A rare complication of numerous diseases and external factors, retroperitoneal hemorrhage is defined as sudden bleeding into the retroperitoneal space [1] and must be recognized early because of its life-threatening nature. In general, conditions that can induce bleeding in the retroperitoneum are broadly divided into two categories - traumatic and spontaneous [2]. Mechanical damage to the visceral structures (both solid and hollow organs), major blood vessels, or musculoskeletal tissues is readily observed in severe trauma (crush injuries, motor vehicle accidents, falls, severe fractures, etc.), and up to 12% of blunt-trauma patients were diagnosed with retroperitoneal hemorrhage in isolated case series [1] [3]. On the other hand, several authors have documented the appearance of spontaneous retroperitoneal hemorrhage due to an array of intrinsic diseases [1] [2] [4] [5] [6]. Neoplastic processes (primarily of renal origin, such as renal cell carcinoma, angiomyolipoma, but also pheochromocytoma, hemangioma, paragangliomas, etc.), drugs (anticoagulants - coumadin, low molecular dose heparin), nephritis, polyarteritis nodosa (PAN) and vascular malformations have been confirmed as underlying causes of spontaneous retroperitoneal hemorrhage [1] [4] [5]. The clinical presentation depends on the severity and rate of blood loss and accumulation in the peritoneum and on the presence of additional injuries [2]. The most common symptoms are an abdominal pain (particularly flank pain), hematuria, and a state of shock [4] [5], as blood loss universally leads to hypotension and hypovolemia.

• Fever

  However, there may be complications related to the endoscopic procedure including mucosal laceration, bleeding, fever, and perforation. [ncbi.nlm.nih.gov]

  […] abdominal compartment syndrome (e.g. intra-abdominal hypertension, renal failure) history of risk factors (often no significant history if spontaneous) Psoas haematomas can present with constipation, urinary frequency, compressive femoral neuropathy or fever [lifeinthefastlane.com]

  She denied shortness of breath, chest pain, fever, chills, nausea, and vomiting. The patient initially reported having diarrhea, but further inquiry revealed that her stools had been softer than usual but not watery or more frequent. [mdedge.com]

  Common side effects include bleeding, fever, and swelling of the legs. As a medication, it is used to treat a number of conditions including anaphylaxis, cardiac arrest, and superficial bleeding. [fi.nativelib.net]

• Pallor

  She was in hypotension with severe pallor. Patient was initially resuscitated with intravenous (IV) fluids, and then two units of blood as her hemoglobin (Hb) was 6 g%. [jscisociety.com]

  Symptoms of hypovolemia were commonly observed as well, such as syncope, pallor, and dizziness. [ncbi.nlm.nih.gov]

  The pain was associated with sweating, dizziness, pallor, and dyspnoea. He has no history of trauma, drug use, or other chronic diseases. Finally, this patient was referred to our department by the orthopedist. [omicsonline.org]

• Gangrene

  There was no evidence of ongoing bleeding or gangrenous bowel. We evacuated a significant amount of blood and retroperitoneal clot. The abdomen was closed primarily after a pelvic drain was placed. [redorbit.com]

• Abdominal Pain

  RESULTS: Four patients had abdominal pain, two patients had hematuria, and one patient had abdominal pain and hematuria. There was retroperitoneal hemorrhage in three patients on abdominal CT. [ncbi.nlm.nih.gov]

  The most common symptoms are an abdominal pain (particularly flank pain), hematuria, and a state of shock, as blood loss universally leads to hypotension and hypovolemia. [symptoma.com]

• Acute Abdomen

  Spontaneous retroperitoneal hemorrhage is a lethal cause of acute abdomen that is most frequently related to drugs, coagulopathy and intra-abdominal tumors. [ncbi.nlm.nih.gov]

  […] of the acute, non-traumatic abdomen in adolescents and adults; and more! [books.google.com]

• Severe Abdominal Pain

  A patient with end-stage renal disease on maintenance hemodialysis developed sudden severe abdominal pain and distension. [ncbi.nlm.nih.gov]

  However, the presentation in a middle-aged female with sudden onset hypotension with anemia with severe abdominal pain (left iliac and lumbar region) following defecation (increased abdominal pressure) with a preexisting thrombus in the left iliac vein [jscisociety.com]

  Abdominal compartment syndrome is a rare but serious complication of severe RPH often presenting as acute renal failure with severe abdominal pain distention causing respiratory distress and cardiovascular collapse. [benthamopen.com]

