CASE 14043 Published on 26.09.2016
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Calyceal rupture

Section

Uroradiology & genital male imaging

Case Type

Anatomy and Functional Imaging

Authors

Matthew Hensley, DO; David Berndt, MS-4,;Jonathan Rohe, CMNT PET; Kandace Klein, DO; Darko Pucar, MD PhD

Department of Radiology and Imaging
Medical College of Georgia at Augusta University
1120 15th Street, BA-1411 30912 Augusta,
United States of America
Email:dpucar@augusta.edu
Connected authors
Darko Pucar UNITED STATES OF AMERICA
Patient

47 years, female

Categories
Area of Interest Kidney ; Imaging Technique CT, Nuclear medicine conventional
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Clinical History
A 47-year-old female patient presented with a four-day history of left lower back pain radiating to the left flank, left upper quadrant, and left lower quadrant; nausea; vomiting; and lightheadedness. Laboratory results revealed a normal white blood cell count and negative urinalysis.
Imaging Findings
Non-contrast CT demonstrated mild left hydronephrosis and proximal hydroureter with perinephric and periureteral inflammatory changes, but there was no urolithiasis or other identifiable source of obstruction (Fig. 1, 2).

Nuclear medicine MAG3 renal scan revealed timely left renal uptake, but there was delayed renal clearance with more than 50% residual radiotracer (Fig. 3, 4). Progressive radiotracer accumulation was noted with the mildly prominent left intrarenal collecting system and renal pelvis. Following the administration of Lasix, some of the retained radiotracer cleared via the left ureter, but there was visualization of extraluminal radiotracer in the infrarenal space indicating calyceal rupture (Fig. 3).
Discussion
Background: Rupture of the renal collecting system is a rare finding that is usually due to an obstructive ureteral or staghorn calculus but may be secondary to trauma, neoplasm, or iatrogenic causes [1, 2]. Iatrogenic rupture was a common complication of retrograde pyelogram precipitating pyelosinus backflow and calyceal rupture resulting in urinoma formation. Forniceal rupture likely occurs because the larger calyces at the renal poles form a more acutely angled fornix which withstands less hydrostatic pressure leading to rupture [7, 8].

Clinical Perspective: The symptoms associated with renal calyceal/forniceal rupture are acute flank/abdominal pain with nausea and vomiting [3, 4, 5]. Leukocytosis and fever may be present [2, 6].

Imaging Perspective: Calyceal rupture is usually diagnosed via contrasted CT and traditionally confirmed with retrograde pyelogram. In this case, the calyceal rupture was diagnosed via MAG3 renogram. Additionally, this case is unusual as the source of the hydroureteronephrosis and subsequent calyceal rupture was not identified on non-contrasted CT, and the patient denied recent stone passage.

Outcome: The left calyceal rupture was treated with placement of a 6 French Double J ureteral stent, and the patient was discharged home with prescriptions for oxybutynin and tamsulosin. Placement of a percutaneous nephrostomy tube is also a possible treatment choice, and small urinomas usually resolve spontaneously [5, 9].

Take Home Message: If there is a contraindication to administering iodinated contrast, a nuclear medicine renogram is a practical alternative to diagnose suspected calyceal rupture.
Differential Diagnosis List
Left renal calyceal rupture.
Urolithiasis
Urothelial carcinoma
Extrinsic compression of the renal pelvis or ureter
Final Diagnosis
Left renal calyceal rupture.
Case information
URL: https://eurorad.org/case/14043
DOI: 10.1594/EURORAD/CASE.14043
ISSN: 1563-4086
License

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Figure 1

Nuclear medicine MAG3 renal scan

Nuclear medicine MAG3 renal scan
Nuclear medicine MAG3 renal scan demonstrating radiotracer accumulation within the mildly prominent renal collecting system and extraluminal radiotracer in infrarenal space consistent with calyceal rupture.
Figure 2

Coronal non-contrast CT

Coronal non-contrast CT
Coronal non-contrast CT demonstrating mild left hydronephrosis with perinephric and periureteral inflammatory changes.
Figure 3

Axial non-contrast CT

Axial non-contrast CT
Axial non-contrast CT showing mild left hydroureter with periureteral inflammatory changes.
Figure 4

Nuclear medicine MAG3 renal scan

Nuclear medicine MAG3 renal scan
Nuclear medicine MAG3 renal scan revealing delayed left renal clearance with more than 50% residual radiotracer.