography or CT scan. Occasionally angiography is needed. Treatment depends on the cause of haemorrhage ranging from drainage of haematoma to radical surgery. Patients presenting with retroperitoneal haemorrhage and having a normal CT scan and angiography should be viewed with suspicion because of high incidence of small renal tumours in these patients.

References

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2Brkovic D, Moehring K, Doersam J et al. Aetiology, diagnosis and management of spontaneous perirenal haematomas. Euro Urol 1996: 29: 302-307.
3Kendall AR, Senayba, Coll ME. Spontaneous subcapsular renal haematoma: Diagnosis and management. J Urol 1988; 139: 246-250.
4Sagel SS, Siegel MJ. Stonely RJ, Jost RG. Detection of retroperitoneal haemorrhage by computed tomography. Am J Roentgen 1977; 129: 403.
5Meyers MA, Whalen JP, Evans JA. Diagnosis of perirenal and subcapsular masses: anatomic-radiologic correlation. Am J Roentgen 1974: 121: 523-538.
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9Chatterjee T. Heindel W. Vorreuther R et al. Recurrent bleeding of angiomyolipoma in tuberous sclerosis. Urologia Intenationalis 1996: 56: 44-47.