British Journal of Radiology (2007) 80, e115-e116
© 2007 British Institute of Radiology
doi: 10.1259/bjr/92395831
Concentric bladder wall thickening due to haemorrhage following suprapubic aspiration: ultrasound and CT features
O R Brook, MD
1
H Mandel, MD
2
G Bar-Joseph, MD
3 and
M Soudack, MD
1
1 Department of Diagnostic Imaging, 2 Metabolic Unit, Meyer Children's Hospital, Technion Faculty of Medicine, 3 Pediatric Intensive Care Unit, Meyer Children's Hospital, Rambam Medical Center, Haifa, Israel
Correspondence: Dr O R Brook, Department of Diagnostic Imaging, Rambam Medical Center, Ha'Aliya Hashniya 8, PO Box 9602, Haifa 31096, Israel. E-mail: o_brook{at}rambam.health.gov.il
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Abstract
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A 5-week-old baby with coagulopathy due to hepatic mitochondrial disorder developed a bladder haematoma secondary to suprapubic urine aspiration. Unlike previously reported cases, the haematoma manifested itself only as concentric thickening of the bladder wall without an intraluminal component. The ultrasound and CT features are described. Recognition of these findings is important when discussing the differential diagnosis of bladder wall thickening.
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Introduction
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Blind needle suprapubic aspiration (SPA) is the first choice procedure for urine sampling in septic infants. It is simple and safe with negligible discomfort and minimal morbidity [1, 2]. Complications are rare. In one large series, transient gross haematuria was reported in 0.6% [1]. Significant bleeding halted only by cauterization was described once [1]. Haematoma resulting from suprapubic bladder aspiration is considered to be a very rare complication [1, 2]. We describe an infant with post-suprapubic aspiration intramural haematoma causing concentric thickening of the anterior bladder wall. This is the first report in the English literature that includes ultrasound and CT features.
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Case report
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A 5-week-old male infant born after full pregnancy and normal delivery was admitted to another hospital for evaluation of vomiting, tachypnoea, progressive hypotonia and apathy that started a few hours prior to his admission. The possibility of sepsis was raised, and the infant underwent septic workup, including two unsuccessful suprapubic aspirations for urine testing. Laboratory studies revealed hypoglycaemia, severe metabolic acidosis with a persistent elevated plasma lactate level of 5–20 mmol l–1 (normal up to 2 mmol l–1) and elevated liver enzymes. Severe coagulopathy (international normalized ratio (INR) > 4.5) suggested progressive hepatic failure. The baby's condition continued to deteriorate, and he was transferred to the paediatric intensive care unit (ICU) in a tertiary medical centre. Upon admission, the baby was pale and encephalopathic, with tachycardia and apnoeic spells, necessitating mechanical ventilation. Haemoglobin level was 4 g dl–1, and there was evidence of excessive bleeding at the cutaneous venous puncture sites. Ultrasound, performed to detect the source of bleeding, disclosed a moderate amount of free peritoneal fluid and a thickened bladder wall that had no evidence of vascularity by Doppler investigation (Figure 1a,b
). Abdominal CT scan 2 days later, ordered to look for the origin of the haemorrhage, demonstrated hyperdense ascites, indicative of intraperitoneal haemorrhage, and a concentrically thickened bladder wall 65–80 Hounsfield units in density (Figure 2). Both the ultrasound and CT findings were compatible with bladder wall haematoma. Ten days after admission, the baby died of fulminant hepatic and multiorgan failure associated with severe lactic acidosis.
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Figure 1. (a) Transverse and (b) longitudinal views of concentrically thickened bladder wall, partially laminated without an echogenic rim. Catheter tip is seen in the bladder.
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Figure 2. Axial slice from CT abdomen showing diffuse massive thickening of the bladder wall. Also seen is free fluid in the pelvis, adjacent to the bladder. The air bubble in the bladder is due to the catheterization.
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Tyrosinaemia Type I was ruled out based on the absence of urinary succinylacetone. The combination of severe lactic acidosis, hypoglycaemia, hepatic failure and multiorgan failure suggested mitochondrial respiratory chain defect. The parents permitted liver and muscle biopsies, which were performed immediately after death. The finding of hepatic steatosis and abnormal ultrastructural changes of mitochondria, combined with reduced respiratory chain Complex IV activity and normal Complex II activity in both liver and muscle specimens, suggested mitochondrial disorder. The study of the primary genetic defect in this patient is in progress.
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Discussion
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We describe the ultrasound and CT findings of intramural bladder wall haematoma, secondary to suprapubic aspiration. The haematoma resulted from bleeding diathesis in an infant with severe coagulopathy due to hepatic mitochondrial disorder. There are three [4–6] previous reports regarding this complication of SPA in humans, two without radiological findings [5, 6]. One report addresses the ultrasound features in post-SPA bladder wall haematoma but it concerns dogs [1]. In humans, there is a single report, describing the ultrasonographic features in three cases of urinary bladder haematoma [1], but the appearance was different from the current case. The previously described haematomas were large, occupying most of the bladder lumen. They showed an echogenic thick, smooth rim and, in two cases, a laminated appearance with concentric layers of alternating hyperechogenicity and hypoechogenicity. In our case, the ultrasound scan shows a partially laminated appearance without an echogenic rim. The wall thickening is primarily concentric with no pseudomass in the lumen.
The differential diagnosis of a thickened bladder wall in children includes tumour, cystitis, neurogenic bladder, amyloidosis, haemorrhage or consequent to posterior urethral valve.
Intramural haematoma should be given high priority in the differential diagnosis of bladder wall thickening in a patient with a coagulation disorder, especially after an invasive procedure. Ideally, MRI, on account of its lack of ionizing radiation, is the preferred imaging modality. In our case, it was not immediately available and therefore CT was performed after ultrasound.
Familiarity with the ultrasound and CT features and knowledge of the clinical background are essential to make the proper diagnosis and avoid further unnecessary diagnostic procedures.
Received for publication May 20, 2005.
Revision received October 30, 2005.
Accepted for publication November 2, 2005.
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References
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- Pryles CV, Saccharow, L. Further experience with the use of percutaneous suprapubic aspiration of the urinary bladder: bacteriologic studies in 654 infants and children. Pediatrics 1969;43:1018–24.[Abstract/Free Full Text]
- Lanier B, Daeschner CW. Serious complication of suprapubic aspiration of the urinary bladder. J Pediatr 1971;79:711[CrossRef][Medline]
- Morrell RE, Duritz G, Oltorf C. Suprapubic aspiration associated with hematoma. Pediatrics 1982;69:455–7.[Abstract/Free Full Text]
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- O'Brien RT, Wood EF. Urinary bladder mural hemorrhage associated with systemic bleeding disorders in three dogs. Vet Radiol Ultrasound 1998;39:354–6.[CrossRef][Medline]
- Lam AH, Tang S. Sonographic findings in bladder haematoma. Australas Radiol 1994;38:48–50.[Medline]
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Abstract
Introduction
