Retroperitoneal hemorrhage

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
• May present with:
  • Abdominal pain
  • Flank pain
  • Back pain
  • Hypotension

Differential Diagnosis

Abdominal Trauma

• Abdominal compartment syndrome
• Diaphragmatic trauma
• Duodenal hematoma
• Genitourinary trauma
• Liver trauma
• Pelvic fractures
  • Acetabular pelvic fractures
  • Open book pelvic fracture
  • Straddle pelvic fracture
  • Pelvic avulsion fracture
• Retroperitoneal hemorrhage
• Renal trauma
• Splenic trauma
• Trauma in pregnancy
• Ureter trauma

Diagnosis

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
  • Pancreaticoduodenal injuries, major vascular injury
• Zone 2: Flank/Perinephric
  • Renal, 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
  • Warfarin (Coumadin) Reversal
  • Dabigatran (Pradaxa) Reversal
  • Unfractionated heparin reversal
• Treat underlying etiology

Disposition

• ICU

See Also

• Abdominal trauma
• coagulopathy
• Warfarin (Coumadin) Reversal
• Dabigatran (Pradaxa) Reversal
• Unfractionated heparin reversal
• Ultrasound: Aorta