Surgeons in Mexico removed a 52-year-old woman's right kidney after finding more than half a liter of blood collected around it. One of their reasons was that a tumor could not be ruled out before the operation. When pathologists examined the organ, they found no cancer. Instead, they saw an organized blood clot and signs of both older and newer injury to the kidney.
The case, published Sept. 20 in the Journal of Surgical Case Reports by doctors at Hospital General de Tlaxcala, describes Wünderlich syndrome, an uncommon but potentially life-threatening form of spontaneous bleeding from the kidney. MedicalDaily previously reported how her symptoms mimicked a gallbladder attack. The case also shows a hard choice surgeons face with these bleeds: whether a tumor can be excluded before surgery, or only after the kidney is gone.
A Gallbladder Workup That Became a Kidney Operation
The woman had poorly controlled type 2 diabetes. She arrived after 24 hours of pain in her upper right abdomen that spread to her right lower back, along with vomiting bile. Her exam showed a positive Murphy sign, a classic clue for gallbladder inflammation, and tenderness over her right kidney.
An ultrasound found multiple gallstones. Her hemoglobin was low at 10.9 g/dL, her white blood cell count was elevated at 15,480 per microliter, and her blood sugar measured 468 mg/dL.
CT urography changed the picture. It showed a collection of blood estimated at 577 cubic centimeters around the right kidney, pressing on nearby structures, along with a 3-centimeter staghorn stone, a large branching stone, in the renal pelvis.
After doctors brought her blood sugar under control with an insulin infusion, surgeons performed an open operation. They removed her gallbladder first. Prominent lymph nodes next to the inferior vena cava, the body's main vein, prompted them to remove those nodes, and they then performed a radical nephrectomy, removing the right kidney along with surrounding tissue. An open approach was used because laparoscopic equipment was unavailable and the specimen was too large for minimally invasive removal.
Tumors Are the Usual Suspect When a Kidney Bleeds on Its Own
The concern about cancer was not far-fetched. According to a 2023 review in RadioGraphics, tumors account for about 60% to 65% of Wünderlich syndrome cases. The most common benign culprit is angiomyolipoma, and the most common malignant one is clear cell renal cell carcinoma. Vascular diseases cause another 20% to 30%, and in 5% to 10% of patients, no cause is found.
A large hematoma can also make the kidney hard to read on imaging. The review notes that CT helps distinguish a hematoma from an underlying mass, but it warns that "large hematomas may obscure small renal cysts or masses."
The textbook warning signs often do not show up either. The classic Lenk triad of sudden flank pain, a mass in the flank, and shock from blood loss appears in only about 20% of patients, according to the review. This woman's pain pattern pointed her doctors toward her gallbladder instead.
Why the Surgeons Did Not Wait
Removing the whole kidney is not the only response to a spontaneous kidney bleed. The RadioGraphics review lists conservative management, nephron-sparing surgery, and transarterial embolization, in which a catheter is used to block the bleeding vessel. The review calls embolization a first-line option and says it can control bleeding in up to 96% of cases involving angiomyolipomas.
When the cause is unclear, the review says a dedicated kidney-mass CT scan may be performed four to eight weeks after the first scan, once some of the blood has cleared, to look for an underlying lesion.
The Tlaxcala surgeons chose nephrectomy "because of the extensive hematoma, the risk of recurrent hemorrhage, the associated staghorn calculus with high predisposition to infection, and the inability to exclude renal malignancy preoperatively."
Kidney stones themselves are common, and the National Institute of Diabetes and Digestive and Kidney Diseases describes how they form and how they are treated.
The Kidney Had Been Bleeding for a While
The pathology report helps explain what had been happening. Pathologists found a hematoma under the kidney's capsule and in its outer layer, along with acute-on-chronic ischemic glomerulonephritis, acute tubular necrosis, and focal segmental glomerulosclerosis, a type of scarring in the kidney's filters. There was no tumor.
The clot showed signs of organization, a process that takes time. The authors pointed to a "discrepancy between the abrupt onset of symptoms and the chronic histological features," and concluded that the bleeding came before her symptoms, likely enlarging until it caused pressure and irritation.
In other words, the kidney surgeons removed a kidney that was not healthy. The report did not measure how much the right kidney had been contributing to her overall kidney function before surgery.
She was discharged six days after the operation. At a three-month check, she remained free of symptoms with preserved kidney function.
The case does not mean every spontaneous kidney bleed requires surgery, or that the absence of a tumor makes the operation a mistake. It shows why pathology often provides the final answer. Anyone with severe flank or abdominal pain, especially with signs of blood loss such as dizziness or fainting, should get prompt medical care.
Key Questions Answered
What is Wünderlich syndrome?
It is spontaneous bleeding from the kidney into the space under its capsule or around it, without any injury.
Why did surgeons suspect cancer?
Tumors cause about 60% to 65% of these bleeds, and the large hematoma meant a kidney cancer could not be ruled out before surgery.
Was cancer found?
No. Pathology showed an organized blood clot and signs of older and newer kidney injury, with no tumor.
Do all kidney bleeds require removing the kidney?
No. Options include conservative management, embolization, and kidney-sparing surgery, depending on the cause, the size of the bleed, and the patient's condition.
Why did surgeons remove the kidney?
They cited the large hematoma, the risk of bleeding again, the staghorn stone's infection risk, and the inability to exclude cancer.
How did the patient do?
She went home six days after surgery and was free of symptoms, with preserved kidney function, three months later.
Published by Medicaldaily.com
