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Case 3

Spontaneous Uroepithelial Hemorrhage Caused by Warfarin Overdose

The chest radiograph (Fig. 3A) showing the aortic valve should have been considered an indication that the patient was undergoing anticoagulation. Uroepithelial hemorrhage is a rare but well-documented complication of anticoagulant therapy. Patients usually present with flank pain followed by gross hematuria within 24-72 hr [1]. On excretory urography, the presence of multiple small nodular filling defects or predominately smooth narrowing of the renal pelvis and ureters in a patient undergoing anticoagulant therapy should suggest the diagnosis. The absence of urinary tract infection and the rapid resolution of ureteral filling defects on urography after correction of the hemorrhagic diathesis should support the diagnosis.

View larger version (156K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A. —38-year-old man with acute left flank pain and gross hematuria. Posteroanterior chest radiograph shows aortic valve prosthesis (arrow), which indicates that patient is undergoing anticoagulation therapy.

This 38-year-old man with a history of aortic valve replacement because of rheumatic endocarditis had ingested a large amount of warfarin before admission as a suicide attempt. He presented with acute left flank pain and gross hematuria. On admission, prothrombin time was 48, and partial thromboplastin time was greater than 180. Urinalysis was negative for bacteria or WBC. Excretory urography and CT showed findings compatible with uroepithelial hemorrhage (Fig. 3B). After warfarin was discontinued, the patient's symptoms and hematuria resolved. Follow-up excretory urography 1 week later (Fig. 3C) revealed improvement of the previous findings (Figs. 3D,3E,3F).

View larger version (123K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B. —38-year-old man with acute left flank pain and gross hematuria. Excretory urogram at 5 min shows narrowed left renal pelvis, infundibula, and proximal ureter (large arrows). Multiple smooth, fixed, round filling defects with obtuse margins are seen in proximal left ureter (small arrows). Inferior pole calyces are dilated.

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C. —38-year-old man with acute left flank pain and gross hematuria. Follow-up excretory urogram 1 week later shows less narrowing of left collecting system and resolution of calyceal dilatation.

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3D. —38-year-old man with acute left flank pain and gross hematuria. Contrast-enhanced axial CT scans at level of renal pelvis (D) and at level of proximal ureter (E and F) show thickened left renal pelvis, with high attenuation within thickened wall as a result of blood or enhancement. Similar process is seen involving left ureter (arrows).

View larger version (86K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3E. —38-year-old man with acute left flank pain and gross hematuria. Contrast-enhanced axial CT scans at level of renal pelvis (D) and at level of proximal ureter (E and F) show thickened left renal pelvis, with high attenuation within thickened wall as a result of blood or enhancement. Similar process is seen involving left ureter (arrows).

View larger version (84K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3F. —38-year-old man with acute left flank pain and gross hematuria. Contrast-enhanced axial CT scans at level of renal pelvis (D) and at level of proximal ureter (E and F) show thickened left renal pelvis, with high attenuation within thickened wall as a result of blood or enhancement. Similar process is seen involving left ureter (arrows).

Renal complications of anticoagulant therapy include subcapsular, perinephric, intraparenchymal, renal sinus, and uroepithelial hemorrhage. These findings may be indistinguishable from those of pyeloureteritis cystica, transitional cell carcinoma, or inflammatory strictures [1, 2]. Other causes that may cause luminal narrowing as seen in this case include metastasis, leukoplakia, malakoplakia, tuberculosis, radiation, retroperitoneal fibrosis, and vasculitis. However, the absence of urinary tract infection and the rapid resolution of ureteral filling defects on urography after correction of the hemorrhagic diathesis should support the diagnosis. The intramural blood should resolve 3-6 weeks after correction of coagulation factors [1, 3].

Transitional cell carcinoma is incorrect. That disorder usually presents with painless hematuria. As many as 40% of patients may present with a nonfunctioning kidney because of ureteral obstruction, which is usually unilateral and focal. On excretory urography, the ureter is dilated distal to the obstructing mass forming the goblet, or Bergman's, sign.

Pyeloureteritis cystica is incorrect. This condition consists of multiple small subepithelial fluid-filled cysts in the ureteral wall, usually in patients with chronic urinary tract infections. It is usually asymptomatic but may be accompanied by hematuria and symptoms of urinary tract infection. Resolution may or may not occur with antibiotics.

Tuberculosis is incorrect. Urinary tract infection with Mycobacterium tuberculosis is a result of hematogenous dissemination of organisms to the kidney from other sites, usually the lungs. Ureteral involvement is the result of renal infection that spreads down the collecting systems. Ureteral infection produces ulcerations, fibrosis, stricture, and calcification. The ureter is shortened and straightened (a "pipestem" ureter).

References

1. Smith WL, Weinstein AS, Wiot JF. Defects of the renal collecting systems in patients receiving anticoagulants. Radiology 1974;113:649 -651[Medline]
2. Kaiser JA, Jacobs RP, Korobkin M. Submucosal hemorrhage of the renal collecting system. Am J Roentgenol Radium Ther Nucl Med 1975;125:311 -313[Medline]
3. Viamonte M, Roen SA, Viamonte M Jr, Casal GL, Rywlin AM. Subepithelial hemorrhage of renal pelvis simulating neoplasm (Antopol-Goldman lesion). Urology 1980;16:647 -649[Medline]

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This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Vitellas, K. M. Articles by Bova, J. G. Search for Related Content PubMed Articles by Vitellas, K. M. Articles by Bova, J. G. Social Bookmarking                      What's this?