腹腔內積血罕見的鑑別診斷- 非外傷性腎臟腫瘤破裂之案例報告與文獻回顧

黃英哲¹ 、柳易揚¹

¹高雄長庚紀念醫院外科部泌尿科

Rare Differential Diagnosis of Hemoperitoneum: A Case Report and Review of Atraumatic Ruptured Renal Tumor

Ying-Che Huang¹、Yi-Yang Liu¹

¹Divisions of Urology, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital

Case description: A 53-year-old female presented to our emergency department with a chief complaint of right-side abdominal pain for 1 week. The patient denied systemic disease, operation and trauma history. On physical examination, the patient was in acute distress. She was afebrile with a temperature of 36.9°C. Her pulse was 96 beats/min, and her blood pressure was 200/105 mmHg. There was knocking pain in the right flank. A computed tomographic (CT) scan obtained subsequently showed (1) a heterogeneous enhanced, ill-defined mass (6.5cm) in the upper pole of right kidney,  highly suspecting malignancy (2) much ascites (30 to 80 Hounsfield Unit) in the cul-de-sac, indicating intraperitoneal hemorrhage (3) no retroperitoneal hemorrhage. A complete blood count revealed a normal white blood cell count of 7.1 × 103/µl, with a hemoglobin of 10.3 g/dL and platelets 224 × 103/ul. Blood chemistry showed sodium to be 142 mEq/l; potassium, 3.6 mEq/l; serum creatinine, 0.58 mg/dl; serum glucose, 195 mg/dl; and C-reactive protein, 5.6 mg/dl. Under the impression of right renal mass and intra-abdominal bleeding of unknown cause, the patient was taken for exploratory laparotomy. Intraoperatively, no intraperitoneal lesion was noted except hemoperitoneum with many blood clots and blood resulting from the spontaneous ruptured renal tumor. Therefore, right radical nephrectomy was performed. On gross examination, one circumscribed, yellowish and whitish lobulated tumor is noted in the upper pole of the right renal parenchyma with hemorrhage, measuring 6.7 x 6.0 x 5.5 cm. The tumor extends into perinephric tissue, but no lymph-vascular invasion was noted. Histology report indicated chromophobe renal cell carcinoma (RCC) with sarcomatoid differentiation, Pathological stage III (pT3aNx). During the postoperative period, postoperative ileus was noted. Symptoms subsided after medication treatment and the patient was discharged in the following days. Currently, the patient received follow-up in our Urology outpatient department.

Discussion: The most common cause of renal bleeding is trauma. Atraumatic rupture and bleeding of the kidney are rare. The first spontaneous retroperitoneal hemorrhage was described by Wunderlich in 1856 ¹, which may cause by a sudden increase of intraparenchymal pressure such as coughing and sneezing. Vascular anomalies, infections, coagulation disorders and tumors are the risk factors of atraumatic renal bleeding. More than 60% of patients with atraumatic renal bleeding is associated with the renal tumor. The most common tumor of renal bleeding is angiomyolipoma, followed by RCC ².

The kidneys sit behind a lining in the abdominal cavity and are “retroperitoneal” organs. Usually, spontaneous ruptured renal tumors cause retroperitoneal hemorrhage ^1,2. Intraperitoneal hemorrhage will only be noted if severe retroperitoneal hemorrhage causes peritoneal rupture. In our case, we only found the atraumatic ruptured renal tumor with intraperitoneal hemorrhage but no definite retroperitoneal hemorrhage. This is a rare sign of ruptured renal tumors.

To the best of our knowledge, ruptured renal tumors in previous studies included angiomyolipoma, clear cell RCC and papillary RCC ². But no chromophobe RCC was reported. We herein present the first case of chromophobe RCC with spontaneous rupture and only intraperitoneal hemorrhage instead of retroperitoneal hemorrhage.

Conclusions: Atraumatic ruptured and bleeding of renal cell carcinoma is a rare cause of hemoperitoneum. Image studies are usually not distinguishable and can mimic intra-abdominal bleeding of unknown cause.

1.     Swift DL, Lingeman JE, Baum WC. Spontaneous retroperitoneal hemorrhage: a diagnostic challenge. J Urol. Apr 1980;123(4):577-82. doi:10.1016/s0022-5347(17)56029-2

2.     Hora M, Hes O, Klecka J, et al. Rupture of papillary renal cell carcinoma. Scand J Urol Nephrol. 2004;38(6):481-4. doi:10.1080/00365590410018648