Case Study - March 2009

This is the CT scan of a 27-year-old rugby player who presented with frank haematuria and right flank pain two days after a match in which he recalled a hard fall when making a tackle. His circulation was stable and he had only slight tenderness in the right upper quadrant.

  1. What do the images show?
  2. How would you manage him?
  3. Would you re-image him, and if so, how?

Reveal Answer

Open answer There is no fixed answer to this question, however your response should be similar to the one below:

  1. There is a large perinephric haematoma on the right without contrast extravasation, and there is a laceration in the cortex of the upper pole of the right kidney; see images below
  2. Provided the patient remains haemodynamically stable, he can be managed conservatively
  3. Further imaging, to assess healing, is advisable and this is best accomplished using DMSA scintigraphy, performed 6-8 weeks after the original injury

Further comments
Closed renal injuries, especially those involving only a laceration of the renal cortex with a perinephric haematoma, can usually be managed without surgical intervention. Surgery is only needed if there are signs of progressive bleeding.

Antibiotics are only indicated if there is evidence of extravasation of contrast medium (i.e. urine) outside the perinephric fascia.

Follow-up assessment is desirable and usually shows very little scarring after 6-8 weeks. This is best done using DMSA scintigraphy; subsequent DMSA scinitgraphy (after 6 weeks) showed normal function in the right kidney with no evidence of scarring.

Long-term follow-up to monitor blood pressure was, historically, recommended after renal injury because of the risk of subsequent hypertension. It is now believed that this risk has been over-emphasised and long-term blood pressure checks are probably not necessary.

illustrative image for answer to question $n

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