Do you know Wunderlich?, A dangerous stranger

Congress:

ECR 2020

Poster Number:

C-06396

Type:

Educational Exhibit

Keywords:

Performed at one institution, Not applicable, Retrospective, Haemorrhage, Acute, Education, CT-Angiography, CT, Retroperitoneum, Kidney, Emergency, Abdominal Viscera

Authors:

E. A. prada suarez¹, Y. P. Narváez Rojas², D. Vargas Flores², F. F. Sanjines², L. M. Suarez Carvajal³, G. A. Averanga Ticona², F. J. MEJIA⁴, A. J. MORENO SALAZAR¹, L. F. Borrino⁵; ¹malvinas/AR, ²Buenos Aires/AR, ³Pablo Nogues/AR, ⁴SAN MIGUEL/AR, ⁵Pablo Nogues, Bu/AR

DOI:

10.26044/ecr2020/C-06396

DOI-Link:

https://dx.doi.org/10.26044/ecr2020/C-06396

Fig. 14: Axial CT shows enhanced cyst (Bosniak IIF) in the left kidney (red arrow).

Fig. 15: Nephrogenic and late phase of the same patient in Fig.14 (four years later),...

Fig. 17: Coronal CT same patient of Figure 10. The left kidney shows a subcapsular...

Fig. 13: Patient with an overinfected renal cyst secondary to pyelonephritis and renal...

Learning objectives

Review the retroperitoneal anatomy. Learnthe pathophysiologyof spontaneous renal hemorrhage "Wunderlich syndrome" Describe the clinical and imaging findings on computed tomography (CT) providing correlation with the most common causes. Illustrate with images the causes most commonly involved in spontaneous renal hemorrhage.

Background

Wünderlich syndrome is defined as spontaneous, nontraumatic kidney bleeding with an hematoma contained in the subcapsular or perirenal space.(1) The classic symptomatology is defined by Lenk's triad: flank pain, palpable mass and hypovolemic shock (2). This symptom and signs are not specific and may vary. It consists of a sudden accumulation of blood near the kidney. The hemoperitoneum is exceptional, leaving the bleeding limited by the resistance of the perirenal tissue, however, in its typical form of presentation it constitutes an urgent situation with hemodynamic...

Findings and procedure details

ANATOMY The retroperitoneum is the space that lies between the posterior parietal peritoneum and anterior to the transversalis fascia, and extends from the diaphragm to the pelvis. It is generally divided by fascias in the anterior and posterior pararenal spaces and the one of the great vessels. Fig. 1 Anterior pararenal space: The anterior pararenal space is the portion of the retroperitoneum that lies between the posterior surface of the parietal peritoneum and the anterior reflection of the perirenal fascia and laterally by the lateroconal...

Conclusion

It is important to understand Wunderlich Syndrome as a rare but deadly entity, as well as knowledge of diagnostic imaging methods in the emergency department, ultrasound for the initial evaluation due its rapid access and computed tomography as the study of choice to detect bleeding (100% sensitivity) and in most cases, allow to establish the presumptive etiological diagnosis as part of the images resident's training.

Personal information and conflict of interest

E. A. Prada Suarez; Malvinas/AR - nothing to disclose G. A. Averanga Ticona; Buenos Aires/AR - nothing to disclose Y. P. Narváez Rojas; Buenos Aires/AR - nothing to disclose A. J. Moreno Salazar; Malvinas/AR - nothing to disclose F. F. Sanjines; Buenos Aires/AR - nothing to disclose L. F. Borrino; Pablo Nogues, BU/AR - nothing to disclose J. Crosta; Buenos Aires/AR - nothing to disclose D. Vargas Flores; Buenos Aires/AR - nothing to disclose L. Palacios; Buenos Aires/AR - nothing to disclose

References

Katabathina, V.S. and cols Wunderlich syndrome: cross-sectional imaging review. Comput Assist Tomogr. 2011;35:425–433 Rohit Sharma and cols. Wunderlich syndrome. https://radiopaedia.org/articles/wunderlich-syndrome. Tirkes T, and cols. Peritoneal and retroperitoneal anatomy and its relevance for cross-sectional imaging. RadioGraphics 2012;32(2):437–451. R. Salesa, V. and cols. Síndrome de Wünderlich. Hemorragia renal espontánea. Unidad Coronaria de Manresa. Fundacion Privada; Revista de cirugía española 2000;Vol.68;Núm. 5;493-495 Cinman AC, and cols. Spontaneous perinephric hemorrhage in a 65 years old man.J Urol, 133 (1985), pp. 829-832 Medline. Moratalla MB. Wunderlich's syndrome due to spontaneous...