Spontaneus Suburothelial Hemorrhage Associated With Forniceal Rupture and Retroperitoneal Hemorrhage

Abstract

Spontaneous suburothelial hemorrhage is a rare process of unclear pathologic etiology, although it has been associated with bleeding diathesis and anticoagulation. The most common clinical presentation is acute onset flank pain and macroscopic hematuria. On imaging, there is a mural thickening of the renal pelvis and upper ureters leading to luminal narrowing. Despite luminal narrowing, hydronephrosis has only rarely been reported in the association. The imaging finding of mural thickening has led to the misdiagnosis as malignancy, resulting in unnecessary nephrectomy. Suburothelial hemorrhage can be unilateral or bilateral, although the majority of reported cases are unilateral. We present a case of a patient with bilateral spontaneous suburothelial hemorrhage with forniceal rupture and spontaneous retroperitoneal hemorrhage, a unique triad compared to prior cases presented in the literature.

Keywords: bleeding diathesis; forniceal rupture; gross hematuria; hematuria; spontaneous retroperitoneal hemorrhage; suburothelial hemorrhage; therapeutic anticoagulation.

Figure 1. Axial contrast-enhanced CT of the abdomen and pelvis in the portal venous phase through the interpolar kidneys (A), lower pole kidneys (B), and through the bladder and pelvis (C) demonstrates marked and hyperdense circumferential thickening of both renal pelves extending to the ureters (green arrows). There is also hyperdense fluid consistent with hemorrhage in the bilateral perinephric regions and retroperitoneum, tracking down around the bladder and in the presacral region within the pelvis (orange arrows). The abdominal aorta appears intact.

Figure 2. Axial contrast-enhanced CT of the abdomen obtained in the renal excretory phase with consecutive images through the kidneys (A-D) demonstrate accumulation of contrast outside of the collecting system and in the right perirenal space, also outlining the right renal vein (blue arrows). A focus of contrast contributing to this collection was seen arising from a right superior pole fornix (red arrow), compatible with forniceal rupture. Images obtained through the bilateral renal pelves (D), proximal ureters (E) and more caudal ureters (F) demonstrate prominent and high-density circumferential thickening of both renal pelves and ureters (yellow arrows).

Figure 3. Reconstructed coronal contrast-enhanced CT images of the abdomen and pelvis obtained in the renal excretory phase with consecutive images through the kidneys (A) and ureters (B) again demonstrate the hyperdense fluid likely consisting of mixed hemorrhagic products and urine (orange arrows), with mural thickening involving the renal pelves bilaterally (yellow arrows). There is a lack of dilation of the collecting system despite narrowed lumen of the collecting system. Extravasated retroperitoneal contrast is again seen surrounding the right renal vein (blue arrow).

Figure 4. Cardiac CT examination from a year prior demonstrating a normal non-contrast appearance of the kidneys and retroperitoneum.