Eid A. et al., 2025: Delayed perinephric hematoma following ESWL in an anticoagulated patient: A case report.
Aseel Eid 1, Ammar Hassouneh 2, Salsabeel Bishawi 3, Aya Milhem 1, Jana Dibas 1, Sondos Baradia 4
1Department of Medicine, An Najah National University, Nablus, Palestine.
2Department of Radiology, Hebron Governmental Hospital, Hebron, Palestine.
3Department of Medicine, An Najah National University, Nablus, Palestine. Electronic address:
4Department of Medicine, Hebron University, Hebron, Palestine.
Abstract
Introduction and importance: Extracorporeal shock wave lithotripsy (ESWL) is a widely used non-invasive treatment for renal stones; however, it carries a risk of hemorrhagic complications, particularly in patients with comorbidities such as hypertension, diabetes, and anticoagulation therapy. Perinephric hematoma is a rare but potentially serious complication that requires prompt recognition and appropriate management.
Case presentation: We report a case of a 58-year-old male with hypertension, diabetes, and long-term anticoagulation who developed a massive perinephric hematoma one week after undergoing ESWL for bilateral renal stones. He presented with severe left flank pain and a significant hemoglobin drop, with imaging confirming a large perinephric hematoma. He was managed conservatively in the intensive care unit (ICU) with close monitoring, bed rest, fluid resuscitation, pain control, and temporary cessation of anticoagulation. Over 10 days, his condition improved without the need for invasive intervention, and he was discharged on oral medications with a planned follow-up for renal function assessment and anticoagulation resumption.
Clinical discussion: This case highlights the importance of early diagnosis using CT imaging in patients presenting with post-ESWL flank pain and anemia. Conservative management, including strict monitoring, supportive care, and temporary anticoagulation withdrawal, was successful in achieving hemodynamic stability without invasive intervention. This underscores the need for individualized treatment strategies based on patient risk factors and clinical presentation.
Conclusion: This case underscores the importance of early recognition of ESWL-associated hemorrhagic complications, particularly in high-risk patients. It also highlights the effectiveness of conservative management as a viable approach to achieving successful recovery without the need for surgical or interventional procedures.
Int J Surg Case Rep. 2025 Aug;133:111626. doi: 10.1016/j.ijscr.2025.111626. Epub 2025 Jul 7. PMID: 40669202; PMCID: PMC12281448
Comments 1
This article is a case report of a 58-year-old patient who developed a huge perinephric hematoma after the SWL procedure. It is of note that the patient had hypertension, diabetes mellitus and anticoagulation therapy. Moreover, the patient was given SWL bilaterally for a 16x12 mm stone in the left kidney and a 15x 6 mm stone in the right kidney.
Although SWL is a non-invasive treatment for stone disintegration it is highly important to avoid complications. This patient had both hypertension and anticoagulation therapy. Nothing is mentioned on how the anticoagulation was handled and there is no information on how the blood pressure was at the time of SWL. In this specific patient the anticoagulation therapy should have been stopped in time before SWL, when depends on which kind of medication he was taking. Moreover, it is important that the blood pressure is adequately treated. In a patient with this medical history, it had been recommended not to carry out bilateral SWL at the same occasion.
In this specific case the authors were successful in dealing with the bleeding. It is necessary to consider, however, that also with a non-invasive approach it is important to be aware of various risk factors for hematoma before proceeding to treatment.
Bleedings that break through the capsule might be particularly difficult to manage.
Hans-Göran Tiselius