AJR 2000; 174:1023-1024
© American Roentgen Ray Society
Diagnosis of Renal Pelvis Subepithelial Hemorrhage Using Unenhanced Helical CT
Alexi Phinney1,2,
Julian Hanson1 and
Lee B. Talner1
1
Department of Radiology, Harborview Medical Center, University of Washington
School of Medicine, 325 Ninth Ave, Seattle, WA 98104
2
Department of Radiology, Virginia Mason Medical Center, Box 900, Seattle, WA
98111.
Received July 12, 1999;
accepted after revision August 31, 1999.
Address correspondence to L. B. Talner.
Introduction
A 41-year-old man developed right flank pain and gross hematuria over a
48-hr period. He was taking warfarin (Coumadin; DuPont, Wilmington, DE)
because of a prosthetic aortic valve and previous coarctation repair; after a
recent dose change, his international normalized ratio (INR) was markedly
elevated at 10.0 (therapeutic range, 3.0-4.5). Results of previous
investigations for self-limited episodes of hematuria had been negative.
Unenhanced helical CT of the urinary tract showed high-attenuation
thickening of the right renal pelvis and proximal ureter, indicative of
subepithelial hemorrhage (Fig.
1A). Contrast-enhanced CT (Fig.
1B) showed a delay in contrast excretion, mild calicectasis, and
constriction of the renal pelvis. No parenchymal lesions were revealed. CT
urography performed 1 month earlier (Fig.
1C) had shown a healthy right kidney and ureter. Hematuria and
pain resolved after correction of coagulopathy.
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Fig. 1A. —41-year-old man receiving anticoagulation therapy who presented with
gross hematuria and right-sided flank pain. Unenhanced helical renal CT scan
shows high-attenuation thickening of pelviureteric wall caused by hemorrhage
(arrows).
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Fig. 1B. —41-year-old man receiving anticoagulation therapy who presented with
gross hematuria and right-sided flank pain. IV contrast-enhanced helical CT
scan shows mild calyceal dilatation and constriction of lumen of renal pelvis.
Fact that pelviureteral wall thickening (arrows) is caused by
hemorrhage is not obvious on contrast-enhanced scan.
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Fig. 1C. —41-year-old man receiving anticoagulation therapy who presented with
gross hematuria and right-sided flank pain. Unenhanced helical renal CT scan
obtained during CT urography 1 month before A and B shows renal
pelvis with normal appearance (arrows).
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Discussion
The incidence of hemorrhage in anticoagulated patients varies from 4% to
24% [1]. Hemorrhage occurs most
commonly from the urinary tract (in as many as 40% of patients)
[1]. Anticoagulation may unmask
preexisting abnormalities such as calculi, parenchymal and epithelial
neoplasms, nephritis, cystitis, or benign prostatic hypertrophy. Bleeding may
be parenchymal, subcapsular, perinephric, or, rarely, subepithelial, as in
this patient.
Subepithelial renal sinus hemorrhage is usually encountered in
coagulopathic patients [2]. On
IV urography, focal pelviureteral wall irregularity may be indistinguishable
from transitional cell carcinoma, pyeloureteritis cystica, or submucosal edema
[3]. Unenhanced CT readily
identifies the hemorrhage [2,
4], which may be masked if only
contrast-enhanced examinations are performed. High-attenuation material along
the antidependent surface of the renal pelvis suggests a subepithelial rather
than an intraluminal location. Subepithelial hemorrhage may compress the renal
pelvis, as in this patient, or rupture into the collecting system and cause
"clot colic." Unenhanced CT of the urinary tract may be repeated
several weeks after correction of coagulopathy to confirm resolution of
subepithelial hemorrhage
[2].
Our patient experienced several earlier episodes of self-limiting gross
hematuria, but routine outpatient investigations, including CT urography, had
not revealed a cause. Unenhanced CT during an acutely painful episode promptly
established the diagnosis and ruled out calculi and distal obstruction. This
case illustrates the value of unenhanced helical CT of the urinary tract in
the emergent examination of patients with acute loin pain and hematuria. When
findings of this examination are normal, additional contrast-enhanced CT of
the kidneys promptly followed by conventional urinary tract radiography
provides optimal noninvasive detection of parenchymal lesions and collecting
system disorders in the patient with hematuria.
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Cuttino JT Jr, Clark RL, Feaster SH, Zwicke DL. The evaluation of
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1987;149: 527
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Fishman MC, Pollack HM, Arger PH, Banner MP. Radiographic
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AJR
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Kaiser JA, Jacobs RP, Korobkin M. Submucosal hemorrhage of the
renal collecting system. AJR
1975;125: 311
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Miller V, Witten DM, Shin MS. Computed tomographic findings in
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Introduction
Discussion
