From the Guidelines
The management of retroperitoneal hematoma depends on the etiology, size, and patient's hemodynamic stability, with conservative management recommended for stable patients with small, contained hematomas, and immediate surgical intervention or angioembolization for hemodynamically unstable patients or those with expanding hematomas. For stable patients with small, contained hematomas, conservative management is recommended, including bed rest, serial hemoglobin monitoring, and supportive care with intravenous fluids and pain control, as suggested by 1. Vital signs should be monitored closely, with hemodynamic parameters checked every 1-2 hours initially, and serial abdominal examinations and hemoglobin levels every 6-8 hours are essential to detect expansion. For patients on anticoagulants, reversal agents should be administered: vitamin K 10mg IV and prothrombin complex concentrate for warfarin, protamine for heparin, and specific reversal agents for DOACs when available, as recommended by 1. Some key points to consider in the management of retroperitoneal hematoma include:
- Hemodynamic stability: patients who are hemodynamically unstable require immediate intervention, as stated in 1
- Etiology: the underlying cause of bleeding must be addressed to prevent recurrence, whether it's trauma, anticoagulation, vascular abnormalities, or malignancy, as mentioned in 1
- Size of hematoma: small, contained hematomas can be managed conservatively, while larger or expanding hematomas require surgical intervention or angioembolization, as suggested by 1
- Imaging: CT angiography (CTA) is usually performed to detect the site of active retroperitoneal bleeding, and can provide valuable preoperative information for endovascular or surgical repair, as stated in 1. Post-procedure, patients need close monitoring in an ICU setting with attention to potential complications like abdominal compartment syndrome, infection, or renal impairment from compression, as recommended by 1. The goal of management is to prevent morbidity, mortality, and improve quality of life, by addressing the underlying cause of bleeding, and providing appropriate supportive care and intervention, as suggested by 1.
From the Research
Management of Retroperitoneal Hematoma
The management of retroperitoneal hematoma can be complex and depends on various factors, including the cause, size, and location of the hematoma, as well as the patient's overall health status.
- The primary goal of management is to stabilize the patient and prevent further bleeding.
- According to 2, an anatomical-based interventional approach may be necessary if the patient does not stabilize with volume resuscitation.
- Supportive therapy, such as vitamin K, fresh frozen plasma, and blood transfusion, may be used to manage the condition, as seen in 3.
- In some cases, surgical intervention may be necessary to evacuate the hematoma, as reported in 3.
- Conservative management, including bed rest and monitoring, may be sufficient for smaller hematomas or those that are not causing significant symptoms, as noted in 4.
- Imaging studies, such as computed tomography (CT) scans and abdominal ultrasound, are commonly used to diagnose and monitor retroperitoneal hematomas, as seen in 5 and 4.
- Restarting anticoagulation therapy after the acute event may be a safe practice, as reported in 4, but this decision should be made on a case-by-case basis.
Risk Factors and Clinical Features
Retroperitoneal hematomas can occur spontaneously or as a result of trauma, invasive procedures, or anticoagulation therapy.
- Anticoagulation therapy is a significant risk factor for developing a retroperitoneal hematoma, as seen in 5, 3, and 6.
- Chronic renal insufficiency is also a common comorbidity in patients with spontaneous retroperitoneal hematomas, as reported in 4.
- Abdominal pain is the most common symptom of retroperitoneal hematoma, as noted in 5 and 4.
- Other symptoms may include leg pain, hip pain, and back pain, as seen in 5.