Retroperitoneal hematoma

Retroperitoneal hematoma
Retroperitoneal hematoma. (Image courtesy of RadsWiki)

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Retroperitoneal hemorrhage and retroperitoneal hematoma are potentially life-threatening conditions. Common causes of retroperitoneal hemorrhage are cardiac catheterization and trauma.

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.

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. Again, it should be emphasized that this sign appears 24 to 48 hours after a severe retroperitoneal bleed and should not be used to gauge whether a retroperitoneal bleed is present acutely.

Differentiating retroperitoneal heamatoma from other diseases

Disease	Clinical feature			Laboratory findings	Imaging findings
	Fever	Weight loss	Abdominal pain
Retroperitoneal hematoma	_	_	✔	Anemia	MRI is the best radiologic tool to differentiate between retroperitoneal masses.
Retroperitoneal abscess	✔	_	✔	Leukocytosis, positive inflammatory markers
Retroperitoneal tumors (.e.g. liposarcoma)	✔	✔	✔	positive tumor marker
Chronic pancreatitis	_	✔	✔	DM type II, amylase and lipase levels may be slightly elevated

Classification of acute abdomen based on etiology Presentation Clinical findings Diagnosis Comments Fever Rigors and Chills Abdominal Pain Jaundice Hypotension Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Common causes of Peritonitis Spontaneous bacterial peritonitis + Diffuse − − − − Hypoactive Ascitic fluid PMN>250 cells/mm³ Culture: Positive for single organism Ultrasound for evaluation of liver cirrhosis - Perforated gastric and duodenal ulcer + Diffuse − + + + N Ascitic fluid LDH > serum LDH Glucose < 50mg/dl Total protein > 1g/dl Air under diaphragm in upright CXR Upper GI endoscopy for diagnosis Acute suppurative cholangitis + + RUQ + + + + ± Acute cholangitis + − RUQ + − − − N Abnormal LFT Ultrasound shows biliary dilatation Biliary drainage (ERCP) + IV antibiotics Acute cholecystitis + RUQ + − − Hypoactive Hyperbilirubinemia Leukocytosis Ultrasound shows gallstone and evidence of inflammation Murphy’s sign Acute pancreatitis + Epigastric ± − − N Increased amylase / lipase Ultrasound shows evidence of inflammation Pain radiation to back Acute appendicitis + RLQ − + + Hypoactive Leukocytosis Ultrasound shows evidence of inflammation Nausea & vomiting, decreased appetite Acute diverticulitis + LLQ ± + − Hypoactive Leukocytosis CT scan and ultrasound shows evidence of inflammation Hollow Viscous Obstruction Small intestine obstruction − Diffuse − + ± Hyperactive then absent Leukocytosis Abdominal X ray Nausea & vomiting associated with constipation, abdominal distention Gall stone disease/Cholelithiasis ± − Volvulus - Diffuse - + - Hypoactive Leukocytosis CT scan and abdominal X ray Nausea & vomiting associated with constipation, abdominal distention Biliary colic - RUQ + - - N Increased bilirubin and alkaline phosphatase Ultrasound Nausea & vomiting Renal colic - Flank pain - - - N Hematuria CT scan and ultrasound Colicky abdominal pain associated with nausea & vomiting Vascular Disorders Ischemic causes Mesenteric ischemia ± Periumbilical - - - Hyperactive Leukocytosis and lactic acidosis CT scan Nausea & vomiting, normal physical examination Acute ischemic colitis ± Diffuse - + + Hyperactive then absent Leukocytosis CT scan Nausea & vomiting Hemorrhagic causes Ruptured abdominal aortic aneurysm - Diffuse - - - N Normal CT scan Unstable hemodynamics Intra-abdominal or retroperitoneal hemorrhage - Diffuse - - - N Anemia CT scan History of trauma Gynaecological Causes Fallopian tube Acute salpingitis + LLQ/ RLQ − ± ± N Leukocytosis Pelvic ultrasound Vaginal discharge Ovarian cyst complications and endometrial disease Torsion of the cyst - RLQ / LLQ - ± ± N Increased ESR and CRP Ultrasound Sudden onset severe pain with nausea and vomiting Endometriosis - RLQ/LLQ - +/- +/- N Normal Laproscopy Menstrual-associated symptoms, pelvic symptoms Cyst rupture - RLQ / LLQ - +/- +/- N Increased ESR and CRP Ultrasound Sudden onset severe pain with nausea and vomiting Pregnancy Ruptured ectopic pregnancy - RLQ / LLQ - - - N Positive pregnancy test Ultrasound History of missed period and vaginal bleeding Functional Irritable Bowel Syndrome - Diffuse - - - - N Clinical diagnosis ROME III/IV criteria Pharmacologic studies based criteria - High dietary fiber Osmotic laxatives Antispasmodicdrugs Diagnostic Findings Images courtesy of RadsWiki Patient #1 Hematoma in Psoas muscles Hematoma in Psoas muscles Patient #2 MRI demonstrates a right sided retroperitoneal hematoma MRI demonstrates a right sided retroperitoneal hematoma MRI demonstrates a right sided retroperitoneal hematoma Patient #3 Retroperitoneal hematoma: The