Figure 1
Axial Non contrast CT at the level of the right renal pelvis
Axial non contrast CT demonstrates a hyperdense thickening of the renal pelvis (arrow) the contralateral kidney appears normal.
Spontaneous suburothelial haematoma in anticoagulated patient
SectionUroradiology & genital male imaging
Case TypeClinical Cases
Authors
Ana Catarina Silva M.D., Jorge Venâncio M.D.
Centro de Tomografia de Braga
Portugal
Connected authors
72 years, female
Clinical History
A 72-year-old woman with gross spontaneous haematuria.
Imaging Findings
A 72-year-old woman presented with gross spontaneous haematuria.
She was taking warfarin due to an auricular fibrillation. Her international normalized ration (INR) was immensurable.
Unenhanced computed tomography (CT) showed a high attenuation circumferential thickening of the right renal pelvis and right ureter that extended along its proximal third (Fig. 1 and Fig. 2). No renal or ureteral stone or peri-ureteral stranding was present excluding therefore an inflammatory cause for the mural thickening.
Contrast-enhanced CT at excretory phase confirmed the suburethelial and mural thickening (Fig. 3). No other renal or ureteral lesions were present. Also both urinalysis and cystoscopy were negative.
After correction of the coagulopathy the haematuria resolved.
CT urography performed after 1 month showed normal renal pelvis and ureter ( Fig. 4 and Fig 5).
She was taking warfarin due to an auricular fibrillation. Her international normalized ration (INR) was immensurable.
Unenhanced computed tomography (CT) showed a high attenuation circumferential thickening of the right renal pelvis and right ureter that extended along its proximal third (Fig. 1 and Fig. 2). No renal or ureteral stone or peri-ureteral stranding was present excluding therefore an inflammatory cause for the mural thickening.
Contrast-enhanced CT at excretory phase confirmed the suburethelial and mural thickening (Fig. 3). No other renal or ureteral lesions were present. Also both urinalysis and cystoscopy were negative.
After correction of the coagulopathy the haematuria resolved.
CT urography performed after 1 month showed normal renal pelvis and ureter ( Fig. 4 and Fig 5).
Discussion
The incidence of haemorrhage in anticoagulated patient varies from 4% to 24% [1, 2] and most often has origin in the urinary tract [3, 4].
Although subepithelial haemorrhage of the renal sinus is usually present in overcoagulated patients [5] a hematoma that extends from the renal pelvis along the ureter has only been seldom reported in the literature [6-8]. This condition although rare can be the cause of gross haematuria in overcoagulated patients and it is readily and easily diagnosed at unenhanced CT. However it can be masked if only contrast-enhanced examinations are performed [9]. However due to the rarity of this condition other differential diagnosis must be considered and excluded, namely:
1 -Inflammatory and infectious ureteritis, that are usually accompanied with systemic symptoms and changes in the urine tests;
2- Reactive thickening secondary to an impacted ureteral stone, easily diagnosed if a stone is identified;
3 - Primary neoplasia that can manifest as an eccentric focal or multifocal mural thickening that usually enhances after contrast administration and that also extends to the peritureteral tissues;
4 - Metastasis to the ureter that although rare can occur particularly from breast, gastrointestinal tract, prostate, cervix and kidney [10].
Only when the previous diagnoses have been excluded and the appropriate clinical and laboratory setting of haematuria and immeasurable INR is present allied with the imaging findings of spontaneous smooth high-attenuation material along the antidepend surface of the renal pelvis or as circumferential smooth, also spontaneously hyperdense ureteral wall thickening can the diagnosis of spontaneous suburethelial haematoma can be made. Nevertheless subsequent imaging studies after correction of coagulopathy should be performed to confirm the diagnosis and confidently exclude other pathologies like neoplasms [11].
The resolution on subsequent findings confirms the diagnosis as it occurred in our patient.
Although subepithelial haemorrhage of the renal sinus is usually present in overcoagulated patients [5] a hematoma that extends from the renal pelvis along the ureter has only been seldom reported in the literature [6-8]. This condition although rare can be the cause of gross haematuria in overcoagulated patients and it is readily and easily diagnosed at unenhanced CT. However it can be masked if only contrast-enhanced examinations are performed [9]. However due to the rarity of this condition other differential diagnosis must be considered and excluded, namely:
1 -Inflammatory and infectious ureteritis, that are usually accompanied with systemic symptoms and changes in the urine tests;
2- Reactive thickening secondary to an impacted ureteral stone, easily diagnosed if a stone is identified;
3 - Primary neoplasia that can manifest as an eccentric focal or multifocal mural thickening that usually enhances after contrast administration and that also extends to the peritureteral tissues;
4 - Metastasis to the ureter that although rare can occur particularly from breast, gastrointestinal tract, prostate, cervix and kidney [10].
