X ray conference2012.06.13

報告者： fellow 1 陳筱惠

Case 01

Patient Profile

•Name: 紀 O雀•Sex: female•Age: 72-year-old•Chart number: 21520569•Date of admission: 2012/05/01

Chief Complaint

•Sudden onset of right flank pain for 1 day

Present Illness

•Underlying heart disease•Sudden onset of right flank pain for 1 day•Associated S/S: fever and nausea, no

hematuria, frequency, or other urinary symptoms

Past History•Unkown heart diseases before, other

significant systemic diseases: denied•Current medicine: nil

Personal History

•Allergy: no known allergy•Alcohol: denied; betel-nut: denied;

cigarette: denied•Over-the-counter medication or chinese

herb: nil

Family History

•No family history of malignancy, bleeding diathesis, heart, liver, kidney, or hereditary diseases

Physical Examination• Vital signs: blood pressure: 144/89mmHg;

temperature: 37.2‘C; pulse rate: 141/min; respiratory rate: 20/min

• General appearance: acute ill looking• Eye: conjunctiva: pale, sclera: no icteric• Neck: supple, no lymphadenopathy or jugular vein

engorgement • Chest: symmetric expansion

breathing sound: bilateral clear heart sound: regular heart beats, no S3 or S4,

no murmurs• Abdomen: soft, flat, no tenderness, muscle guarding,

or rebounding liver/spleen: impalpable bowel sound: normoactive• Back: right flank knocking pain• Extremities: no lower limb pitting edema• Skin: intact, no rash

Laboratory data – 04/30WBC 16.4x1000/ul

Hgb 9.8 g/dl

Hct 29.5 %

MCV 88.9 fl

PLT 189 x1000/uL

Segment 87 %

Sugar 249 mg/dl

BUN 24.5 mg/dl

Creatinine 1.53 mg/dl

Lipase 29 IU/L

Alk-p 61 IU/L

GPT 20 IU/L

Na 137 mEq/L

K 4.8 mEq/L

CRP 74.17 mg/L

Urinalysis – 04/30

•04/30 urine culture: -

Color Yellow

Turbidity Clear

SP. Gravity 1.087

PH 5.5

Leukocyte -

Nitrite -

Protein 2+

Glucose Trace

Ketone -

Urobilinogen 0.1

Bilirulin -

Blood Trace

RBC 3/uL

WBC 0/uL

Epithelial cell 1/uL

Abdominal CT – 04/30

•Heterogenous content mass (83x85x50-mm) seemingly derived from the R’t renal cortex.

•Presence of contrast extravsation seen in the delay phase suggestive of low-pressure bleeding. Hemorrhage infiltration in the subcapsular, peri and para-renal space.

•No discernible enhancing soft tissue inside the hematoma

•No evidenced of blood clots in the collecting system or urinary bladder

Angiography – 05/01

•A small pseudoaneurysm in the branch of right superior renal artery without contrast extravasation

Transcatheter angiographic embolization

Hospitalization course

•5/17 urologist’s consultation: right angiomyolipoma (AML) with bleeding▫Conservative treatment▫Elective exploratory laparotomy for kidney

hematoma/nephrectomy•5/24 kidney echo•6/8 uro opd: follow up CT

Discussion – spontaneous renal bleeding

Wünderlich's syndrome: causes, diagnosis and radiological managementClin Radiol. 2002 Sep; 57 (9): 840-5

•Etiologies:▫61.5% tumor (31.5% malignant, 29.7%

benign)▫17% vascular disease▫2.4% infection▫6.7% idiopathic

Etiology of spontaneous perirenal hemorrhage: A meta-analysis.J Urol 2002;167:1593-6

•Managements:▫Radical nephrectomy

For high incidence of small renal tumors when no apparent etiology and normal contralateral kidney with careful pathologic examinationSpontaneous subcapsular renal hematoma: Diagnosis and management. J Urol 1988;

139: 246-50

Nonfatty lesions other than hematomaRational approach to evaluation and management of spontaneous perirenal

hemorrhage. Surg Gynecol Obstet 1990; 170; 121-5

▫Operative exploration: Not necessary because of the diagnostic accuracy of CT

Spontaneous subcapsular and perirenal hematomas. Radiology 1989; 172: 601-2

▫Follow- up CT at 3 month intervals until hematoma resolves and a definite diagnosis is possible

Case 02

Patient Profile

•Name: 詹 O燕•Sex: female•Age: 46-year-old•Chart number: 21521255•Date of admission: 2012/05/12

Chief Complaint

•Right flank pain for days

Present Illness

•Underlying diseases: hypertension•Right flank pain for days, with radiation to

back•Associated S/S: mild fever, no dysuria or

hematuria•LMD: treated as right acute

pyelonephritis▫Left renal mass was noticed accidentally.

