A rare case of Wunderlich syndrome five days after left hemicolectomy for colorectal cancer

• This is a rare case of WS after surgery in patients with small AML.
• Renal Angiomyolipoma (AML), a benign mesenchymal tumor, is the most frequent cause of WS.
• Ten million people worldwide have such lesion.
• We have reported a rare case of WS due to rupture of small AML after five days from colorectal surgery.
• We suppose that the breaking of the lesion was favored by bridging therapy with low-molecular weight heparin.

IntroductionWunderlich syndrome (WS) is a surgical emergency characterized by spontaneous, non-traumatic retroperitoneal hemorrhage. Angiomyolipoma (AML), a benign mesenchymal tumor, is the most frequent cause of WS. We present a case of WS, appearance five days after a left hemicolectomy for cancer.Presentation of caseA 66 years-old man with a sigmoid adenocarcinoma and a small left AML (3.4 cm) was undergone to left hemicolectomy. He was subjected to bridging therapy with high doses of low-molecular-weight heparin for prosthetic replacement of heart valve secondary to endocarditis and atrial fibrillation. Five days after surgery he presents retroperitoneal hemorrhage due to rupture of AML diagnosed by a CT scan and scintigraphy with labeled red blood cells. Total left nephrectomy was performed as the patient became unstable.DiscussionRupture of a renal AML is the main cause of WS. This risk increases with the size of the tumor (>4 cm) and during pregnancy. CT scan is the best imaging modalities for diagnosis. The bridging therapy increases the perioperative bleeding risk. These patients are conservative treated with selective transarterial embolization. Nephrectomy is limited for the patients hemodynamically unstable or in case of failed embolization.ConclusionThis is a unusual case of WS after surgery in patients with small AML and treated with high dose of anticoagulant for cardiac disease. There are no other similar cases in literature.