We report the case of a 75-year-old female patient with a medical history of hysterectomy, multiple sclerosis Marschall-Marchetti and grade II hypertensive heart disease under medical treatment.
He came to the emergency department due to macroscopic hematuria, dysuria, pain in the right renal fossa and hypogastrium of several hours of evolution.
The clinical picture began 4 days before with pain in the right lumbar fossa associated with vegetative cut, labeling and treated as a possible nephritic colic in primary care.
Physical examination revealed moderate mucocutaneous stiffness, discrete pain upon palpation in the right lumbar area and hypogastrium with apparent bladder balloon.
Abdominal X-ray showed no abnormalities.
The hematological profile highlighted the presence of anemia (3.34 million), 29.5% of hematocrit and 10 g hemoglobin) with the rest of parameters within normal limits.
Bladder catheterization was performed, showing macroscopic hematuria and performing vesical lavages with generous extraction of bladder clots.
The ultrasound study reported the presence of a discrete right pyeloureteric ectasia, with kidneys of normal morphology and echostructure.
Similarly, a nodular bladder endocardial lesion of 6 x 6 cmts was objective, probably related to coagulum at this level.
The patient was admitted with continuous and vigorous bladder lavage.
CT scan showed pelvic non-ectasia, with the objective of achieving a right pyeloureteral junction up to its distal portion, with no etiologic evidence.
There was a delay in the uptake, concentration and elimination of contrast in the right renal unit without evidence of parenchymal lesions.
An early and intense contrast uptake in the right renal sinus with rapid contrast passage was insinuated, with no clear pathological significance at that time.
The bladder was endowed with caogulos without parietal alterations.
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persistence and severity of hematuria underwent endoscopic examination under sedation, observing the presence of an important organized endovesical coagulum, which after evacuation showed the absence of lesions in the bladder mucosa.
However, the origin of the hemorrhage in the right upper urinary tract was noted, when observing urine voiding by the corresponding ureteral meatus.
Right ureteral dilation was performed, showing a moderate dilation of the total ureter.
Similarly, the occupation endorse by coagulo pyeloureterium and significant hemorrhage at the pyelic level were found, without being able to show the etiology of the process, given its intensity.
early renal origin of severe hematuria, evident anemia despite replacement and transfusion (Hcto 21% and hemoglobin 7 g/dl) and the absence of right interventional radiology in the center was decided to perform a nephrectomy.
The histological study of the specimen revealed the presence of a complex vascular channels of wall and lumen dilated in the pyelic submucosa and calcified with abundant material in its interior.
The channels presented arterial and venous, with focal erosions of the epithelium and acute hemorrhagic fever, with urinary tract and clot occupied by coagulos.
The definitive diagnosis was congenital arteriovenous fistula in the renal pelvis, compatible with cirsoid aneurysm.
