Introduction
Spontaneous suburothelial hemorrhage (SSH), additionally known as Antopol-Goldman lesion (AGL), is a uncommon benign situation that may mimic transitional cell carcinoma (TCC), resulting in potential pointless interventions. Regardless of its medical significance, SSH has been sparingly documented within the English literature, with solely roughly 50 reported circumstances, primarily within the type of remoted case stories and small collection. This case report presents the primary documented case of SSH in Ethiopia, emphasizing the significance of recognizing and understanding this situation inside various medical settings.
The misdiagnosis of SSH as TCC can have hazardous implications, together with pointless invasive procedures and coverings. Subsequently, rising consciousness of SSH and its attribute options is essential for correct prognosis and acceptable affected person administration. Radiological imaging, complemented by correct medical information, performs a central function in attaining an correct prognosis of SSH. Radiologists bear the accountability of recognizing and differentiating SSH from malignant entities, enabling optimum affected person care.
Case Presentation
We current the case of a 20-year-old feminine affected person who was admitted two weeks after present process cesarean part supply for a sign of macrosomia. She was admitted as a consequence of decrease extremity deep vein thrombosis (DVT) following a 21-day historical past of leg swelling. The affected person’s full blood rely (CBC) profile was inside regular limits, and her worldwide normalized ratio (INR) was between 1.0 and a couple of.0. She was began on prophylactic warfarin remedy and subsequently discharged.
Three weeks after her discharge, the affected person returned to the hospital with signs of vomiting, frank hematuria, and stomach distension. Bodily examination revealed pores and skin ecchymoses, bruises, and a protracted bleeding time, as evidenced by steady bleeding from finger suggestions pricked for a blood pattern and intravenous entry websites. Warfarin was quickly discontinued, and her INR was decided to be solely mildly elevated, with laboratory determinations ranging between 2.0 and three.0.
Throughout her hospital keep, an abdominopelvic ultrasound examination was carried out, revealing ascites with echodebrinous sediments and floaters, in addition to bilateral pelviureteric mass-like thickening. A computed tomography (CT) scan was carried out, which confirmed hemoperitoneum (Determine 1), thickening of the bilateral renal pelvis and proximal ureters (Determine 2), giving the looks of enhancing urothelial plenty on post-contrast photos (Figures 3 and 4). It was famous that little consideration had been given to the non-contrast enhanced examine, which revealed areas of spontaneous hyperdensity within the lesions, according to blood, together with hyperdense thickening (hemorrhage) of the jejunal wall (Determine 5).
Determine 1 NCECT (left) and CECT (proper) exhibiting pelvic peritoneal hematoma (notice the density of the hematoma: within the vary of 50s and above right here indicated is 54.85 HU).
Determine 2 Axial NCECT on the degree of the renal pelvis (left) and proximal ureters (proper), exhibiting symmetrical easy, hyperdense thickening of the partitions of the bilateral renal pelvis (arrows) and ureters (arrow head) with delicate bilateral hydronephrosis.
Determine 3 Axial CECT at respective ranges (of Determine 1) (left and proper); notice how a hematoma may very well be simply missed as an “enhancing” mass lesion (arrows and arrow head) had the CECT solely been seen.
Determine 4 CECT; Sagittal (proper and left) and coronal (center) recon photos exhibiting the bilateral renal sinus, PUJ and proximal ureteric wall thickening (lengthy arrows, angled brief arrows).
Determine 5 NCECT (left) and CECT (proper) on the mid-abdomen area exhibiting a phase of jejunal loop wall thickening with pre-contrast hyperdensity and post-contrast non-enhancement.
At this level, spontaneous suburothelial hemorrhage was suspected, and conservative administration was initiated. Subsequently, the affected person was transferred to a different referral hospital to obtain ongoing intensive care help.
