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Retroperitoneal Hematoma

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.


Presentation

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 [1] [2] [3] [4] [5]. Hence, the terms spontaneous, traumatic, and idiopathic retroperitoneal hematomas are used in the literature [1] [2] [5]. Mortality rates for traumatic RH range from 6-60% according to different reports, suggesting that an early diagnosis is of critical importance [1] [2]. Unfortunately, this condition is missed up to 10% of patients [2]. 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 [2] [3] [6]. Femoral numbness and neuropathy were identified in up to a third of cases [3] [6]. 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 [1] [2] [3]. In severe cases, patients suffer from life-threatening hypotension and a severe hematocrit drop that is unresponsive to standard therapy [6].

Fever
  • 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]
  • 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]
  • […] 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]
  • Fever, dropping blood count or flank pain are indications for repeated imaging (ultrasonography or CT).[urology-textbook.com]
  • Nausea, vomitting, low grade fever and a decreasing haemoglobin are common findings. Urine examination is frequently normal.[indianjurol.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]
Respiratory Distress
  • Because of the high risk of surgical intervention, we performed ultrasound-guided abdominal paracentesis and thoracentesis to relieve IAH and respiratory distress.[ncbi.nlm.nih.gov]
Dyspnea at Rest
  • Three of the patients presented with dyspnea at rest, fatigue, pleura effusions in chest XR and increased heart rate although b-blocker therapy.[ncbi.nlm.nih.gov]
Abdominal Pain
  • Emergency physicians should always consider SRH in the differential diagnosis in patients under enoxaparin therapy presenting with abdominal pain. Computed tomographic scan is the imaging modality of choice for evaluating SRH.[ncbi.nlm.nih.gov]
  • 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]
  • A 21-year-old man, who had been wearing a seatbelt, was brought to our hospital after a motor vehicle collision, complaining of abdominal pain. Computed tomography (CT) revealed retroperitoneal hematoma in the upper pelvic region.[ncbi.nlm.nih.gov]
  • A 57-year-old man was admitted to our hospital because of abdominal pain. He had no past medical history relating to his present condition, and he received EMR at another hospital 11 days before his admission.[ncbi.nlm.nih.gov]
  • A woman, known for polycythemia vera and a single functioning right kidney, was admitted with mild abdominal pain in a context of recent deep venous thrombosis under low-molecular weight heparin.[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]
Tenderness in the Right Upper Quadrant
  • Abdominal examination revealed distention and mild tenderness in the right upper quadrant of the abdomen. The patient had a history of aortic valve replacement surgery and was on warfarin treatment at an international normalized ratio of 2.4.[ncbi.nlm.nih.gov]
Hepatomegaly
  • Clinical examination revealed hepatomegaly associated with polycythemia vera. Biochemical evaluation disclosed an acute renal failure, and renal ultrasonography showed no dilation of the renal pelvis.[ncbi.nlm.nih.gov]
Tachycardia
  • 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]
  • 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]
  • Nevertheless, 7 hours after the biopsy, the patient reached our emergency department with severe diffuse abdominal pain, hypotension, tachycardia, and confusional state.[ncbi.nlm.nih.gov]
  • Approximately 36 hours after admission, she became acutely hypotensive and developed tachycardia. She was transferred to the medical intensive care unit and intubated for respiratory arrest.[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]
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]
  • 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]
  • Turner sign Eponymictionary – Cullen sign Journal articles Chan YC, Morales JP, Reidy JF, Taylor PR.[lifeinthefastlane.com]
  • It can present with Grey Turner's sign (flank bruising).[en.wikipedia.org]
Asthenia
  • The patient was admitted in hospital as she presented with gastrointestinal bleeding (melena), asthenia and progressive anemia.[ncbi.nlm.nih.gov]
Adnexal Mass
  • Imaging studies revealed a nonspecific adnexal mass, and CA 125 levels were normal. Both women underwent exploratory laparotomy for an adnexal mass and were found to have an organized retroperitoneal hematoma.[ncbi.nlm.nih.gov]

Workup

The diagnosis can be missed because of the nonspecific presentation of retroperitoneal hematoma [2], 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 [7]. 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 [4] [5]. 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 [4] [8] [9]. 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 [4] [9].

