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

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


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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