A retroperitoneal hematoma, developing primarily after abdominal or pelvic blunt trauma, is a potentially life-threatening complication of various malignancies that presents with non-specific symptoms such as pain in the abdomen, the back, the leg, and the hip area, as well as abdominal distension and ascites. The diagnosis must be made early on, and imaging studies, including ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) should be used to determine the exact location of metastatic spread.
Retroperitoneal hematoma (RH) can appear as a result of various etiologies, including the chronic use of anticoagulants (warfarin, heparin, antiplatelet drugs), surgical procedures, rupture of aortic aneurysms, and blood dyscrasias, but by far, the most common cause is abdominal or pelvic trauma     . Hence, the terms spontaneous, traumatic, and idiopathic retroperitoneal hematomas are used in the literature   . Mortality rates for traumatic RH range from 6-60% according to different reports, suggesting that an early diagnosis is of critical importance  . Unfortunately, this condition is missed up to 10% of patients . The clinical presentation, however, might not always be indicative of a RH, with most common signs being abdominal pain and a sense of suprainguinal tenderness, but pain may sometimes appear in the leg, the hip, or radiate to the back   . Femoral numbness and neuropathy were identified in up to a third of cases  . RH can also present as an abdominal mass accompanied by distension, whereas newly form ascites is a highly indicative sign of an ongoing process in the abdomen   . In severe cases, patients suffer from life-threatening hypotension and a severe hematocrit drop that is unresponsive to standard therapy .
Entire Body System
On arrival, the patient had hypotension, tachycardia, tachypnea, low-grade fever, and Glasgow Coma Scale score of 12. Abdominal examination revealed distention and mild tenderness in the right upper quadrant of the abdomen. [ncbi.nlm.nih.gov]
Robotic Surgery, social media, STAMPEDE trial, SUSPEND trial, tamsulosin, The Urology Foundation, Twitter, Ureteric stones, urological oncology We present the case of a middle age male with ESRD with post transplant graft rejection, who presented with fever [bjuinternational.com]
Psoas hematomas can present with constipation, urinary frequency, or fever if they are large. They can even compress the femoral nerve and cause a femoral neuropathy 3,4. [radiopaedia.org]
[…] abdominal compartment syndrome (e.g. intra-abdominal hypertension, renal failure) history of risk factors (often no significant history if spontaneous) Psoas haematoma can present with constipation, urinary frequency, compressive femoral neuropathy or fever [lifeinthefastlane.com]
- Leg Swelling
CONCLUSIONS: SRH with concomitant DVT, especially in women aged 45, should be considered in patients with sudden lower abdominal or lumbar pain, leg swelling, anemia, and shock. [ncbi.nlm.nih.gov]
- Abdominal Pain
A case of acute right lower quadrant abdominal pain five days following thrombolytic therapy and percutaneous transluminal coronary angioplasty is presented. [ncbi.nlm.nih.gov]
- Cullen's Sign
’s sign (periumbilical ecchymosis) – late finding Grey-Turner’s sign (ecchymosis of the flanks) – late finding *History of risk factors as above Evaluation and Diagnosis 1,3,4,5 Complete Blood Count for anemia Lipase – suggests pancreatic or duodenal [emdocs.net]
sign Journal articles Chan YC, Morales JP, Reidy JF, Taylor PR. [lifeinthefastlane.com]
- Abdominal Pain Radiating to the Back
The patient was complaining of gradually increasing severe right side abdominal pain radiating to the back and right loin region for 5 days pre-admission. On admission, the patient was in shock state, having tachycardia and tachypnea. [omicsonline.org]