Past History•Underlying diseases: hypertension•Other significant systemic diseases:

denied•Current medicine: antibiotics for APN

Personal History

•Allergy: no known allergy•Alcohol: denied; betel-nut: denied;

cigarette: denied•Over-the-counter medication or chinese

herb: nil

Family History

•No family history of diabetes mellutis, malignancy, bleeding diathesis, heart, liver, kidney, or hereditary diseases

Physical Examination• Vital signs: blood pressure: 125/78mmHg;

temperature: 37.8‘C; pulse rate: 75/min; respiratory rate: 18/min

• General appearance: acute ill looking• Eye: conjunctiva: not pale, sclera: no icteric• Neck: supple, no lymphadenopathy or jugular vein

engorgement • Chest: symmetric expansion

breathing sound: bilateral clear heart sound: regular heart beats, no S3 or

S4, no murmurs• Abdomen: soft, flat, no abdominal tenderness, muscle guarding, or rebounding liver/spleen: impalpable bowel sound: norm-oactive• Back: mild right flank knocking pain• Extremities: no lower limb pitting edema• Skin: intact, no rash

Laboratory data – 05/11

WBC 9.4x1000/ul

Hgb 12.9 g/dl

Hct 36.6 %

MCV 93.6 fl

PLT 371x1000/uL

Segment 65 %

Meta-Myelocyte 3%

BUN 14.9 mg/dl

Creatinine 1.01 mg/dl

GPT 32 IU/L

NA 138 mEq/L

K 3.5 mEq/L

Sugar 123 mg/dl

Urinalysis – 05/11

•05/11 urine culture: E.coli

Color Yellow

Turbidity Clear

SP. Gravity 1.014

PH 6.5

Leukocyte Trace

Nitrite -

Protein 1+

Glucose -

Ketone -

Urobilinogen 0.1

Bilirulin -

Blood 3+

bacteria +

RBC 111/uL

WBC 38/uL

Epithelial cell 13/uL

Abdominal CT – 05/09

Hospitalization course•5/12 urine cytology: negative for

malignancy•Urologist’s consultation note: left renal

mass, suspect hemorrhagic cyst, rule out renal cell carcinoma

Suggest surgical intervention

Case 03

Patient Profile

•Name: 蔡 O梅•Sex: female•Age: 56-year-old•Chart number: 3693317•Date of admission: 2012/05/14

Chief Complaint

•Progressive left flank pain for 1 week

Present Illness

•Status post L’t ESWL in 2012/03, then double J drainage during 2012/03-2012/04 for left side renal stone with obstruction and UTI

•Recurrent left flank pain for 1 week•Associated S/S: fever/chills and dysuria,

no hematuria

Past History•Status post L’t ESWL in 2012/03, then

double J drainage during 2012/03-2012/04 for left side renal stone with obstruction and UTI

•Hypertension and diabetes mellitus under medication control, other significant systemic diseases: denied

•Current medicine: anti-hypertensive medication and oral hypoglycemia agent from LMD

Personal History

•Allergy: no known allergy•Alcohol: denied; betel-nut: denied;

cigarette: denied•Over-the-counter medication or chinese

herb: nil

Family History

•No family history of diabetes mellutis, malignancy, bleeding diathesis, heart, liver, kidney, or hereditary diseases

Physical Examination• Vital signs: blood pressure: 137/71mmHg;

temperature: 37.3‘C; pulse rate: 103/min; respiratory rate: 18/min

• General appearance: acute ill looking• Eye: conjunctiva: mild pale, sclera: no icteric• Neck: supple, no lymphadenopathy or jugular vein

engorgement • Chest: symmetric expansion

breathing sound: bilateral clear heart sound: regular heart beats, no S3 or

S4, no murmurs• Abdomen: soft, flat, no abdominal tenderness, muscle guarding or rebounding liver/spleen: impalpable bowel sound: normoactive• Back: left flank knocking pain• Extremities: no lower limb pitting edema• Skin: intact, no rash

Laboratory lab – 05/12

WBC 10.5x1000/ul

Hgb 11.6 g/dl

Hct 34.3 %

MCV 82.5 fl

PLT 192x1000/uL

Segment 73.5 %

Sugar 173 mg/dl

BUN 8.9 mg/dl

Creatinine 0.77 mg/dl

GPT 22 IU/L

NA 135 mEq/L

K 3.2 mEq/L

CRP 32.39 mg/L

Urinalysis – 05/12

•05/12 urine culture: -

Color Orange

Turbidity Cloudy

SP. Gravity 1.011

PH 6.0

Leukocyte 1+

Nitrite +

Protein -

Glucose -

Ketone Trace

Urobilinogen 1.0

Bilirulin -

Blood -

RBC 0/uL

WBC 3/uL

Epithelial cell 1/uL

Kidney echo – 05/12

•Left kidney: 10.3 cm, right kidney: 11.4 cm

•There is a heterogenous hypoechoic lesion (7.6 x 3.7 cm) in the middle portion of the left kidney with extravasation to the outer surface of the left renal capsule.

Suspect hematoma with central necrosis or secondary infection and local extravasation to the perirenal region

•No obvious evidence of renal stone, mass or cyst

Abdominal CT – 05/14

•Subcapsular cystic mass (50x37-mm) that in thick-wall and focal penetrating into the regional posterior pararenal space related to local infiltrative mass

Sugges L’t renal abscess with local rupture associated regional infiltration, DDx: cystic tumor

Hospitalization course

•5/15 CT guided pigtail drainage of left renal abscess, pus culture: E.coli

Thanks for your listening

Kidney echo – 05/24

•Left kidney: 10.7 cm, right kidney: 11.6 cm

•There is one hetergenous mass lesion in the low pole of right kidney (6.8 cm x 7.0 cm)

•The right kidney is surround by some hypoechoic substance suspecting hematoma.