Case Study - February 2013

A 15 yr old girl presented with left abdominal pain after being accidently being kicked by her horse.

1. This is the CT scan (A and B) – what does it show? 

2. How are these injuries classified? 

3. How can this be managed? 

4. How should urinary leaks be managed? 

5. This patient was managed conservatively and re-presented with increasing left abdominal pain.  What has happened in C? 

6.  She subsequently had this procedure – what can you see (D and E)? 

7. How should this patient be managed subsequently?

Reveal Answer

1. There is laceration of the lower pole of the left kidney with surrounding perinephric  ollection/haematoma.  There is extravasation of contrast, suggesting breach of the collecting system. Grade 4 injury. There is also laceration of the spleen.

 2. American Association for the Surgery of Trauma (AAST) renal injury grading scale:

 Grade              Descriptionof injury

1                         Contusion or non-expanding subcapsular haematoma, no laceration

2                         Non-expanding peri-renal haematoma, cortical laceration

3                          Cortical laceration >1cm without urinary extravasation

4                          Laceration through cortico-medullary junction into collecting system or vascular: segmental renal artery or vein injury with contained haematoma

5                           Laceration:shattered kidney or vascular: renal pedicle injury or avulsion

3. EAU guidelines:

Stable patients with grade 1-4 blunt renal trauma should be managed conservatively with bed rest,
prophylactic antibiotics, close monitoring of BP,HR and temperature until haematuria resolves.

Indications for surgical exploration include:         
haemodynamic instability         
exploration for associated injuries         
expanding or pulsatile perirenal haematoma identified during laparotomy         
grade 5 injury         
incidental finding of pre-existing renal pathology requiring surgical therapy

4. By percutaneous nephrostomy

5. The CT shows increased size of the perinephric collection, suggesting secondary or persistent leakage/bleeding.

6. Intra-operative images of a retrograde pyelogram.  There is extravasation of contrast and a tubular structure is seen (drain). Image E shows that a ureteric stent has been placed to divert the urinary stream.

7. Output from the percutaneous drain should be assessed and once dry and the drain can be removed. The ureteric stent should be left insitu for 6/52, followed by a GA cystoscopy and retrograde studies.  If there is no leakage of contrast, the stent can then be subsequently removed.

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