Emergency Room Patient Presenting with Severe Hematuria

Abstract: Purpose: The purpose of this case study is to describe a patient who presented with hematuria and significant anemia secondary to a renal mass and stone complicated with hydronephrosis. In addition to highlighting the clinical features and medical management for this patient, our aim is to stress the importance of exploring and managing multiple causes for hematuria. Methods: History and physical information were obtained by medical staff on a 64 year old Hispanic male with a history of HTN, BPH, HLD, & prior bladder surgery (1985) who presented with sudden onset of gross hematuria, dysuria, and decreased urine output with red heavy clots for one day. The patient had similar episodes 6 months prior however the incident was milder and resolved on its own. PT also noted 10 lbs weight loss. PT is a retired police officer, fireman, and denied smoking, alcohol, or illicit drugs. Positive findings on physical included a reducible mid-epigastric hernia. There was a urinary catheter in place with gross blood in the foley bag. Results: The patient's lab results indicated severe anemia with a hemoglobin/hematocrit as low as 7.9/26.7g/dL. Urine analysis showed large amounts of blood and few bacteria. BUN and creatinine were elevated. A non-contrast CT scan of the ABD/Pelvis showed right sided hydronephrosis secondary to obstructing mid ureteral stone, abnormal right perinephric stranding, abnormal 10 cm heterogeneous exophytic mass of the inferior right kidney, and gallstones. Work up for pre-op required MRV and Head CT to rule out IVC thrombus and metastasis. PT underwent stent placement for the stone prior to the radical nephrectomy. PT was also consented to have a prophylactic cholecystectomy for the gallstones. During the surgical removal, a lesion was identified on the pancreas suspicious for metastasis or inflammation and was later ruled out with EUS. Conclusion: Although most cases of hematuria are due to a urinary tract infection or urethral stone, it is important to do a thorough evaluation to rule out other significant life threatening causes of hematuria. A biopsy of the kidney done later identified the mass as stage T3 Clear Cell Renal Cell Carcinoma (CCRCC) extending to the renal sinus and major vein. Biopsy also showed glomerulosclerosis, urinary calculus, and chronic interstitial nephritis. This case illustrates and stresses the importance of thorough evaluation of the multiple causes of a patient presenting with hematuria.