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Article history: Gross hematuria is a very common complaint in emergency departments and outpatient clinics. Globally, the in-
Received 2 May 2018 cidence of hematuria is 4 per 1000 patients per year. Infection, urolithiasis, and neoplasm are the most common
Accepted 13 May 2018 etiologies. However, hematuria rarely causes hypovolemic shock or an emergent, life-threatening condition at
Available online xxxx
the initial presentation. In this report, we describe the case of a 64-year-old man who suffered a life-
threatening gross hematuria in a very short time due to ruptured renal arteriovenous malformations (AVMs).
© 2018 Elsevier Inc. All rights reserved.
1. Introduction presentation, the patient's blood pressure was 78/50 mmHg, and his
heart rate was 110 beats per minute. The patient had a history of laparot-
For most clinical scenarios, hematuria itself is not imminently fatal. It omy for a ruptured intra-abdominal aneurysm years ago at other hospital.
is common and frequently benign in young patients, and the cause cannot We started resuscitation with normal saline challenge, blood transfusion,
be identified sometimes [1]. The causes of hematuria vary with age, with and endotracheal tube intubation. We also inserted a Foley catheter, and a
the most common being inflammation, infection, or stones of the urinary massive amount of fresh blood was drained. An abdominal CT was per-
tract. In older patients, a kidney or urinary tract malignancy or benign formed immediately, which demonstrated a large aneurysm in the
prostatic hyperplasia (BPH) is also a common origin of hematuria [2]. interpolar region of the left kidney, with a direct connection to the left
Renal arteriovenous malformations (AVMs) are abnormal communica- renal artery and renal vein, suggestive of renal AVM (Fig. 1, Fig. 2). A mas-
tions between the renal artery and vein, and AVMs are a rare cause of he- sive hematoma in the urinary bladder was also noted (Fig. 3). There was
maturia. The diagnosis of renal AVM can be made by color Doppler no response to initial resuscitation. The blood pressure dropped to 55/
ultrasonography, computerized tomography (CT), magnetic resonance 28 mmHg. We discussed the case with the radiologist and the surgeon,
imaging (MRI), and digital subtraction angiography. The traditional treat- and we agreed that TAE was not indicated due to the patient's unstable
ment is surgery, including nephrectomy and ligation of the feeding ves- condition. Therefore, emergency surgery of open nephrectomy was ar-
sels. In the past decades, newer techniques and agents have increased ranged. However, pulseless electrical activity developed during the oper-
the efficacy of embolization therapy. Transarterial embolization (TAE) is ation. After cardiopulmonary cerebral resuscitation was performed for
a safe and effective choice of treatment that also provides a good outcome 1 min, spontaneous circulation returned. After the surgery, fibroscopy of
[3]. However, TAE is not suitable for every case. The treatment decision the urinary tract showed only blood clots without active bleeding. Al-
depends on the clinical condition and the type of disease process [4]. though the surgery was successful, and there was no recurrent bleeding
from the Foley catheter, via abdomen drainage or according to a repeated
abdomen CT, multiple organ failure and coagulopathy after hypovolemic
2. Case report shock and massive blood transfusion progressed gradually. Unfortunately,
the patient expired on the 22nd day after hospitalization. The pathology
A 64-year-old male presented to our emergency department with the report revealed an AVM measuring 5.5 × 5 × 2.5 cm in size with a
symptoms of massive hematuria, and he was drowsy. Upon physical ex- blood clot in the left kidney.
amination, he was ashen, and his abdomen was soft without tenderness
or guarding. The Glasgow coma scale was E3M4V3. At the time of
3. Discussion
⁎ Corresponding author at: Department of Emergency Medicine, Changhua Christian
Hospital, 135 Nanshsiao Street, Changhua 500, Taiwan. Besides patient history and physical exam, a urine dipstick test is
E-mail address: h6213.lac@gmail.com (Y.-R. Lin). used for the initial evaluation of hematuria. Urine cytology, prostate-
https://doi.org/10.1016/j.ajem.2018.05.028
0735-6757/© 2018 Elsevier Inc. All rights reserved.
Please cite this article as: Chang Y-J, et al, Hematuria as the only symptom at initial presentation of hypovolemic shock caused by ruptured renal
arteriovenous malformations, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.05.028
2 Y.-J. Chang et al. / American Journal of Emergency Medicine xxx (2018) xxx–xxx
Fig. 1. Unenhanced abdominal CT. Dilated left renal pelvis (gray arrow), previous surgical Fig. 3. Unenhanced abdominal CT. Massive hematoma in the urinary bladder (gray arrow).
clips (white arrow). (For interpretation of the references to color in this figure legend, the Foley catheter balloon in situ (white arrow). (For interpretation of the references to color
reader is referred to the web version of this article.) in this figure legend, the reader is referred to the web version of this article.)
Fig. 2. Contrast-enhanced abdominal CT, arterial phase. A large aneurysm with direct References
connection of the left renal artery and renal vein (gray arrow). (For interpretation of the
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arteriovenous malformations, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.05.028
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Please cite this article as: Chang Y-J, et al, Hematuria as the only symptom at initial presentation of hypovolemic shock caused by ruptured renal
arteriovenous malformations, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.05.028