British Journal of Urology (1975). 47, 145-148
Atraumatic Rupture of the Kidney A Case Report with Autopsy P. AARDAL and F. HARTVEIT Department of Pathology and Department of Surgery, University of Bergen, Norway
S. TPJNJUM, N.
A comprehensive review of the literature on atraumatic rupture of the kidney by Joachim and Becker appeared in 1965. Spontaneous bleeding from gross lesions in the kidney (secondary haemorrhage) make up the bulk of reports, while reports of spontaneous haemorrhage from “healthy” renal tissue (primary haemorrhage) are very rare and often of doubtful validity (see Table). The present case belongs to this latter group. The condition is difficult to diagnose preoperatively and treatment is open to discussion. Case Report An 89-year-old woman, previously in good health, woke with sudden acute abdominal pain in her right iliac fossa that spread over the whole abdomen and remained constant until she was admitted 10 hours later. On admission she was in great pain. She denied any previous trauma. The blood pressure was l00/50mm Hg, haemoglobin 12.3 g, haematocrit 39 % and other laboratory findings normal. A straight X-ray of the abdomen showed no definite lesions. A clinical diagnosis of peritonitis was made and laparotomy carried out 2 hours after admission. A retroperitoneal haematoma was found mainly on the right side with extensive bleeding into the mesentery. Both kidneys were palpated but appeared normal, the right being thought to be slightly larger than the left. It was considered that as bleeding had already stopped there was little to be gained from exploration of the retroperitoneal space. Postoperatively there was no evidence of continued bleeding and no blood in the urine at operation or later. She died 9 days later of combined cardio-respiratory failure. At autopsy (0.92/73)the operative findings were confirmed and supplemented. The heart was enlarged (400 g) with left ventricular hypertrophy, and dilated, particularly on the right side. The aorta and renal arteries showed extensive atheromatosis but the lumen of the latter was not reduced. The kidneys were of normal size, the renal pelvis and ureters unremarkable. Both kidneys showed arteriosclerotic changes, with a finely granulated surface. The right kidney was surrounded by a subcapsular haematoma up to 1 cm thick that extended into the supra-renal fat. There was a 4 cm in diameter defect in the lower pole of the kidney that was partially filled with organised thrombus (Fig. 1). No definite bleeding point could be defined within or beside this mass, although tortuous grossly arteriosclerotic intralobular arteries were present. Over this area there was a defect in the kidney capsule and the haematoma continued retroperitoneally tracking into the mesentery of the large and small bowel. Here the overlying peritoneum was covered with fibrin. The lungs were oedematous and the parenchymatous organs showed passive venous congestion. Extensive retroperitoneal bleeding following atraumatic kidney rupture with subsequent reactive changes in the peritoneum, and circulatory failure was considered the cause of death. Histology confirmed that the haematoma was sharply demarcated from the renal parenchyma by healthy granulation tissue (Figs. 2 and 3). The parenchyma was well preserved. Some of the glomeruli were sclerotic and the interlobular arteries were arteriosclerotic (Fig. 4). There was no evidence of tumour or of a cyst wall or other renal pathology.
Comment As in this case atraumatic kidney rupture usually presents with sudden abdominal or flank pain accompanied by signs of shock. Haematuria is frequently present (Polkey and Vynalek 1933; Joachim and Becker, 1965; Howalt and Squires, 1971), but was not seen in this case and her anaemia was not striking enough to suggest bleeding. The investigation of choice diagnostically is renal angiography, as in traumatic cases (Elkin, Meng and deParedes, 1966; Halpern, 145
BRITISH JOURNAL OF UROLOGY
Fig. 1. The cut surface of the right kidney showing defect in parenchyma filled with blood clot. Fig. 2. The sharp borderline between kidney parenchyma and blood clot. Mallory’s PTAH. Fig. 3. As Fig. 2-showing
granulation tissue. H & E.
Fig. 4. Arteriosclerotic artery in renal cortex. H & E.