first sign was hypotension after cardiac catheterization Retroperitoneal hematoma: The first sign was hypotension after cardiac catheterization Retroperitoneal hematoma: The first sign was hypotension after cardiac catheterization Retroperitoneal hematoma: The first sign was hypotension after cardiac catheterization Retroperitoneal hematoma: The first sign was hypotension after cardiac catheterization Retroperitoneal hematoma: The first sign was hypotension after cardiac catheterization Treatment Medical Therapy Pharmacologic Discontinuation of anti-coagulation If possible, anticoagulation therapy including both anti-thrombins and anti-platelet agents should be discontinued. One exception is if the patient has had a coronary stent placed, in which case dual anti-platelet therapy should be continued if at all possible. If Clopidogrel must be discontinued, then low dose aspirin should be continued in a patient with a fresh stent. Reversal of anti-coagulation Antithrombins If the patient has received unfractionated heparin, protamine can be used to reverse the heparin. Protamine does partially reverse enoxaparin as well. Bivalirudin has a fairly short half-life, and does not require reversal. Antiplatelets If the antiplatelet effects must be overcome acutely, then a platelet transfusion can be administered. However, if the antiplatelet agents on board do not bind avidly to the platelets, then these agents can then bind to the new platelets that have just been transfused. Small molecule 2b3a inhibitors such as eptifibatide and Aggrastat are examples of these types of agents. Agents that permanently inhibit the platelet such as aspirin and Clopidogrel can take up to five days to reverse (the time that it takes for new platelets to form). Surgery After blunt trauma, selected retroperitoneal hematomas in the lateral perirenal and pelvic areas do not require operation and should not be opened if discovered at operation. Midline, lateral paraduodenal, lateral pericolonic not associated with pelvic, and portal hematomas are opened after proximal vascular control has been obtained, if appropriate. Retrohepatic hematomas without obvious active hemorrhage are not opened. After penetrating trauma, most retroperitoneal hematomas are still opened. Exceptions include isolated lateral perirenal hematomas that have been carefully staged by CT and some lateral pericolonic hematomas. As with blunt trauma, retrohepatic hematomas without obvious active hemorrhage are not opened. References Petersen JL, Mahaffey KW, Hasselblad V, Antman EM, Cohen M, Goodman SG, et al. Efficacy and Bleeding Complications Among Patients Randomized to Enoxaparin or Unfractionated Heparin for Antithrombin Therapy in Non–ST-Segment Elevation Acute Coronary Syndromes: A Systematic Overview. JAMA 2004 Jul 7; 292(1): 89-96. Jeong TK, Jeong GH, Park BS, Ma SK, Kim SW, Kim NH, et al. Dalteparin-sodium associated retroperitoneal hematoma in a patient with diabetic nephropathy. Korean J Med 2003 64: 322-7. Collet JP, Montalescot G, Fine E, Golmard JL, Dalby M, Choussat R, et al. Enoxaparin in unstable angina patients who would have been excluded from randomized pivotal trials. J Am Coll Cardiol 2003 Jan 1; 41(1): 8-14. Spinler SA, Inverso SM, Cohen M, Goodman SG, Stringer KA, Antman EM. Safety and efficacy of unfractionated heparin vs. enoxaparin in patients who are obese and patients with severe renal impairment: Analysis from the ESSENCE and TIMI 11B studies. Am Heart J 2003 Jul;146(1):33-41. A Vayá, Y Mira, J Aznar. Enoxaparin-related fatal spontaneous retroperitoneal hematoma in the elderly. Thromb Res 2003 Apr 15; 110(1): 69-71. The SYNERGY Trial Investigators. Enoxaparin vs unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes managed with an intended early invasive strategy: Primary results of the SYNERGY randomized trial. JAMA 2004 Jul 7; 292(1): 45-54. Lemos JA, Blazing MA, Wiviott SD, Brady WE, White HD, Fox KA, et al. Enoxaparin versus unfractionated heparin in patients treated with tirofiban, aspirin and an early conservative initial management strategy: Results from the A phase of the A-to-Z trial. Eur Heart J 2004 Oct 25(19): 1688-94. Cadroy Y, Pourrat J, Baladre MF, Saivin S, Houin G, Montastruc JL, et al. Delayed elimination of enoxaparin in patients with chronic renal insufficiency. Thromb Res 1991 Aug 1;63(3):385-90. Antman EM, Morrow DA, McCabe CH, Murphy SA, Ruda M, Sadowski Z, et al. Enoxaparin versus Unfractionated Heparin with Fibrinolysis for ST-Elevation Myocardial Infarction. N Engl J Med 2006 Apr 6;354(14): 1477-88. Gonzalez C, Penado S, Llata L, Valero C, Riancho JA. The clinical spectrum of retroperitoneal hematoma in anticoagulated patients. Medicine 2003 Jul 82(4):257-62.