Retroperitoneal hemorrhage: Difference between revisions
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==Background== | ==Background== | ||
* | [[File:PMC5265200 13244 2016 536 Fig1 HTML.png|thumb|Perinephric space with exaggerated pararenal space to show retroperitoneal structures. Perinephric bridging septa are seen between the left kidney and the adjacent renal fascia.]] | ||
* | [[File:Blausen 0592 KidneyAnatomy 01.png|thumb|Renal anatomy.]] | ||
* | *Bleeding into retroperitoneal space | ||
*Difficult to diagnose given poor sensitivity of physical exam findings (Cullens, Grey-Turners) | |||
*Can accumulate 4L blood before tamponade | |||
===Etiologies=== | ===Etiologies=== | ||
*Trauma | *Trauma (renal, vascular, colon, pancreas or pelvis) | ||
*Leaking/ruptured [[AAA]] | *Leaking/ruptured [[AAA]] | ||
*Iatrogenic (colonoscopy, cardiac catheterization) | *Iatrogenic (colonoscopy, cardiac catheterization, femoral line placement) | ||
*Spontaneous ([[coagulopathy]]) | *Spontaneous ([[coagulopathy]]) | ||
*Hemorrhagic [[pancreatitis]] | *Hemorrhagic [[pancreatitis]] | ||
==Clinical Features== | ==Clinical Features== | ||
*May present with | *Most common in patients with bleeding disorders, on anticoagulants, and on HD<ref>Bhasin HK and Dana CL. Spontaneous retroperitoneal hemorrhage in chronically hemodialyzed patients. Nephron. 1978; 22(4-6):322-327.</ref><ref>Ernits M, et al. A retroperitoneal bleed induced by enoxaparin therapy. Ann Surg. 2005; 71(5):430-433.</ref> | ||
*May present with: | |||
**[[Abdominal pain]] | |||
**[[Flank pain]] | |||
**[[Back pain]] | |||
**[[Hypotension]] | |||
**Bryant's sign (unilateral scrotal ecchymosis from tracking blood) | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Abdominal trauma DDX}} | {{Abdominal trauma DDX}} | ||
== | ==Evaluation== | ||
===Workup=== | |||
[[File:Abdotrauma.png|thumb|Right kidney contusion (open arrow) and blood surrounding the kidney (closed arrow).]] | |||
[[File:Kidneyhematoma.png|thumb|Left kidney injury (open arrow) with retropeitoneal hematoma (closed arrow).]] | |||
''Must have high clinical suspicion to make diagnosis'' | ''Must have high clinical suspicion to make diagnosis'' | ||
*CT scan abdomen/pelvis | *CT scan abdomen/pelvis | ||
**FAST and DPL do not evaluate retroperitoneal space | *Consider [[Aortic ultrasound| ultrasound for AAA]] | ||
*FAST and DPL do not evaluate retroperitoneal space | |||
===Classification of traumatic retroperitoneal hemorrhage<ref>FELICIANO, D. V. (1990) ‘Management of Traumatic Retroperitoneal Hematoma’, Annals of Surgery, 211(2), pp. 109–123. </ref>=== | |||
[[File:Retroperitoneal zones.jpg|thumb|Retroperitoneal zones]] | |||
*Zone 1: Central | |||
**Pancreaticoduodenal injuries, major vascular injury | |||
*Zone 2: Flank/Perinephric | |||
**[[Renal trauma]], ureteric or colonic injury | |||
*Zone 3: Pelvic | |||
**Pelvic fracture or ileofemoral vascular injury | |||
==Management== | ==Management== | ||
*Address A, B, C's | *Address A, B, C's | ||
*Resuscitation with blood products | *Resuscitation with [[blood products]] | ||
*Reverse [[coagulopathy]] | *Reverse [[coagulopathy]] | ||
**[[Warfarin (Coumadin) Reversal]] | |||
**[[Dabigatran (Pradaxa) Reversal]] | |||
**[[Unfractionated heparin reversal]] | |||
*Treat underlying etiology | *Treat underlying etiology | ||
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==See Also== | ==See Also== | ||
*[[Abdominal trauma]] | |||
*[[coagulopathy]] | |||
*[[Warfarin (Coumadin) Reversal]] | |||
*[[Dabigatran (Pradaxa) Reversal]] | |||
*[[Unfractionated heparin reversal]] | |||
*[[Aortic ultrasound]] | |||
==External Links== | ==External Links== | ||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:Trauma]] | [[Category:Trauma]] | ||
Latest revision as of 21:17, 17 March 2021
Background
- Bleeding into retroperitoneal space
- Difficult to diagnose given poor sensitivity of physical exam findings (Cullens, Grey-Turners)
- Can accumulate 4L blood before tamponade
Etiologies
- Trauma (renal, vascular, colon, pancreas or pelvis)
- Leaking/ruptured AAA
- Iatrogenic (colonoscopy, cardiac catheterization, femoral line placement)
- Spontaneous (coagulopathy)
- Hemorrhagic pancreatitis
Clinical Features
- Most common in patients with bleeding disorders, on anticoagulants, and on HD[1][2]
- May present with:
- Abdominal pain
- Flank pain
- Back pain
- Hypotension
- Bryant's sign (unilateral scrotal ecchymosis from tracking blood)
Differential Diagnosis
Abdominal Trauma
- Abdominal compartment syndrome
- Diaphragmatic trauma
- Duodenal hematoma
- Genitourinary trauma
- Liver trauma
- Pelvic fractures
- Retroperitoneal hemorrhage
- Renal trauma
- Splenic trauma
- Trauma in pregnancy
- Ureter trauma
Evaluation
Workup
Must have high clinical suspicion to make diagnosis
- CT scan abdomen/pelvis
- Consider ultrasound for AAA
- FAST and DPL do not evaluate retroperitoneal space
Classification of traumatic retroperitoneal hemorrhage[3]
- Zone 1: Central
- Pancreaticoduodenal injuries, major vascular injury
- Zone 2: Flank/Perinephric
- Renal trauma, ureteric or colonic injury
- Zone 3: Pelvic
- Pelvic fracture or ileofemoral vascular injury
Management
- Address A, B, C's
- Resuscitation with blood products
- Reverse coagulopathy
- Treat underlying etiology
Disposition
- ICU
See Also
- Abdominal trauma
- coagulopathy
- Warfarin (Coumadin) Reversal
- Dabigatran (Pradaxa) Reversal
- Unfractionated heparin reversal
- Aortic ultrasound
External Links
References
- ↑ Bhasin HK and Dana CL. Spontaneous retroperitoneal hemorrhage in chronically hemodialyzed patients. Nephron. 1978; 22(4-6):322-327.
- ↑ Ernits M, et al. A retroperitoneal bleed induced by enoxaparin therapy. Ann Surg. 2005; 71(5):430-433.
- ↑ FELICIANO, D. V. (1990) ‘Management of Traumatic Retroperitoneal Hematoma’, Annals of Surgery, 211(2), pp. 109–123.