Retroperitoneal haemorrhage from a renal carcinoma in association with streptokinase therapy

Abstract

A 42 year old woman presented with a 5-hour history of acute severe generalized abdominal pain, with no associated symptoms. During the preceding 4 days she had complained of dull intermittent right upper quadrant pain. On examination she was pale, clammy and hypotensive, with generalized abdominal tenderness, rebound tenderness and guarding. Resuscitation was instituted with intravenous fluids, blood sent for full blood count, urea and electrolytes, blood sugar, amylase and crossmatching, urinary catheterization performed, and radiographs taken of the chest and abdomen. Haemoglobin estimation was 8.6 g/dl, and a provisional diagnosis of spontaneous intraperitoneal haemorrhage was made. The patient was immediately transferred to the operating theatre where a long midline laparotomy was performed. The peritoneal cavity was full of fresh blood and clot, confirming the suspected diagnosis. The haemorrhaging lesion was a suspicious-looking 4 x 3 cm nodule on the dome of the right lobe of the liver, which had ruptured and stripped the capsule off a large area. Numerous such lesions were seen in both lobes of the liver; they looked like tumour nodules, but there was no evidence of a primary intra-abdominal neoplasm.After unsuccessful attempts to control the haemorrhage by ligation, deep hepatic sutures and hepatic arterial clamping, the liver was packed off with large swabs, the abdomen closed, and arrangements made for subsequent transfer of the patient to a nearby centre with a specialist hepatic surgeon. However, the patient became hypotensive despite rapid infusion of large volumes of intravenous fluids and blood. A second laparotomy revealed gross haemoperitoneum, and both hepatic lobes were literally disintegrating, precluding any possibility of resection.At post-mortem, in addition to the lesions described in the liver, two similar tumour nodules 1 cm in diameter were identified in the apex of the left lung. The absence of an obvious primary tumour was confirmed. Histological examination showed the nodules to be deposits of melanocarcinoma. On closer questioning of relatives, it was disclosed that the patient had undergone excision of a malignant melanoma, 0.9 mm thick, from the skin of the back, 5 years previously.In the absence of a known hepatic lesion the diagnosis of spontaneous rupture may be difficult. A thorough history may provide important clues. The combination of peritoneal irritation and hypovolaemic shock, with a short duration of symptoms, may suggest intraperitoneal haemorrhage. Successful surgical management has been claimed for resection ofthe affected lobe,'-3 hepatic artery ligation,4 or direct injection of ethanol into the bleeding lesion.5 However, despite early diagnosis and prompt surgery, the mortality of this condition is considerable. Retroperitoneal haemorrhage from a renal carcinoma in association with streptokinase therapy Sir, We wish to report an unusual complication of treatment with intravenous streptokinase for suspected myocardial infarction, which we believe has not previous...

Spontaneous haemorrhage into a pituitary tumour after streptokinase therapy

“…Haemorrhage may be more likely into a vascular tumour and has been reported in association with a renal carcinoma. 3 Bleeding into a pituitary tumour has not been previously described after streptokinase but has been reported after anticoagulant treatment.4 Early diagnosis is essential because of the high mortality of untreated cases.5 Reversal of antithrombotic therapy has been recommended when bleeding problems arise but could aggravate the underlying thrombotic episode for which they were prescribed. When pituitary apoplexy arises, we urge rapid referral to a suitable centre where full evaluation and monitoring can be performed.…”