Case Report คำÒสำÒ ญ: ภาวะไตขาดเล อด, ยาค มกำาเน ด, เล อดค งหล งช องท อง
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1 ส ÅÒ¹ ÃÔ¹ à àçªสòã» Õè 31 ฉบ บท 6 พ.ย.-ธ.ค Songkla Med J Vol. 31 No. 6 Nov-Dec 2013 Case Report ภาวะไตขาดเล อด: รายงานผ ป วย 1 ราย ท ม ภาวะ เล อดค งหล งช องท องเป นอาการนำÒ ธน ญญ เพชรานนท มณฑ รา ต ณฑน ช* ช ศ กด ปร พ ฒนานนท วาท ต กาญจนวน ชก ล Renal Infarction: Report of a Case Presenting with Spontaneous Retroperitoneal Hematoma. Tanan Bejrananda, Monthira Tanthanuch, Choosak Pripatnanont, Watid Karnjanawanichkul Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand. * monthira.m@psu.ac.th Songkla Med J 2013;31(6): บทค ดย อ: ภาวะเล อดค งหล งช องท องพบได ไม บ อยในเวชปฏ บ ต ท วไป แต ส งผลต อช ว ตผ ป วยเม อเก ดความล าช า ในการว น จฉ ย รายงานผ ป วยไตขาดเล อดท ม ภาวะเล อดค งหล งช องท องเป นอาการนำา ซ งเป นสาเหต ท พบได ไม บ อย รายงานผ ป วยหญ งไทยค อาย 42 ป ม ประว ต การใช ยาเม ดค มกำาเน ดเป นเวลานาน มาโรงพยาบาล เร องป สสาวะเป นเล อด การว น จฉ ยด วยเอกซเรย คอมพ วเตอร พบเล อดค งหล งช องท อง ผ ป วยได ร บการร กษา ด วยการต ดไต และผลการตรวจทางพยาธ ว ทยา รายงานภาวะไตขาดเล อด สร ป: รายงานผ ป วยท ม ภาวะไตขาดเล อดซ งม ประว ต ร บประทานยาค มกำาเน ดร วมด วย โดยม ภาวะเล อดค ง หล งช องท องเป นอาการนำา คำÒสำÒ ญ: ภาวะไตขาดเล อด, ยาค มกำาเน ด, เล อดค งหล งช องท อง ภาคว ชาศ ลยศาสตร คณะแพทยศาสตร มหาว ทยาล ยสงขลานคร นทร อ.หาดใหญ จ.สงขลา ร บต นฉบ บว นท 22 ม นาคม 2556 ร บลงต พ มพ ว นท 21 กรกฎาคม
2 ภาวะไตขาดเล อด: รายงานผ ป วย 1 ราย ท ม ภาวะเล อดค ง หล งช องท องเป นอาการนำÒ ธน ญญ เพชรานนท และคณะ Abstract: Spontaneous retroperitoneal hematoma (SRH) is a rare condition. A delayed diagnosis can result in death. A case of renal infarction, which is an uncommon cause of SRH, is discussed. Case report: A 42 year-old Thai female with a history of long standing oral contraceptive pill use was admitted with gross hematuria. A computed tomography scan of the kidneys, ureters, and bladder (KUB) system revealed a retroperitoneal hematoma, so nephrectomy was performed and pathological report revealed renal infarction. Conclusions: We report a case of renal infarction with history of oral contraceptive pill use presenting with retroperitoneal hematoma. Keywords: renal infarction, retroperitoneal hematoma, oral contraceptive pill Introduction Spontaneous retroperitoneal hematoma (SRH) is an uncommon condition, with fatalities arising from delayed diagnosis. Most of the cases are tumor in origin, with angiomyolipoma predominant followed closely by renal cell carcinoma while vascular disease is the next most common with polyarteritis nodosa occurring most frequently 1. We report a case of renal infarction presenting with SRH with a long standing history of oral contraceptive pill use. Case report A 42 year-old female with history of oral contraceptive pill use for 10 years, presented with history of 3 days of gross hematuria and right flank pain without history of trauma. She had anemia (hematocrit 26.2%) and palpable right upper quadrant abdominal mass. Her blood examination showed normal platelet and coagulogram, normal electrocardiogram (EKG) and normal renal function with an estimated glomerular filtration rate (GFR) 298 of 102 ml/min. An emergency computed tomography (CT) scan of kidneys, ureters, and bladder (KUB) system revealed large retroperitoneal hematoma and the bleeding point at upper pole of right kidney (Figure 1) without deep vein thrombosis. Right nephrectomy was performed, and multiple areas of renal parenchymal infarction were found (Figure 2). The pathologic result of the kidney showed hemorrhagic infarction with extensive perinephric hemorrhage and thrombosis of the medium and large renal vein (Figure 3). Discussion Renal infarction is rarely initially suspected due to nonspecific clinical symptoms; flank or abdomianl pain and hematuria 2. The most common source of renal emboli is the heart, especially in the setting of atrial fibrillation 3, whereas a thromboembolic phenomenon caused by oral contraceptive pill use is uncommon 4. The investigation for renal infarction is CT KUB, as nephrographic phase images can show these findings, but ideally the ส ÅÒ¹ ÃÔ¹ à àçªสòã» Õè 31 ฉบ บท 6 พ.ย.-ธ.ค. 2556