Thrombocytosis
  • It is likely that the combination of aspirin therapy and thrombocytosis paradoxically placed the patient at increased risk for hemorrhagic complications.[ncbi.nlm.nih.gov]

Treatment

  • Retroperitoneal hematomas are often fatal, and treatment involves aggressive fluid resuscitation with possible surgical decompression.[ncbi.nlm.nih.gov]
  • Key words: retroperitoneal hematoma bleeding anticoagulation treatment surgery.[ncbi.nlm.nih.gov]
  • Review of the literature revealed 8 cases of spontaneous retroperitoneal hematoma secondary to antiplatelet treatment.[ncbi.nlm.nih.gov]
  • Medical data for demographics, clinical presentation, auxiliary examinations, treatment modalities, outcomes, and follow-up were retrospectively analyzed. RESULTS: Nine patients (8 women, 1 man) were enrolled in this study.[ncbi.nlm.nih.gov]
  • The pathophysiological mechanisms underlying development and treatment of these aneurysms are discussed.[ncbi.nlm.nih.gov]

Prognosis

  • Therapy and prognosis will be also discussed.[ncbi.nlm.nih.gov]
  • RH originating from retrorenal or combined interfascial plane had a poor prognosis; 51.7% of such patients died as a result of uncontrollable hemorrhage. CONCLUSION: RH was based in the interfascial planes, not the three compartments.[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]

Etiology

  • 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]
  • Several variants of IVCS have been described, including unusual presenting symptoms, etiologies, and complications.[ncbi.nlm.nih.gov]
  • In patients with advanced chronic kidney disease, anticoagulant therapy should be administered carefully, and the etiology of retroperitoneal hematoma should be further investigated. [Indexed for MEDLINE] Free full text[ncbi.nlm.nih.gov]
  • 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[symptoma.com]
  • Trauma is the most common cause, but non-traumatic etiology has been reported.[press.mu-varna.bg]

Epidemiology

  • 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]
Sex distribution
Age distribution

Pathophysiology

  • The pathophysiological mechanisms underlying development and treatment of these aneurysms are discussed.[ncbi.nlm.nih.gov]
  • Elevated intra-abdominal pressure (IAP) has been identified as a cascade of pathophysiologic changes leading in end-organ failure due to decreasing compliance of the abdomen and the development of abdomen compartment syndrome (ACS).[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 .[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]

Prevention

  • 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]
  • BACKGROUND Dual antiplatelet therapy has proven efficacy in primary and secondary prevention of coronary artery disease with a relatively good safety profile.[ncbi.nlm.nih.gov]
  • Awareness of the determinants and clinical features of RPH may aid in prevention, early recognition, and prompt treatment.[ncbi.nlm.nih.gov]
  • Identifying patients in the ICU at risk for developing ACS with constant surveillance can lead to prevention. ACS is the natural progression of pressure-induced end-organ changes and develops if IAP is not recognized and treated in a timely manner.[ncbi.nlm.nih.gov]
  • The purpose of this study was to demonstrate the clinical characteristics of postoperative retroperitoneal hematoma (RPH) following transforaminal percutaneous endoscopic lumbar discectomy (PELD) and to discuss how to prevent the complication of unintended[ncbi.nlm.nih.gov]

References

Article

  1. Wang F, Wang F. The diagnosis and treatment of traumatic retroperitoneal hematoma. Pak J Med Sci. 2013;29(2):573-576.
  2. Sunga KL, Bellolio MF, Gilmore RM, Cabrera D. Spontaneous retroperitoneal hematoma: etiology, characteristics, management, and outcome. J Emerg Med. 2012;43(2):e157-161.
  3. 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.
  4. Rajiah P, Sinha R, Cuevas C, Dubinsky TJ, Bush WH Jr, Kolokythas O. Imaging of uncommon retroperitoneal masses. Radiographics. 2011;31(4):949-976.
  5. Abe T, Kai M, Miyoshi O, Nagaie T. Idiopathic Retroperitoneal Hematoma. Case Rep Gastroenterol. 2010;4(3):318-322.
  6. 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.
  7. Kawashima A, Sandler CM, Ernst RD, et al. Imaging of nontraumatic hemorrhage of the adrenal gland. Radiographics. 1999;19(4):949-963.
  8. 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.
  9. Yang DH, Goo HW. Generalized lymphangiomatosis: radiologic findings in three pediatric patients. Korean J Radiol. 2006;7(4):287-291.

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Last updated: 2019-07-11 20:35