Retroperitoneal Hemorrhage

• • Nonlocalizing abdominal, flank, or low back discomfort

  • Dropping Hct with or without clinical evidence of hemorrhagic shock

  • Occurs in patients with a history of trauma, femoral vascular access, or anticoagulation/antiplatelet medications

Epidemiology

• • Spontaneous retroperitoneal hemorrhage occurs in critically ill patients who are taking anticoagulant or antiplatelet medications, or both

  • Femoral vascular access common etiology of clinically silent large retroperitoneal hematoma formation

  • Traumatic retroperitoneal hematoma can occur after either blunt or penetrating trauma

  • Traumatic retroperitoneal hematomas divided into 3 anatomic zones:

  • -Zone 1: Centrally located, associated with pancreaticoduodenal injuries or major abdominal vascular injury

    -Zone 2: Flank or perinephric regions, associated with injuries to the genitourinary system or colon

    -Zone 3: Pelvic location, frequently associated with pelvic fractures or ileal-femoral vascular injury

Symptoms and Signs

• • Symptoms depend on anatomic location of the retroperitoneal hemorrhage

  • Nonlocalizing abdominal, flank, or low back discomfort

  • Subtle increasing abdominal girth with more cephalad located hemorrhage

  • Pelvic hematomas may compress the bladder causing urinary symptoms

  • Pancreaticoduodenal hematomas may cause gastric outlet obstruction

  • Perinephric hematomas may manifest in hematuria

  • Femoral nerve palsy

  • Flank and groin ecchymosis are a late sign of retroperitoneal hemorrhage

Laboratory Findings

• • Cardinal laboratory finding is a falling Hct

  • Ancillary laboratory findings are depend on associated organ injury such as elevated amylase/lipase with pancreatic injury

Imaging Findings

• • Abdominal/pelvic CT with IV and PO contrast: Demonstrates the retroperitoneal hematoma as well as associated vascular or organ injury

  • CT scan: Reliably differentiates between hematoma, tumor, and abscess

  • US: Useful as an initial study to verify the presence of a hematoma

  • US bladder scan can diagnose pelvic hematoma in patients with urinary symptoms following femoral vessel catheterization

• • Retroperitoneal tumors

  • Retroperitoneal abscess

  • Intraperitoneal process with retroperitoneal extension

Rule Out

• • Associated vascular or adjacent organ injury:

  • -Pancreaticoduodenal injury

    -Abdominal or pelvic vascular injury

    -Renal laceration

    -Ureter disruption

    -Bladder injury

    -Ascending/descending colon injury

    -Pelvic fracture

    -Femoral pseudoaneurysm formation

• • Serial Hgb evaluation

  • Coagulation assessment

  • Amylase and lipase

  • UA

  • Trauma work-up as indicated

  • Abdominal/pelvic CT scan with IV and PO contrast

  • Angiogram

  • Obtain IV urogram (sometimes)

When to Admit

• • All patients should be admitted and closely monitored in the acute setting

When to Refer

• • Referral depends on etiology and/or anatomic location of injury:

  • -Trauma

    -Vascular

    -Orthopedic

  • Spontaneous retroperitoneal hemorrhage as well as many blunt pelvic vascular injuries can be successfully managed in interventional radiology with percutaneous embolization techniques

• • Large bore IV access

  • Type and cross

  • Normalization of coagulation factors

  • Serial Hct evaluation

  • Patients with spontaneous ...