Walking through the valley of death: Spontaneous Retroperitoneal Hematoma
Authors: Kharmene Sunga and Daniel Cabrera
Image by Dawn Ellner (flickr)
Spontaneous retroperitoneal hematoma (SRH) is an uncommon and potentially lethal disease that presents in a myriad of forms, ranging from dyspnea to syncope to shock. The difficulty in its management lies in its elusiveness – the retroperitoneum is a difficult anatomical area to assess, leading to a 10% rate of misdiagnosis.
As a side note, Wunderlich Syndrome is a spontaneous renal hemorrhage confined to Gerota’s fascia without expansion into the retroperitoneal space. While presentation is similar between the two entities, they are not exactly the same.
The classic presentation of SRH is described by Lenk’s triad: flank pain, flank ecchymosis and signs of hypovolemia/shock. As you may suspect, while classic, Lenk’s triad is not the most common way of presentation. In the largest study to date, the most common symptoms were abdominal, flank, back and leg pain; other symptoms such as flank ecchymosis, dizziness, malaise and syncope were less common.
Traditionally SRH has been associated with the use of anticoagulants and antiplatelets, however in up to a third of patients the bleeding is not related to an obvious or known anticoagulation state. Typically in non-anticoagulated patients the etiology of the bleeding is secondary to tumors, vascular malformations, small aneurysms and vasculopathies in general.
Here comes the key concept: SRH needs to be suspected in all patients complaining about lower torso (abdomen, flank and back) pain regardless of their anticoagulation status, and especially in those patients with signs of hypoperfusion; additionally, SRH needs to be considered in patients with signs of acute blood loss anemia where the site of bleeding is unclear.
The workup of SRH once considered in the differential is relatively straightforward. X-ray has no role. Ultrasound can detect large hematomas but is not sensitive enough to rule it out. Abdomen and pelvis computed tomography (CT) with IV contrast constitutes the mainstay for diagnosis, being able to provide clear anatomical information about the size and sequelae of the SRH and occasionally identifying the etiology. In cases of contrast blush on the CT, a formal angiogram for diagnostic and therapeutic intervention can be considered.
Image from Open-I
It is important to remember that the retroperitoneum has the capacity to sequester large volumes of blood. We recommend active management of SRH patients with signs of hypoperfusion or acute blood loss anemia. This includes aggressive hemodynamic resuscitation and rapid reversal of anticoagulation/antiplatelet medications.
Early consultation with acute surgery and interventional radiology (IR) is advisable, particularly in patients bleeding from vascular abnormalities as they may benefit from embolization or eventual primary surgical hemostasis. In the largest series about 25% required IR and 7% surgery.
These patients usually have shock physiology and it best to manage them in an intensive care setting.
Summary
- Consider SRH in patients with lower torso pain especially if they appear sick
- Consider SRH in patients with signs of acute blood loss anemia, especially if the source of bleeding is unclear
- Abdomen and pelvis CT with IV contrast is method of choice for diagnosis
- Start management with aggressive hemodynamic resuscitation and anticoagulation reversal
- Consider early consultation with acute surgery and IR
- Disposition is usually to an intensive care unit as the patients will require close monitoring
References
- Phillips CK, Lepor H. Spontaneous Retroperitoneal Hemorrhage Caused by Segmental Arterial Mediolysis. Rev Urol. 2006;8(1):36–40.
- González C, Penado S, Llata L, Valero C, Riancho JA. The clinical spectrum of retroperitoneal hematoma in anticoagulated patients. Medicine (Baltimore). 2003 Jul;82(4):257–62.
- Sunga KL, Bellolio MF, Gilmore RM, Cabrera D. Spontaneous Retroperitoneal Hematoma: Etiology, Characteristics, Management, and Outcome. The Journal of Emergency Medicine. 2012 Aug;43(2):e157–61.
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I thought non-contrast CT is the initial test of choice for suspected acute RP bleeding, no?
Excellent point.<br />
Non Contrast CT is as sensitive to the diagnosis of SRH.<br />
Contrast CT can be advantageous trying to find \"blush\" that may lead to an invasive approach, particularly IR.<br />
Great Article. I recently had an elderly male with atraumatic hip pain and this article prompted to look for the spontaneous retroperitoneal hematoma (that he had!)