0:00

Okay, so here we go.

0:02

This is a non-contrast enhanced CT scan.

0:04

The patient had actually had a bolus

0:05

of contrast prior to the CT, so there

0:08

will be some contrast in the kidneys.

0:10

I think that they had it for some

0:12

other exam, either the head or chest.

0:14

Anyway, so here we can see the non-contrast enhanced

0:17

liver looks good, but we're already coming into what

0:20

looks like a complete mess in the left upper quadrant.

0:23

We have a lot of blood products behind

0:24

the kidney and around the kidney here.

0:27

Where you can see some layering of the

0:29

more serious portions of blood and the

0:30

deeper, more cellular portions of blood

0:33

behind it show higher attenuation.

0:35

That's a kind of classic appearance of bleeding.

0:37

So this is a retroperitoneal bleed.

0:39

All right, so let's talk about where we think this is.

0:42

So is this in the anterior pararenal space?

0:46

No, not really.

0:46

That's the pancreas up there.

0:47

This is adjacent to the kidney, and it does

0:50

not expand the muscle of the iliopsoas.

0:53

I barely perceivably.

0:54

See that separation?

0:55

So this is in that perirenal space, PERI.

1:00

Renal space.

1:00

So what else is in the pararenal space?

1:02

We just saw that in the setting of

1:04

abdominal aortic aneurysm rupture.

1:06

And you know, that was pretty dramatic.

1:07

We thought that was probably the only cause

1:08

for this and this perirenal space bleeding.

1:11

But the IVC and the aorta look normal here.

1:13

No increase in size.

1:15

So we're going to say that probably

1:17

this is from the kidney.

1:18

All right, the kidney is bleeding

1:20

here, and now it's your job.

1:22

Um.

1:22

To try to figure out what is bleeding from the kidney.

1:25

You know, what could bleed from the kidney?

1:27

Well, you could have various lesions

1:29

of the kidney that may bleed.

1:30

Um, and in this case, as we come down

1:32

the renal parenchyma, you can see

1:33

that this, the upper pole looks good.

1:35

Mid polar region looks okay.

1:37

There's a tiny cyst back here.

1:39

But as we come down inferiorly, you

1:40

see this kind of fat globulin coming

1:42

off of the inferior pole of the kidney.

1:45

Let's go to coronal, because I have to say

1:47

again, I always do colon and kidney on coronal.

1:50

I think that that's the most

1:51

impressive way to see renal abnormalities.

1:54

And here you can see that the kidney here

1:55

is slightly deformed, and there is a big

1:57

fat-containing lesion of the lower pole.

2:00

So this is a patient who is spontaneously bleeding

2:03

from an AML of the inferior pole of the kidney.

2:08

Um, these are known to bleed.

2:09

They cause retroperitoneal bleeding in that peri-

2:12

renal space.

2:13

So we were able to use the space to isolate

2:15

the fact that it was coming from the kidney

2:17

because we interrogated the IVC and the aorta,

2:19

that we thought were normal, and then we were

2:21

able to look deeper to find the exact cause.

2:24

So this is retroperitoneal bleeding

2:26

in the perirenal space from a renal AML.