Only when the previous diagnoses have been excluded and the appropriate clinical and laboratory setting of haematuria and immeasurable INR is present allied with the imaging findings of spontaneous smooth high-attenuation material along the antidepend surface of the renal pelvis or as circumferential smooth, also spontaneously hyperdense ureteral wall thickening can the diagnosis of spontaneous suburethelial haematoma can be made. Nevertheless subsequent imaging studies after correction of coagulopathy should be performed to confirm the diagnosis and confidently exclude other pathologies like neoplasms [11].
The resolution on subsequent findings confirms the diagnosis as it occurred in our patient.
Differential Diagnosis List
Spontaneous suburothelial haematoma
Final Diagnosis
Spontaneous suburothelial haematoma
References
[1] Landefeld CS, Beyth RJ (1988) Anticoagulant-related bleeding: clinical epidemiology, prediction and prevention. Arch Intern Med; 148: 1733-6. (PMID: 8368229)
[2] Landefeld CS, Beyth RJ (1993) Anticoagulant-related bleeding: clinical epidemiology, prediction, and prevention. Am J Med 95:315-328. (PMID: 8368229)
[3] Culclasure TF, Bray VJ, Hasbargen JA (1994) The significance of haematuria in the anticoagulated patient. Arch Intern Med 154:649-52. (PMID: 8129498)
[4] Van Savage JG, Fried FA (1995) Anticoagulant associated haematuria: a prospective study. J Urol 153: 1594-6. (PMID: 7536272)
[5] Fishman MC, Pollack HM, Arger PH, Banner MP (1984) Radiographic manifestations of spontaneous renal sinus haemorrhage. AJR Am J Roentgenol 142:11611164. (PMID: 6609601)
[6] Belliol E, Richez P, Bar退a D, Raillat A, Tomasini P, Agostini S, et al. (1998) H退matomes ur退t退raux compliquant un traitement anticoagulant. J Radiol 79: 49-51.
[7] Kolko A, Kiselman R, Russ G, Bacques O, Kleinknecht D (1993) Acute renal failure due to bilateral ureteral hematomas complicating anticoagulant therapy. Nephron 65: 165-6. (PMID: 8413784)
[8] Smith WL, Weinstein AS, Wiot JF (1974) Defects of the renal collecting systems in patients receiving anticoagulants. Radiology 113: 649-51. (PMID: 4139731)
[9] Miller V, Witten DM, Shin MS (1982) Computed tomographic findings in suburethelial haemorrhage. Urol Radiol 4:1114. (PMID: 7101597)
[10] Betchold RB, Chen MYM, Dyer RB, Zagoria RJ. CT of the ureteral wall (1998). Am J Roent 170:1283-1289.
[11] Phinney A, Hanson J, Talner LB (2000) Diagnosis of Renal Pelvis Subepithelial haemorrhage Using Unenhanced Helical CT. Am J Roent 174:10231024.
Case information
| URL: | https://www.eurorad.org/case/6990 |
| DOI: | 10.1594/EURORAD/CASE.6990 |
| ISSN: | 1563-4086 |
Figure 2
Axial Non Contrast CT
Axial non contrast CT demonstrates that the hyperdense thickening of the renal pelvis seen at Fig. 1 extends along the the right ureter; the left ureter is normal (arrowheads).
Figure 3
Contrast enhanced CT, excretory phase.
Contrast enhanced CT at the excretory phase, clearly demonstrates the asymmetry of the ureteral wall thickening with marked thickened right ureter (arrow). The left ureter is normal.
Figure 4
Follow up CT Urography.
CT Urography performed 1 month after the episode of gross haematuria demonstrates complete resolution of the suburothelial haematoma at the right renal pelvis.
Figure 5
Follow up CT Urography
CT Urography performed 1 month after the episode of gross haematuria demonstrates complete resolution of the suburothelial haematoma at the right ureter.
Axial Non contrast CT at the level of the right renal pelvis
Axial non contrast CT demonstrates a hyperdense thickening of the renal pelvis (arrow) the contralateral kidney appears normal.
Axial Non Contrast CT
Axial non contrast CT demonstrates that the hyperdense thickening of the renal pelvis seen at Fig. 1 extends along the the right ureter; the left ureter is normal (arrowheads).
Contrast enhanced CT, excretory phase.
Contrast enhanced CT at the excretory phase, clearly demonstrates the asymmetry of the ureteral wall thickening with marked thickened right ureter (arrow). The left ureter is normal.
Follow up CT Urography.
CT Urography performed 1 month after the episode of gross haematuria demonstrates complete resolution of the suburothelial haematoma at the right renal pelvis.
Follow up CT Urography
CT Urography performed 1 month after the episode of gross haematuria demonstrates complete resolution of the suburothelial haematoma at the right ureter.