Diagnosis

Retroperitoneal hemorrhage

Etiology

Cause [ani]

• Trauma: penetrating versus blunt

• Non-traumatic:

  • Iatrogenic (cardiac catheterisation, endovascular procedures)

  • Spontanous:

    • Anticoagulation

    • Coagulopathy: Factor IX/X deficiency, von Willebrand disease, antiphospholipid

    • Ruptured aortic aneurysm

    • Aortic dissection

    • Retroperitoneal artery aneurysm (renal/pancreaticoduodenal artery)

    • Pancreatitis

    • Retroperitoneal cancer hemorrhage

    • Hemorrhage into adrenal cyst

    • Hemodialysis

Pathophysiology

1. Usually asymptomatic until substantial blood loss has occurred

   • Zone 1: Central-medial area between both psoas muscles (aorta, IVC, pancreas)

   • Zone 2: The perirenal area

   • Zone 3: The pelvic area (the bladder, iliac arteries/veins, rectum)

2. Clinical manifestation:

   • Anemia

   • Hemorrhagic shock

Complications [ani]

• Infection/sepsis

• Symptomatic anemia

• Abdominal compartment syndrome

• Small bowel or urinary obstruction

• Hemorrhagic shock:

  • Myocardial infarction

  • Acute kidney injury

  • Acute liver injury

  • Diffuse cerebral hypoperfusion

Epidemiology

Incidence per 100.000 [nb1]

Approach

• Blood test

• Abdominal x-ray

• Ultrasound abdomen

• CT abdomen

• MRI

• Angiography

• Diagnostic laparoscopy

Treatment

1. Underlying condition: [ani]

   • Reversal of anticoagulation (Octaplex)

   • Blood transfusion

   • Intravenous fluids

2. Hemodynamic stable:

   • Observation: hemodynamic monitoring and analgesia

   • Endovascular coil embolisation

3. Unstable, penetrating abdominal trauma, free fluid in abdomen or peritonitis

   • Surgery: Evacuation of hematoma, and hemostasis

4. Traumatic retroperitoneal hematoma:

   • Zone 1: Explore as this is likely a significant vascular injury

   • Zone 2: Selectively explore if active hemorrhage or an expanding hematoma

   • Zone 3: Explore if penetrating injury and angioembolization/preperitoneal packing if blunt injury

Differential diagnoses

Abdominal compartment syndrome, Abruptio placentae, Acute pancreatitis, Aortic dissection, Appendicitis, Cholecystitis, Crohn disease, Disseminated intravascular coagulation, Diverticulitis, Gastritis, Gastrointestinal hemorrhage, Gastrointestinal perforation, Hemolytic anemia, Hemolytic uremic syndrome, Hypovolemia, Internal hemorrhage, Ovarian torsion, Perforated ulcer, Pyelonephritis, Renal artery aneurysm, Ruptured aortic aneurysm, Ruptured ectopic pregnancy, Ruptured ovarian cyst, Sepsis, Shock, Ulcerative colitis