1968). In the present case the diagnosis was made at autopsy. The histological picture with organised blood clot adjacent to healthy renal tissue suggested that the rupture was due to the bleeding rather than vice versa. An arteriosclerotic lesion is most likely although it was not possible to demonstrate the actual vessel with certainty. Atraumatic kidney rupture is rare at present but may be more frequent in transplanted kidneys (Wilson, 1971 ; Ghose et al., 1973), The surgeon is faced with a retroperitoneal haematoma. If the kidney can be defined as the site of bleeding nephrectomy is usually carried out (Polkey and Vynalek, 1933; Joachim and Becker, 1965). However, Howalt and Squires (1971) consider that conservative treatment is indicated as the basic pathology is bilateral, i.e., hypertensive vascular disease involving the smaller vessels
ATRAUMATIC RUPTURE OF THE KIDNEY
Table Cases from the literature of so-called spontaneous rupture of the renal parenchyma, giving author, year, histology, age and blood pressure Case No. 1 2 3 4
5 6 7
Author($ Irwin (1943). US.Naval Med. Bull., 41, 818-820 Levy and Hudson (1951). Brit. J. Urol., 23, 168-170 Murphy and Harney (1951). Ann. Surg., 134, 127-130 Uson et a/. (1959) J. Urol., 81, 388-394 Valtonen (1 966). Brit. J. Urol., 38, 484-487 Howalt and Squires (1971). Am. J. Surg., 123, 484-488 Howalt and Squires (1971). Am. J. Surg., 123, 484-488
Blood pressure (mm Hg)
angiomata and pyelonephritis haernangioma ? cyst? laceration’
“hypertension” (case 6)
(case 1) occlusive vascular disease
Patient denied trauma.
of the kidney. The extent of the bleeding in the present case suggested rupture of a larger vessel, but even so the bleeding had stopped at the time of operation and did not recur. Thus minimal surgery to control the bleeding may be adequate in the absence of gross renal disease, or advisable in bilateral disease, nephrectomy being reserved for bleeding from obvious renal lesions such as tumours that would justify the operation even in the absence of haemorrhage. Survey of the literature (see Table) supports Howalt and Squires’ (1971) view that hypertensive vascular disease is the underlying lesion, and indicates that the complication occurs primarily in middle age. The designation “renal apoplexy” is perhaps not out of place. Summary
A case of atraumatic rupture of the parenchyma of the right kidney with gross retroperitoneal haemorrhage is reported in an old woman. The underlying vascular lesion was probably arteriosclerotic and associated with hypertension.
References ELKIN,M., MENG,C.-H. and DEPAREDES, R. G. (1966). Roentgenologic evaluation of renal trauma with emphasis on renal angiography. American Journal of Roentgenology, 98, 1-26. GHOSE, M. K., KEST,L. M., COHEN,S. M., ROZA,O., BERMAN, L. B., LIDSKY,I., TEITELBAUM, S. and GALVIN, J. B. (1973). Spontaneous rupture of renal allo-transplants. Journal of Urology, 109, 790-795. HALPERN, M.(1968). Angiography in renal trauma. Surgical CIinics of North America, 48, 1221-1233. HOWALT,J. S. and SQUIRES, J. W. (1972). Spontaneous rupture of the kidney. American Journal of Surgery, 123, 484-488. .- . .- - .
JOACHIM. 0.R. and BECKER, E. L. (1965). Spontaneous rupture of the kidney. Archives of International Medicine, 115. 176-183.
POLKEY,.H. J. and VYNALEK, W. J. (1933). Spontaneous nontraumatic perirenal and renal hematomas. Archives of Surgery, 26, 196-218. WILSON,R. E. (1972). In discussion on Howalt and Squires paper. American Journal ofsurgery, 123,488.
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The Authors S. Tenjum, Cand. med., Registrar, Department of Surgery. N. P. Aardal, Cand. med.. Registrar, Department of Pathology. F. Hartveit, M.D., Professor of Pathology.
Requests for reprints should be addressed to: Professor Hartveit, The Gade Institute, Department of Pathology, Haukeland Sykehus, 5000 Bergen, Norway.