Dialogue and Literature Assessment
Spontaneous suburothelial hemorrhage (SSH), also referred to as Antopol-Goldman lesion, was first described by Antopol and Goldman in 1948 based mostly on their case collection of seven sufferers.1 It has been referred to utilizing numerous terminologies, together with suburothelial, sub-epithelial, parietal, or mural hemorrhage/hematoma, with the prefix “spontaneous” used to distinguish it from post-traumatic and iatrogenic circumstances.2,3 Whereas the precise etiology stays unclear, the vast majority of reported circumstances, together with ours, have been attributed to bleeding diathesis brought on by extreme anticoagulant use or different coagulation abnormalities.2,4,5 Oral anticoagulants, particularly warfarin, are essentially the most generally implicated brokers, though different anticoagulants can even result in comparable problems.6,7 A typical pattern noticed in SSH circumstances is a supra-therapeutic worldwide normalized ratio (INR), with an exponentially elevated danger of bleeding when the INR exceeds 5. Nonetheless, subtherapeutic or regular INR ranges may also be related to SSH.7
Typically, anticoagulant-related hemorrhages happen in 4% to 24% of sufferers receiving prophylactic or therapeutic anticoagulation.8–10 These hemorrhages mostly contain the stomach wall and gastrointestinal tract, whereas renal hematomas are uncommon. Suburothelial and renal sinus hemorrhages, that are thought of the most typical varieties of renal hematomas related to anticoagulant remedy, are exceptionally uncommon. Different types of renal system hematomas embrace parenchymal, subcapsular, perinephric, and pararenal hematomas.7
The medical presentation of SSH usually includes macroscopic painful or painless hematuria, with or with out flank ache.11 Though unilateral renal involvement with no left or proper predilection is often reported, bilateral symmetrical illness, as noticed in our case, suggests a systemic illness quite than a malignancy.4 Though the obtainable case stories are extra steadily linked to the aged inhabitants, probably as a consequence of elevated anticoagulant use for numerous indications on this age group, SSH can happen at any age, from neonates to younger adults, no matter intercourse.12 Spontaneous hemorrhages in different organs, mucosal websites, and petechial bleedings can assist within the prognosis however are not often reported. Moreover, related intestinal mural hematoma, which was famous in our case, is a uncommon discovering.13 We have now not but discovered any information of related hemoperitoneum; nevertheless, our case confirmed hematoma within the bilateral paracolic gutters, inter-loop areas, and pelvis. The intraperitoneal hemorrhagic effusion seen in our case may very well be associated to altered intramural osmotic gradients ensuing from the intramural hematoma.14 It stays unclear whether or not this mechanism is chargeable for the enlargement of subepithelial hematomas in circumstances of SSH. Uncommon circumstances of retroperitoneal hematoma related to AGL have been reported.8
Nearly all of SSH circumstances fully resolve inside 1–4 weeks of conservative remedy.8 In circumstances the place conservative administration fails to resolve hematuria, selective arterial embolization has been utilized.15 Because of a lack of expertise, underreporting, and restricted expertise with this situation, many circumstances have been misdiagnosed as urothelial malignancies, resulting in unintended radical nephrectomies. The reported misdiagnosis fee post-nephrectomy is bigger than 30%.16–18
On CT, suburothelial hematomas current as mural thickening of the renal pelvis and higher ureter. Their pre-contrast hyperdensity, post-contrast non-enhancement, and subsequent spontaneous decision are key discriminators of this entity from different mimickers, reminiscent of urothelial malignancies. Focal pelviureteral wall irregularity on intravenous pyelography (IVP) and mass-like thickening of the renal pelvis on ultrasound have been reported as imaging findings. Non-contrast-enhanced CT (NCECT) adopted by contrast-enhanced CT (CECT) is the popular imaging modality, revealing a hyper-dense, non-enhancing mural thickening.19 The differential prognosis on IVP consists of transitional cell carcinoma, pyeloureteritis cystica, or submucosal edema, whereas on CT, transitional cell carcinoma or renal cell carcinoma stays the first consideration.20 Different mimickers embrace ureteral wall thickening associated to infectious and/or inflammatory ureteritis and reactive thickening from impacted ureteral stone.
Reported problems of SSH embrace amyloidosis, compressive urinary tract obstruction, rupture into the gathering system with resultant clot formation, and forniceal rupture resulting in retroperitoneal hematoma.19 Though associations with hydronephrosis and urinary obstruction are unusual, delicate hydronephrosis was seen in our case. Suggestions for screening CT and the need of follow-up CT have produced blended conclusions. Some research recommend a confirmatory follow-up CT inside two to 4 weeks,4,7,21 whereas others suggest that elevated consciousness and assured prognosis may remove the necessity for follow-up imaging.22,23 Magnetic resonance imaging (MRI) can even present thickening of the urothelial wall, just like CT, with variable T1 and T2 sign depth adjustments reflecting the age of the hematoma, acute and subacute bleeds, and hemosiderin deposition.24
Conclusion
Spontaneous suburothelial hemorrhage is a generally misdiagnosed entity that follows a benign and self-limiting course. Given that almost all of reported circumstances, together with ours, are secondary to the underlying coagulation abnormalities, the time period “spontaneous” may be deceptive. We suggest adopting a extra descriptive terminology, reminiscent of “coagulopathy-related suburothelial hemorrhage”, to higher mirror the underlying etiology.
This report not solely underscores the significance of differentiating SSH from TCC to halt inessential interventions but additionally emphasizes the pivotal function of radiology in diagnosing SSH. Moreover, it highlights the importance of correct medical information integration to help in correct prognosis. By reporting the primary case of SSH in Ethiopia and offering a complete dialogue on this situation, we hope to lift consciousness, encourage additional analysis, and improve medical follow within the recognition and administration of this uncommon entity. Given the paucity of literature on MRI of SSH and the flexibility of MRI in fashionable medical follow, we notably recommendation additional examine into the traits of SSH on MRI. And since prevention is essentially the most essential technique in probably preventable circumstances like this one, we anticipate that future analysis on this entity would think about in search of potential preventative measures.
