Vicarious Contrast Excretion by the Gallbladder in Acute Renal Failure with Severe Loin Pain and Patchy Ischemia after Anaerobic Exercise

A 20-year-old male was admitted with severe bilateral loin pain and acute kidney injury (AKI). He had played a soccer match 48 h before hospitalization. He developed severe bilateral loin pain, nausea, and vomiting ∼10 h after the match. He initially presented to a secondary hospital, where contrast-enhanced CT was performed. No structural abnormalities were identified; however, his serum creatinine was 2.4 mg/dL. Due to persistent loin pain and worsening renal function, he was transferred to our hospital for further evaluation. On admission, his serum creatinine level was 2.1 mg/dL, and creatine kinase was within normal limits at 103 U/L. Urinalysis, including microscopy, was normal. Physical examination revealed tenderness in both flanks and decreased bowel sounds. A non-enhanced CT 28 h after the initial, showed bilateral multiple wedge-shaped areas of contrast enhancement in both kidneys, consistent with patchy renal ischemia. Contrast material was also detected in the gallbladder, suggesting vicarious iodinated contrast excretion in the setting of ARF [Figure 1a-b]. The patient was managed with intravenous fluids and analgesia. A follow-up CT performed 48 h later demonstrated persistent clear wedge-shaped areas of the contrast dye in both kidneys and complete disappearance of contrast from the gallbladder [Figure 1c-d]. The patient’s kidney function gradually improved, and he was discharged.

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Figure 1:

Initial non-contrasted computed tomography (CT) (a) axial view, (b) coronal view of the abdomen showing bilateral multiple clear wedge-shaped areas of contrast enhancement of both kidneys (short white arrows) and vicarious excretion of iodinated contrast dye by the gallbladder (long white arrows) and follow-up CT (c) axial view, (d) coronal view performed 48 hours after admission showing persistent clear wedge-shaped areas of the contrast dye in both kidneys (short white arrows) and complete disappearance of contrast dye within the gallbladder (long white arrows).

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Vicarious contrast excretion (VCE) refers to excretion of contrast medium via an abnormal alternative route (1).¹ VCE into GB in contrast-induced AKI has been reported.² Acute renal failure with severe loin pain and patchy ischemia after anaerobic exercise (ALPE) is a rare cause of exertional acute kidney injury in patients with or without renal hypouricemia.³ This report is meaningful as VCE into GB occurs in the context of ALPE.