• Cullen's Sign

  but may have Cullen’s sign (umbilical ecchynosis) and Gray-Turner’s sign (flank ecchymosis) +/- palpable swelling haematuria haemodynamic instability and shock evidence of abdominal compartment syndrome (e.g. intra-abdominal hypertension, renal failure [lifeinthefastlane.com]

  ’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]

• 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]

• Hypotension

  A 55-year-old man with ESRD presented with acute abdominal pain and hypotension caused by a spontaneous retroperitoneal hemorrhage. This case report demonstrates the necessity of having broad differential diagnoses when evaluating patients with ESRD. [ncbi.nlm.nih.gov]

  The patient with hypotension post cath should be rapidly stabilized, and if not stabilized, then rapidly diagnosed and treated for the cause of hypotension. [cathlabdigest.com]

• Tachycardia

  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]

  On admission, the patient was in shock state, having tachycardia and tachypnea. [omicsonline.org]

  We recognized hemorrhage in our patients on the basis of progressive anemia, tachycardia with low blood pressure, and abdominal distension. [bmcresnotes.biomedcentral.com]

  These can include tachycardia and hypotension/poor peripheral perfusion. Abdominal tenderness may or may not be present. [ncbi.nlm.nih.gov]

• Back Pain

  This has implications for physicians who treat patients with acute low back pain. They must be alert to potentially life-threatening causes of low back pain. [ncbi.nlm.nih.gov]

  Symptoms The patient may complain of intense flank pain or back pain. Signs The patient may develop tachycardia and hypotension if the rate of hemorrhage is rapid. [medicalopedia.org]

• Grey Turner's Sign

  It can present with Grey Turner's sign (flank bruising). [en.wikipedia.org]

  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]

  (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 injury [emdocs.net]

  The classically taught flank bruising or “Grey-Turner” sign is of little to no clinical use in the acute trauma presentation.[3][12] Hemorrhage should be suspected as the primary cause of hypotension/shock in the trauma patient. [ncbi.nlm.nih.gov]

• Stroke

  Stroke 1989; 20: 864-70. Pubmed 【2001年版】 ［文献］ Lyden PD; NINDS rtPA Stroke Study Group. A modified National Institutes of Health Stroke Scale for use in stroke clinical trials: preliminary reliability and validity. Stroke 2001; 32: 1310-7. [att.ebm-library.jp]

  In 2013, approximately 6.9 million people had an ischemic stroke and 3.4 million people had a hemorrhagic stroke. [fi.nativelib.net]

  Heart disease and stroke statistics--2008 update: a report from the american heart association statistics committee and stroke statistics subcommittee Circulation 2008; 117: e25-146. ], the absolute number of RPH is in thousands. [benthamopen.com]

The nonspecific symptomatology of a retroperitoneal hemorrhage may present as a challenge for the physician, which is why a proper diagnostic workup must be conducted. A detailed patient history should define the onset and progression of symptoms, detect if any underlying disorders are present, and confirm if any drugs were recently used (especially anticoagulants). A comprehensive clinical examination is the next step, with an emphasis on abdominal palpation and vital sign assessment. As soon as clinical suspicion toward a bleeding disorder is raised, imaging studies, the key step in recognizing retroperitoneal hemorrhage, should be employed. Plain radiography is of limited benefit in evaluating bleeding disorders (although a degree of haziness in the lower abdomen that can be detected by this method might suggest bleeding), which is why ultrasonography (US) is a preferred first-line method [1]. Ascites, organ contusions and hyperechoic masses in the retroperitoneum are signs of retroperitoneal hemorrhage on US [1]. The use of contrast-enhanced computed tomography (CT) is recommended when ultrasonography and clinical findings point toward retroperitoneal bleeding, as it can delineate the exact location of bleeding, but also confirm damage to the viscera and major blood vessels [1] [3] [7].

