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Renal Trauma

Leyla Azmoun, MD
Piran Aliabadi, MD
B Leonard Holman, MD

December 11, 1995

Presentation

A 63-year-old man presented with abdominal and left flank pain after he was repeatedly kicked in the abdomen during an assault. Physical exam revealed tender, echymotic areas over his abdomen and left flank. His vital signs were stable and his neurological exam was normal. His hematocrit was 38% and urinalysis showed 10 red blood cells in his urine.

Imaging Findings

Abdominal CT

A radiograph of the pelvis did not show any fractures.

Contrast enhanced computed tomography of the abdomen demonstrates a moderate-sized left subcapsular hematoma which compresses the renal parenchyma (arrows). The left nephrogram is slightly diminished and there is no excretion of contrast by the left kidney. A wedge-shaped low density laceration is seen in the anterior midpole of the left kidney (arrow). There is mild infiltration of the left perinephric fat (arrows), but no large perinephric hematoma is seen.

Diagnosis

Renal trauma

Discussion

Renal injuries occur in 15 to 40% of patients with abdominal trauma. In patients with multivisceral trauma requiring emergent laparotomy, imaging evaluation is usually limited to emergency excretory urography prior to surgery. In more stable patients, CT allows accurate diagnosis and staging of major renal injuries. CT can determine the depth of cortical laceration, the amount of infarcted renal parenchyma, the extent of perirenal hemorrhage, the status of the renal collecting system and the vascular pedicle. Although excretory urography is the most cost-effective screening modality in the evaluation of stable patients with isolated flank trauma, its accuracy falls significantly with more severe renal injuries. The majority of patients with extensive renal injuries are not adequately staged by excretory urography alone. Therefore, contrast-enhanced CT should be performed in patients with suspected major renal trauma, multivisceral injuries or inadequate staging with excretory urography.

The classification of renal injuries by CT is based on the extent and depth of parenchymal lacerations, the integrity of the renal collecting system and the status of the renal pedicle. Renal contusions, superficial cortical lacerations and small perirenal hematomas account for 90% of all renal injuries. These lesions can often be treated conservatively. Major renal injuries include deep cortical lacerations with or without disruption of the collecting system, comminuted renal fractures and vascular pedicle injuries with either avulsion, intimal dissection or traumatic occlusion. These injuries often require surgical intervention. Angiography is the diagnostic method of choice in demonstrating intimal tears of the main renal artery, post-traumatic pseudoaneurysm and arteriovenous fistulae.

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