Retroperitoneal haemorrhage

Reviewed and revised 3 September 2015

OVERVIEW

Retroperitoneal haemorrhage is bleeding into the retroperitoneal space, either occurring spontaneously or secondary to an injury or illness

CAUSES

Spontaneous (aka Wünderlich syndrome)

• underlying bleeding diathesis e.g. anticoagulants, anti-platelet agents, haemophilia
• vascular abnormalities of the kidneys or adrenal glands (e.g. necrotizing arteritis, connective tissue diseases,ruptured visceral artery anerysm)
• neoplastic disease of the kidneys (e.g.angiomyolipoma) or adrenal glands (e.g. adrenal myelolipoma, pheochromocytoma, and adrenal hemangiomas)

Secondary

• trauma
• iatrogenic (e.g. femoral cannulation, IR cannulation)
• extension from ruptured AAA

ASSESSMENT

• loin and/ or abdominal pain
• often no cutaneous signs, but may have Cullen sign (umbilical ecchymosis) and Grey Turner sign (flank ecchymosis)
• +/- palpable swelling
• haematuria
• haemodynamic instability and shock
• evidence of abdominal compartment syndrome (e.g. intra-abdominal hypertension, renal failure)
• history of risk factors (often no significant history if spontaneous)
• Psoas haematoma can present with constipation, urinary frequency, compressive femoral neuropathy or fever if large

INVESTIGATIONS

Bedside

• Intra-abdominal pressure monitor
• Blood gas (Hb, lactate, metabolic state)

Laboratory

• FBC (anaemia, thrombocytopenia)
• UEC (renal impairment)
• lipase (pancreatitis)
• Coagulation profile (bleeding diathesis)

Imaging

• CT abdomen with contrast (diagnoses retroperitonal haemorrhage, extent of the hemorrhage)
  • “blush” on contrast CT suggest active bleeding

MANAGEMENT

Resuscitation

• may require haemostatic resuscitation if unstable

Specific therapy

• observation and serial examination
• conservative management should only be reserved for patients who are stable
• Interventional radiology with intra-arterial embolisation or stent-grafting is preferred
• open surgical decompression is rarely needed

Seek and treat underlying cause and complications

• underlying bleeding diathesis
• abdominal compartment syndrome
• can be complicated by superimposed infection or abscess

Supportive care and monitoring

• provide adequate analgesia (e.g. paracetamol, morphine, ketamine)

Disposition

• May require HDU/ICU admission

OTHER INFORMATION

Anatomy of the retroperitoneal space

• no specific delineating boundaries
• the retroperitoneal space can be subdivided into:
  • Perirenal space
  • Anterior pararenal space
  • Posterior pararenal space
• organs are retroperitoneal if they have peritoneum on their anterior side only, and thus lie between the parietal peritoneum and the abdominal wall

Retroperitoneal organs (SAD PUCKER mnemonic)

• Suprarenal glands (aka the adrenal glands)
• Aorta/IVC
• Duodenum (second and third segments [some also include the fourth segment] )
• Pancreas (only head, neck, and body are retroperitoneal. The tail is intraperitoneal)
• Ureters
• Colon (only the ascending and descending colons, as transverse and sigmoid retain mesocolon)
• Kidneys
• Esophagus
• Rectum

References and links

LITFL

• Eponymythology – Atraumatic abdominal ecchymosis
• Eponymictionary – Grey Turner sign
• Eponymictionary – Cullen sign

Journal articles

• Chan YC, Morales JP, Reidy JF, Taylor PR. Management of spontaneous and iatrogenic retroperitoneal haemorrhage: conservative management, endovascular intervention or open surgery? International journal of clinical practice. 62(10):1604-13. 2008. [pubmed]
• Sunga KL, Bellolio MF, Gilmore RM, Cabrera D. Spontaneous retroperitoneal hematoma: etiology, characteristics, management, and outcome. The Journal of emergency medicine. 43(2):e157-61. 2012. [pubmed]

FOAM and web resources

• Radiopaedia — Retroperitoneal haemorrhage, Spontaneous retroperitoneal haemorrhage, Psoas haematoma