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Retroperitoneal Hemorrhage

Retroperitoneal hemorrhage is a somewhat uncommon but potentially life-threatening event. It can develop after an external injury to the abdomen, or as a result of various intrinsic conditions of neoplastic, iatrogenic, or autoimmune origin, in which case the term spontaneous retroperitoneal hemorrhage is used. The severity of symptoms depends on the extent of bleeding, but abdominal pain, shock, and a poor general condition are usually noted. Imaging studies are necessary to confirm the diagnosis.


Presentation

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]
  • Clinically significant adrenal hemorrhage by metastasis is exceedingly rare and non-specific symptoms, such as abdominal, chest or back pain, nausea and vomiting, confusion, weakness, hypotension, shock and high fever, are often observed in these patients[ncbi.nlm.nih.gov]
  • A computed tomography (CT) PE/DVT scan was obtained due to sudden increasing oxygen requirement, and low grade fever which showed sub-segmental pulmonary emboli. Enoxaparin (weight based) 80 mg, subcutaneous every 12-hours was initiated.[ijcasereportsandimages.com]
  • […] 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]
Pallor
  • 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]
  • 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]
High Fever
  • Clinically significant adrenal hemorrhage by metastasis is exceedingly rare and non-specific symptoms, such as abdominal, chest or back pain, nausea and vomiting, confusion, weakness, hypotension, shock and high fever, are often observed in these patients[ncbi.nlm.nih.gov]
Fishing
  • Here, we report a case of retroperitoneal hemorrhage developed after endoscopic removal of a fish bone stuck in the duodenal wall, and then resolved spontaneously by conservative care.[ncbi.nlm.nih.gov]
Animal Bite
  • bites Insect bite Spider bite Snakebite Other: Ballistic trauma Stab wound Blunt trauma / superficial/ closed Penetrating trauma / open Aerosol burn Burn / Corrosion / Chemical burn Frostbite Occupational injuries Traumatic amputation By region Hand[en.wikipedia.org]
Abdominal Pain
  • 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]
  • 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]
  • A patient with end-stage renal disease on maintenance hemodialysis developed sudden severe abdominal pain and distension.[ncbi.nlm.nih.gov]
  • She presented with a sudden onset of lower abdominal pain, dizziness and a palpable abdominal mass after prolonged straining to defecate.[ncbi.nlm.nih.gov]
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]
  • We present the case of a 29-year-old, pregnant woman who, at 27 weeks' gestation, suffered an acute abdomen with hypovolemic shock that led to intrauterine fetal death in spite of an emergency laparotomy.[ncbi.nlm.nih.gov]
  • Robert Gore (co-editor of Textbook of Gastrointestinal Radiology) has assembled an expert panel of authors on the topic of The Acute Abdomen.[books.google.com]
  • abdomen and new material on CT and MR angiography, lung cancer screening, pulmonary embolism, coronary artery calcium screening, and interventional CT techniques including radiofrequency ablation and CT fluoroscopy.[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
  • sign Grey Turner's sign Retroperitoneal hemorrhage Animal bites Insect bite Spider bite Snakebite Other: Ballistic trauma Stab wound Blunt trauma / superficial/ closed Penetrating trauma / open Aerosol burn Burn / Corrosion / Chemical burn Frostbite[en.wikipedia.org]
  • ’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) history of risk factors[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]
Absent Bowel Sounds
  • Her abdomen was extremely distended, firm to the touch, and had absent bowel sounds. Both lower extremities were cool to the touch, with significantly diminished femoral pulses.[redorbit.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]
Grey Turner's Sign
  • It can present with Grey Turner's sign (flank bruising).[en.wikipedia.org]
  • 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]
Insect Bite
  • bite Spider bite Snakebite Other: Ballistic trauma Stab wound Blunt trauma / superficial/ closed Penetrating trauma / open Aerosol burn Burn / Corrosion / Chemical burn Frostbite Occupational injuries Traumatic amputation By region Hand injury Head injury[en.wikipedia.org]

Workup

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].