Liver, Gall & Pancreas
Non-specific symptoms such tachycardia, hypotension, and anaemia are the most prevalent in this complication. With this case, our aim is to describe serious complications related to XLIF. [ncbi.nlm.nih.gov]
Signs The patient may develop tachycardia and hypotension if the rate of hemorrhage is rapid. Rarely, later in the course, the patient may develop a Grey-Turner’s sign with bulging flanks, and a bluish discoloration in the region of the flank. [medicalopedia.org]
- Venous Insufficiency
The occurrence rate of chronic venous insufficiency was 87.5% during follow-up. [ncbi.nlm.nih.gov]
- Heart Disease
There was no personal or family history of coagulopathy or stroke, valvular heart disease trauma, chest pain or illicit intravenous drug usage. He smoked 20 cigarettes daily and consumed alcohol in moderation in the past. [jmedicalcasereports.biomedcentral.com]
- Grey Turner's Sign
Rarely, later in the course, the patient may develop a Grey-Turner’s sign with bulging flanks, and a bluish discoloration in the region of the flank. [medicalopedia.org]
Wunderlich Triad Pain: Back, groin, flank, abdomen (most common presenting symptom) Palpable mass Shock Leg paresis and/or anterior thigh hypoesthesia Secondary to hematoma compressing the femoral nerve Cullen’s sign (periumbilical ecchymosis) – late finding Grey-Turner’s [emdocs.net]
Turner sign Eponymictionary – Cullen sign Journal articles Chan YC, Morales JP, Reidy JF, Taylor PR. [lifeinthefastlane.com]
Her physical examination disclosed left abdominal and costovertebral angle tenderness, left flank ecchymosis (Grey Turner sign). Abdominal computerised tomography revealed spontaneous retroperitoneal haemorrhage. [ncbi.nlm.nih.gov]
It can present with Grey Turner's sign (flank bruising). [en.wikipedia.org]
- Anterior Thigh Pain
The retroperitoneal hematoma with its compressive effects gives rise to a variety of ambiguous signs and symptoms which include transient lower limb paralysis, testicular pain, anterior thigh pain, urinary tract infection, groin pain, inguinoscrotal mass [medical-dictionary.thefreedictionary.com]
The diagnosis can be missed because of the nonspecific presentation of retroperitoneal hematoma , which is why a thorough examination of patients who suffered from recent abdominal or pelvic trauma, or who are receiving anticoagulant therapy, must be carried out when the previously mentioned complaints are noticed. For this reason, a detailed patient history that confirms the use of medications or recent trauma may be the crucial step in making a presumptive diagnosis. After a comprehensive physical examination, imaging studies need to be employed. Abdominal ultrasonography, although being a fast and convenient first-line study, has a very low detection rate of retroperitoneal hematomas, making CT scan the gold-standard for identifying this clinical entity . Acute and subacute hematomas (being present for < 7 days or between 7 days and 7 weeks, respectively) have a high-attenuating heterogeneous appearance on CT, whereas chronic hematomas (lasting > 7 weeks), exhibit a low-attenuating pattern due to degradation of red blood cells and subsequent accumulation of hemosiderin  . Some reports have observed the striking similarities of RH with malignant tumors (eg. sarcomas), but the typical findings of hematomas - a sharply defined margin and progressive reduction in size are used to discriminate between these lesions   . MRI requires more preparation and time that may not always be feasible, but its superiority compared to CT by revealing a hyperintense mass on both T1 and T2-weighted images is well-documented  .
