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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.