Perirenal Hemorrhage



Perirenal Hemorrhage


Michael P. Federle, MD, FACR



DIFFERENTIAL DIAGNOSIS


Common



  • Renal Trauma


  • Angiomyolipoma, Renal


  • Renal Cell Carcinoma


  • Ruptured Abdominal Aortic Aneurysm


  • Coagulopathic (“Retroperitoneal”) Hemorrhage


  • Acquired Cystic Disease of Uremia


  • Adrenal Hemorrhage


  • Renal Abscess (Mimic)


  • Renal Metastases & Lymphoma (Mimic)


Less Common



  • Vasculitis, Abdominal Manifestations


  • AD Polycystic Disease, Kidney


  • Renal Artery Aneurysm


  • Arteriovenous Malformation, Renal


  • Acute Pancreatitis


  • Adrenal Pheochromocytoma


  • Adrenal Carcinoma


  • Hemorrhagic Fever with Renal Syndrome


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • Check for trauma, tumor, or anticoagulation


  • Trauma



    • May be either blunt or penetrating


    • Kidneys more often injured than adrenals in blunt trauma


    • Look carefully at other organs



      • Other injuries in up to 80% of cases


  • Tumor



    • Look for claw sign identifying mass arising from kidney


    • Tumors may cause spontaneous hemorrhage or bleed with trauma



      • Always consider underlying tumor if the amount of perirenal hemorrhage exceeds what would be expected based on severity of trauma


  • Anticoagulation



    • Look for other sites of bleeding, especially into abdominal wall muscles



      • Iliopsoas and rectus muscles common sites


    • Hematocrit sign (cellular-fluid level) strongly suggests coagulopathy as cause of hemorrhage



      • Sensitivity > 85%; specificity > 95%


Helpful Clues for Common Diagnoses



  • Renal Trauma



    • Most common cause of perirenal hemorrhage


    • Look for extravasation of contrast indicating active bleeding


    • Perirenal fluid may be combination of blood and urine



      • For any renal laceration evident on CT, it is vital to obtain 8-10 minute delayed scans to evaluate for urinary extravasation


    • Consider iatrogenic causes



      • Percutaneous biopsy


      • Nephrostomy


      • Retrograde ureteral catheterization


      • Lithotripsy


  • Angiomyolipoma, Renal



    • Accounts for almost 50% of all cases of spontaneous perirenal hemorrhage



      • Hemorrhage more common in tumors > 4 cm


    • Look for fat-containing mass in kidney



      • Mass may be obscured by hemorrhage


    • May confuse heterogeneous fatty mass with hemorrhage in the perirenal space


  • Renal Cell Carcinoma



    • Slightly fewer cases of bleeding than AML


    • Soft tissue density exophytic renal mass


    • May have calcifications, which would be very unusual for an AML


  • Ruptured Abdominal Aortic Aneurysm



    • Can bleed into any or all retroperitoneal compartments



      • May follow the renal vessels into the perirenal space


    • Bleeding contiguous with large or eccentric aneurysm


  • Coagulopathic (“Retroperitoneal”) Hemorrhage



    • Usually patients receiving heparin or Coumadin


    • Bleeding usually starts in iliopsoas compartment; spreads into retroperitoneum


    • Look for hematocrit sign


  • Acquired Cystic Disease of Uremia



    • Spontaneous bleeding into cysts & perirenal space


    • Look for underlying tumor also


  • Adrenal Hemorrhage




    • More common in neonates but can be seen in children and adults


    • Secondary to traumatic & nontraumatic causes


    • Unilateral hemorrhage more common in trauma


    • Nontraumatic etiologies typically present with bilateral hemorrhage



      • Stress (including recent surgery or hypotension)


      • Hemorrhagic diathesis or coagulopathy


      • Bleeding adrenal tumor


      • Sepsis (Waterhouse-Friderichsen syndrome)


  • Renal Abscess (Mimic)



    • High attenuation pus may simulate blood


    • Present clinically with fever, flank pain, and increased white cell count


  • Renal Metastases & Lymphoma (Mimic)



    • NHL may cause perirenal infiltrative mass that might mimic hemorrhage


    • Look for lymphadenopathy and other sites of lymphoma


    • Consider post transplant lymphoproliferative disorder (PTLD)


Helpful Clues for Less Common Diagnoses



  • Vasculitis, Abdominal Manifestations



    • Most likely diagnosis in absence of renal trauma, mass, aneurysm or anticoagulation


    • Most common causes



      • Polyarteritis


      • Lupus


      • Wegener granulomatosis


  • AD Polycystic Disease, Kidney



    • Bleeding into cysts is common; less often into perirenal space


  • Renal Artery Aneurysm



    • Increased risk of rupture in pregnancy


  • Arteriovenous Malformation, Renal



    • Dense enhancement during the arterial phase with premature opacification of renal vein


    • May have remote history of penetrating trauma (including iatrogenic, such as biopsy)


  • Acute Pancreatitis



    • May infiltrate perirenal (& other retroperitoneal) spaces


    • May mimic perirenal hemorrhage


  • Adrenal Pheochromocytoma



    • Highly vascular adrenal tumor prone to hemorrhage, necrosis



      • Hemorrhage may extend into perirenal space


    • Clinical presentation & lab data may be helpful in making diagnosis


  • Adrenal Carcinoma



    • Large suprarenal mass often containing hemorrhagic, cystic & calcific areas


    • Look vascular invasion



      • Renal vein, IVC


  • Hemorrhagic Fever with Renal Syndrome

Aug 2, 2016 | Posted by in GENERAL | Comments Off on Perirenal Hemorrhage
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