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]
  • Age, sex, presence of comorbidities, hemoglobin decrease, transfusion requirement, ICU stay, and length of ICU stay were recorded.[ncbi.nlm.nih.gov]
Erythrocytosis
  • Complications include cystic hemorrhage or infection, erythrocytosis, and renal cell carcinoma.[ncbi.nlm.nih.gov]

Treatment

  • 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]
  • However, treatment of these patients is still controversial, both conservative and surgical treatments have been advocated.[ncbi.nlm.nih.gov]
  • Spontaneous adrenal hemorrhage is a very rare but serious disorder of the adrenal gland that can require emergent treatment.[ncbi.nlm.nih.gov]
  • Conservative treatment is the first choice, and prognosis is good when diagnosed early.[ncbi.nlm.nih.gov]
  • Half a month of comprehensive treatment later, the patient was discharged from the hospital.[ncbi.nlm.nih.gov]

Prognosis

  • Conservative treatment is the first choice, and prognosis is good when diagnosed early.[ncbi.nlm.nih.gov]
  • Primary osteosarcoma of the kidney is a very rare neoplasm with a very poor prognosis and unclear histogenesis. Only 20 cases have been reported in the literature. It has a strong tendency to recur locally and spread to distant sites.[ncbi.nlm.nih.gov]
  • In patients who were hemodynamically stable, RPH volume as quantified by non-contrast abdominal/pelvic CT did not contribute to prognosis.[ncbi.nlm.nih.gov]
  • It has a better prognosis compared to that of the acute type. Surgery Inappropriate surgical evacuation can exacerbate haemorrhage by relieving haematoma induced tamponade.[radiopaedia.org]
  • […] prevention Depending on the speed of bleeding, the amount of reasons and found sooner or later, aortic rupture mortality is very high, after pregnancy, combined with peritoneal hemorrhage on the mother and child are serious harm, other causes of bleeding prognosis[healthfrom.com]

Etiology

  • Histology revealed an endothelial-lined adrenal cyst suggesting a vascular or lymphatic etiology.[ncbi.nlm.nih.gov]
  • Abnormal vital signs and a chief complaint of pain can produce a diagnosis ranging from a cardiac etiology to an infectious source. Our goal is to discuss a case in which an ESRD dialysis patient presented with a rare, life-threatening emergency.[ncbi.nlm.nih.gov]
  • Although trauma is the most common cause of adrenal hemorrhage, non-traumatic etiologies have also been reported.[ncbi.nlm.nih.gov]
  • The etiology includes spontaneous, posttraumatic, postoperative and iatrogen occurrence. Retroperitoneal hematoma may also occur in patients under anticoagulative therapy.[thieme-connect.com]
  • Introduction Etiology Prevention Complication Symptom Examine Diagnosis Treatment Basic Nursing Introduction Brief Introduction of Peritoneal Clearance Hemorrhage Hemorrhage in Retroperitoneal Space is one of the complications of severe abdominal injury[healthfrom.com]

Epidemiology

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

Pathophysiology

  • 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 13. Pearce William H, Christopher K. Zarins, J. Michael Bacharach.[mds.marshall.edu]
  • The pathophysiology of the spontaneous RPHs is unclear.[omicsonline.org]

Prevention

  • It could prevent reintervention and prolongation of the hospitalisation.[ncbi.nlm.nih.gov]
  • 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]
  • Although inferior vena cava (IVC) filter placement has demonstrated an excellent therapeutic efficacy in preventing pulmonary embolism, several filter-related complications have been reported.[ncbi.nlm.nih.gov]
  • An early diagnosis and timely treatment are important in cases of retroperitoneal hemorrhage to prevent life-threatening complications.[ncbi.nlm.nih.gov]
  • There have been defined the typical complications and preventive measures. Implementation of the scientific results.[cnaa.md]

References

Article

  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.

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Last updated: 2018-06-21 21:20