Retroperitoneal hematomas are often fatal, and treatment involves aggressive fluid resuscitation with possible surgical decompression. [ncbi.nlm.nih.gov]
Therapy and prognosis will be also discussed. [ncbi.nlm.nih.gov]
In particular, the checkmark sign, indicated an extremely poor prognosis. [de.slideshare.net]
It has a better prognosis compared to that of the acute type. Surgery Inappropriate surgical evacuation can exacerbate hemorrhage by relieving hematoma induced tamponade. [radiopaedia.org]
The patient presented to the emergency room with significant right flank pain, and computed tomography (CT) demonstrated a large, right-sided retroperitoneal hematoma with no identifiable etiology. [ncbi.nlm.nih.gov]
Through literature revision, we have discussed the etiological aspects of this disease and the importance of obtaining the preoperative diagnosis for an appropriate and conservative operative treatment. [scielo.br]
Trauma is the most common cause, but non-traumatic etiology has been reported. [press.mu-varna.bg]
Systematic review: the epidemiology of ischaemic colitis. Aliment Pharmacol Ther 2004 ; 19 : 729 – 38. 7. Assessment of potential risk factors associated with ischaemic colitis. [academic.oup.com]
Epidemiology of renal trauma: In blunt abdominal trauma, up to 40% present with renal injury. In urban areas, 80% of renal injuries occur in the context of polytrauma. In ski resorts, 2/3 of renal injuries are due to skiing accidents. [urology-textbook.com]
Wight J, Paisley S (2003) The epidemiology of inhibitors in haemophilia A: a systematic review. Haemophilia 9: 418-435. White GC 2nd, Rosendaal F, Aledort LM, Lusher JM, Rothschild C, et al. (2001) Definitions in hemophilia. [omicsonline.org]
The pathophysiological mechanisms underlying development and treatment of these aneurysms are discussed. [ncbi.nlm.nih.gov]
On the pathophysiology of intestinal ischemic injury. Clinical review. Acta Chir Scand 1987 ; 153 : 321 – 4. 4. Ischemic proctosigmoiditis. Am J Gastroenterol 1996 ; 91 : 2305 – 9. 5. Ischemic colitis: clinical practice in diagnosis and treatment. [academic.oup.com]
A plethora of conditions have been used as a possible hypothesis of the pathophysiology of SRH. Unrecognized minor trauma in the microcirculation in the presence of coagulopathy has been suggested [ 13, 14 ]. [jmedicalcasereports.biomedcentral.com]
The pathophysiology of the spontaneous RPHs is unclear. [omicsonline.org]
Our review shows that even if many works suggest that fondaparinux is a safe and effective alternative to LMWH in the prevention of venous thromboembolism following major orthopaedic surgery, it should carefully be used in elderly people and patients [ncbi.nlm.nih.gov]
- Wang F, Wang F. The diagnosis and treatment of traumatic retroperitoneal hematoma. Pak J Med Sci. 2013;29(2):573-576.
- Sunga KL, Bellolio MF, Gilmore RM, Cabrera D. Spontaneous retroperitoneal hematoma: etiology, characteristics, management, and outcome. J Emerg Med. 2012;43(2):e157-161.
- Murai Y, Adachi K, Yoshida Y, Takei M, Teramoto A. Retroperitoneal hematoma as a serious complication of endovascular aneurysmal coiling. J Korean Neurosurg Soc. 2010;48(1):88–90.
- Rajiah P, Sinha R, Cuevas C, Dubinsky TJ, Bush WH Jr, Kolokythas O. Imaging of uncommon retroperitoneal masses. Radiographics. 2011;31(4):949-976.
- Abe T, Kai M, Miyoshi O, Nagaie T. Idiopathic Retroperitoneal Hematoma. Case Rep Gastroenterol. 2010;4(3):318-322.
- Kent KC, Moscucci M, Mansour KA, et al. Retroperitoneal hematoma after cardiac catheterization: prevalence, risk factors, and optimal management. J Vasc Surg. 1994;20:905–910.
- Kawashima A, Sandler CM, Ernst RD, et al. Imaging of nontraumatic hemorrhage of the adrenal gland. Radiographics. 1999;19(4):949-963.
- Surabhi VR, Menias C, Prasad SR, Patel AH, Nagar A, Dalrymple NC. Neoplastic and non-neoplastic proliferative disorders of the perirenal space: cross-sectional imaging findings. Radiographics. 2008;28(4):1005-1017.
- Yang DH, Goo HW. Generalized lymphangiomatosis: radiologic findings in three pediatric patients. Korean J Radiol. 2006;7(4):287-291.