3 Renal Infarction: Report of a Case Presenting with Spontaneous Retroperitoneal Hematoma 1A Bejrananda T, et al. 1B 1C Figure 1 1A CT KUB, coronal view and Figure 1B CT KUB cross-section view showed retroperitoneal hematoma in right posterior pararenal space, 7.7x8.3 cm in size, posterior to the ureteropelvic junction with involvement of right perirenal and pararenal space delayed nephrogram of right kidney, moderate right hydronephrosis, no visible enhancing solid tumor. Figure 1C CT KUB with contrast; the bleeding point in upper pole of right kidney Songkla Med J Vol. 31 No. 6 Nov-Dec
4 ภาวะไตขาดเล อด: รายงานผ ป วย 1 ราย ท ม ภาวะเล อดค ง หล งช องท องเป นอาการนำÒ ธน ญญ เพชรานนท และคณะ 2A 2B Figure 2 2A and 2B Gross pathology; the perinephric fat showed extensive hemorrhage, multiple areas of wedge-shaped hemorrhagic infarction throughout the kidney, the pelvis showed mild dilatation without hemorrhage or tumor mass The renal artery was patent but found thrombosis of medium and large renal vein. Figure 3 Microscopic appearance of an acute renal infarct. Compare the intact architecture of the normal kidney cortex with the hyperemic kidney that was dying, then the pale pink infarcted kidney in which both tubules and glomeruli were dead. This was acute coagulative necrosis, which initially leaved the pale outlines of the infarcted cells. 300 ส ÅÒ¹ ÃÔ¹ à àçªสòã» Õè 31 ฉบ บท 6 พ.ย.-ธ.ค. 2556
5 Renal Infarction: Report of a Case Presenting with Spontaneous Retroperitoneal Hematoma images should be performed during the corticomedullary phase 5. The contrast enhanced CT findings of wedge shaped peripheral perfusion defects are typical of renal infarcts. These can be described as focal or global, and are considered global if the perfusion defect encompasses more than 50% of the renal cortex 5,6. The most sensitive serum indicator for renal infarction is an elevation in serum lactate dehydrogenase, which was found to be present in almost 100% of cases in one reported series 1, our patients data did not show the same result, maybe due to the delayed presentation to emergency. In early presentation of renal infarction, the recommendation for treatment is anticoagulation, with medically managed patients performing better than those undergoing surgery 7,8. However, the ischemic tolerance of the kidney is estimated at 90 minutes, and there is no role for thrombolytic therapy after this time as it is unlikely to lead to a recovery in renal function 9. So the treatment of our patient, who had 3 days delayed presentation, the thrombolytic therapy could not be used for treatment. After nephrectomy, the pathological report revealed thrombosis of the medium and large renal vein, which we could identify the origin of the thrombus. The only clue of suggestion was longstanding usage of contraceptive pill, even all negative results of investigation for emboli. Conclusion Renal infarction is an uncommon cause of renal hemorrhage. It is important to document that all patient who are diagnosed as renal Bejrananda T, et al. infarction have to clarify cause and risk factor such as oral contraception use in benefit of prevention of recurrent thromboembolism. References 1. Zhang JQ, Fielding JR, Zou KH. Etiology of spontaneous perirenal hemorrhage: a meta-analysis. J Urol 2002; 167: Domanovits H, Paulis M, Nikfardjam M, et al. Acute renal Iinfarction: clinical characteristics of 17 patients. Medicine (Baltimore) 1999; 78: Hazanov N, Somin M, Attali M, et al. Acute renal embolism. Forty-four cases of renal infarction in patients with atrial fibrillation. Medicine (Baltimore) 2004; 83: Alamir A, Middendorf DF, Baker P, et al. Renal artery dissection causing renal infarction in otherwise healthy men. Am J Kidney Dis 1997; 30: Urban BA, Fishman EK. Tailored helical CT evaluation of acute abdomen. Radiographics 2000; 20: Wong WS, Moss AA, Federle MP, et al. Renal infarction: CT diagnosis and correlation between CT findings and etiologies. Radiology 1984; 150: Gagnon RF, Straaton K, Herba MJ, et al. Resolution of massive renal artery thromboembolism with conservative therapy. Can Med Assoc J 1981; 125: Fergus JN, Jones NF, Thomas ML. Kidney function after renal artery embolism. Br Med J 1969; 4: Blum U, Billmann P, Krause T, et al. Effect of local low-dose thrombolysis on clinical outcome in acute embolic renal artery occlusion. Radiology 1993; 189: Songkla Med J Vol. 31 No. 6 Nov-Dec
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