• Abdominal CT Scan Abnormal

  abdominal imaging Abnl abdominal MRI Abnl abdominal ultrasound Abnl liver ultrasound Abnl pelvic CT scan Abnl pelvic MRI Abnormal abdominal CT scan Abnormal abdominal imaging Abnormal abdominal MRI Abnormal abdominal ultrasound Abnormal computerized [icd9data.com]

• X-Ray Abnormal

  […] abdominal X-ray abnormal Imaging of abdomen abnormal Imaging of liver abnormal Imaging of spleen abnormal Magnetic resonance imaging of abdomen abnormal Plain X-ray abdomen abnormal ICD-9-CM Volume 2 Index entries containing back-references to 793.6 [icd9data.com]

• Hemoglobin Decreased

  Her hemoglobin decreased to 46 g/L. An abdominal ultrasound showed a hematoma in the left retroperitoneal space, and computed tomography (CT) findings revealed a 6 cm × 8 cm × 10 cm hematoma in the left psoas muscle. [ncbi.nlm.nih.gov]

• ST Elevation

  DOI http://dx.doi.org/10.18590/mjm.2017.vol3.iss1.5 Abstract When patients present with life threatening conditions, a rapid cost-benefit analysis prioritizes care and commits treatment to a certain course that, in the case of ST Elevation Myocardial [mds.marshall.edu]

Abstract The purpose of this study was to report a single hospital's experience of endovascular treatment of patients with retroperitoneal hemorrhage (RPH) secondary to anticoagulant treatment. [ncbi.nlm.nih.gov]

Conservative treatment is the first choice, and prognosis is good when diagnosed early. [ncbi.nlm.nih.gov]

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]

ﾋﾄ, human(primates), 012150, human, 外傷, ｶﾞｲｼｮｳ, injury, 023276, *, 出血, ｼｭｯｹﾂ, hemorrhage, 011323, 腹膜疾患, ﾌｸﾏｸｼｯｶﾝ, peritoneal disease, 054354, ショック症状, ｼｮｯｸｼｮｳｼﾞｮｳ, shock(symptom), 040187, shock, X線CT, XｾﾝCT, X-ray computed tomography, 055741, 予後, ﾖｺﾞ, prognosis [togodb.biosciencedbc.jp]

To review the etiology, diagnosis and treatment of spontaneous retroperitoneal hemorrhage. [ncbi.nlm.nih.gov]

He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education. [lifeinthefastlane.com]

Review the epidemiology of retroperitoneal hematoma. Outline the management considerations for retroperitoneal hematoma. [ncbi.nlm.nih.gov]

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]

Femoral nerve dysfunction after retroperitoneal hemorrhage: pathophysiology revealed by computed tomography. Arch Phys Med Rehabil 1984;65:37–40 PubMed Google Scholar 2. Fealy S, Paletta GA Jr. [link.springer.com]

Pathophysiology of abdominal aortic aneurysms: insights from the elastase-induced model in mice with different genetic backgrounds. Ann N Y Acad Sci 2006;1085:59–7 https://doi.org/10.1196/annals.1383.029 13. Pearce William H, Christopher K. [mds.marshall.edu]

The pathophysiology of the spontaneous RPHs is unclear. [omicsonline.org]

We considered that the filter should be removed to control retroperitoneal hemorrhage and prevent secondary infection of the hematoma. Removal of the retrievable filter was effective in managing these complications. [ncbi.nlm.nih.gov]

There have been defined the typical complications and preventive measures. Implementation of the scientific results. [cnaa.md]

1. Fan W, Deng Z, Liu F, et al. Spontaneous retroperitoneal hemorrhage after hemodialysis involving anticoagulant agents. J Zhejiang Univ Sci B. 2012;13(5):408-412.
2. Abe T, Kai M, Miyoshi O, Nagaie T. Idiopathic Retroperitoneal Hematoma. Case Rep Gastroenterol. 2010;4(3):318-322.
3. Daly KP, Ho CP, Persson DL, Gay SB. Traumatic Retroperitoneal Injuries: Review of Multidetector CT Findings. Radiographics. 2008;28(6):1571-1590.
4. Phillips CK, Lepor H. Spontaneous Retroperitoneal Hemorrhage Caused by Segmental Arterial Mediolysis. Rev Urol. 2006;8(1):36-40.
5. Danaci M, Kesici GE, Kesici H, Polat C, Belet U. Coumadin-induced renal and retroperitoneal hemorrhage. Ren Fail. 2006;28(2):129-32.
6. Baksi A, Gupta S, Ray U, Ghosh S. Spontaneous retroperitoneal haemorrhage in a young adult. BMJ Case Rep. 2014;2014:bcr2013202361.
7. Rajiah P, Sinha R, Cuevas C, Dubinsky TJ, Bush WH Jr, Kolokythas O. Imaging of uncommon retroperitoneal masses. Radiographics. 2011;31(4):949-976.