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YAJEM-57530; No of Pages 3

American Journal of Emergency Medicine xxx (2018) xxx–xxx

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American Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/ajem

Hematuria as the only symptom at initial presentation of hypovolemic shock caused by


ruptured renal arteriovenous malformations
Yi-Jui Chang a, Chu-Chung Chou a,b,c, Chin-Fu Chang a, Yan-Ren Lin a,b,c,d,⁎
a
Department of Emergency Medicine, Changhua Christian Hospital, Changhua, Taiwan
b
School of Medicine, Chung Shan Medical University, Taichung, Taiwan
c
School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
d
Department of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan

a r t i c l e i n f o a b s t r a c t

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.)

such as hypertension and congestive heart failure [7]. Approximately


specific antigen blood test, cystoscopy, intravenous pyelogram, ultraso- one-third of patients may present with signs and symptoms of conges-
nography, and CT could be considered according to clinical clues [5]. tive heart failure, and about half of patients have cardiomegaly and hy-
Renal AVM is a rare cause of hematuria and occurs in less than 1% of pertension [8]. However, the most common presentation of renal AVMs
the general population. Renal AVM may be either congenital or ac- is hematuria due to the rupture of small venules into the renal collecting
quired. The latter is more common and is usually secondary to trauma system from increased intravascular pressure. Catheter angiography is
or intervention [6]. Activation of the renin-angiotensin system resulting the gold standard method for the diagnosis of renal AVMs, and renal
from ischemia distal to renal AVMs may cause hemodynamic changes AVMs can be treated at the same time during the procedure [9]. How-
ever, noninvasive imaging is more commonly used to establish a diag-
nosis of renal AVM. Color Doppler ultrasonography is an ideal imaging
modality for screening patients with suspected renal AVMs due to its
low cost and noninvasive nature [6]. CT can play an important role in
evaluating renal AVMs. Unenhanced scans will show an intrarenal or
perinephric mass. On contrast enhanced CT, well-marginated enhanced
renal lesions will be seen. Early enhancement of the draining renal vein
will also be noted [10]. MRI can also be used to diagnose renal AVMs.
The lesions will show well-marginated signal void on T2-weighted im-
aging, and lesions will enhance quickly on contrast enhanced T1-
weighted imaging. However, MRI is more expensive and does not pro-
vide the real-time flow dynamics, which are seen on ultrasonography
[5]. TAE is the most common choice of treatment for renal AVMs. It min-
imizes damage to the renal parenchyma [11]. The goals of treatment for
renal AVMs are maximal preservation of renal function and minimiza-
tion of procedural complications. If the size of a renal AVM is too large
or the blood flow is too high, TAE is contraindicated due to the risk of
emboli migration into the venous system and resultant pulmonary em-
bolism [7]. In our case, the patient expired due to ruptured renal AVMs
leading to hypovolemic shock despite aggressive resuscitation and
emergent operation. Although it is rare, ruptured renal AVMs can be le-
thal. Emergent exploratory laparotomy may be considered in patients
with a massive hematuria and in critical condition according to their
history and physical exam. Imaging studies may delay the timing of
bleeding control.

Fig. 2. Contrast-enhanced abdominal CT, arterial phase. A large aneurysm with direct References
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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
Y.-J. Chang et al. / American Journal of Emergency Medicine xxx (2018) xxx–xxx 3

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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

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