Retroperitoneal hemorrhage: Difference between revisions
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Revision as of 12:25, 23 November 2017
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
Flank Pain
- Vascular
- Abdominal aortic aneurysm
- Renal artery embolism
- Renal vein thrombosis
- Aortic dissection
- Mesenteric ischemia
- Renal
- Pyelonephritis
- Perinephric abscess
- Perinephric hematoma
- Papillary necrosis
- Renal cell carcinoma
- Obstructive uropathy
- May or may not be due to nephrolithiasis
- Renal infarction
- Renal hemorrhage
- Ureter
- Nephrolithiasis
- Blood clot
- Stricture
- Tumor (primary or metastatic)
- Bladder
- Tumor
- Varicose vein
- Cystitis
- GI
- Biliary colic
- Pancreatitis
- Perforated peptic ulcer
- Appendicitis (appendix may be pushed to RUQ in pregnancy)
- Inguinal Hernia
- Diverticulitis
- Cancer
- Bowel obstruction
- Gynecologic
- Ectopic Pregnancy
- PID/TOA
- Ovarian cyst
- Ovarian torsion
- Endometriosis
- Mittelschmerz or benign ovulatory pain
- GU
- Other
- Shingles
- Lower lobe pneumonia
- Retroperitoneal hematoma, abscess, or tumor
- Epidural abscess
- Epidural hematoma
- Rib contusion/fracture
Evaluation
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
- Zone 1: Central[3]
- 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.