What is the management of a retroperitoneal hematoma?

Management of Retroperitoneal Hematoma

The management of retroperitoneal hematoma depends primarily on the patient's hemodynamic status, with conservative management being effective for most stable patients, while interventional radiology with embolization or surgical intervention is reserved for unstable patients or those who fail conservative management. 1, 2

Diagnostic Approach

• Initial Imaging:

  • CT of abdomen and pelvis with IV contrast is the gold standard for hemodynamically stable patients 1, 3
  • CT angiography (CTA) of abdomen and pelvis is equally appropriate and can better identify active bleeding 1
  • First follow-up scan should be within 24-72 hours if there are concerns about hematoma expansion 3

• For unstable patients:

  • Bedside ultrasound can help detect fluid collections in traumatic cases 3
  • Aortography may be considered for immediate diagnosis and intervention in critically unstable patients 1

Management Algorithm

1. Hemodynamically Stable Patients

• Conservative management is first-line and effective in most cases (90%) 2, 4:
  • Fluid resuscitation with crystalloids
  • Blood transfusion as needed
  • Correction of coagulopathy (if present)
  • Reversal of anticoagulation (if applicable)
  • Close monitoring with serial hemoglobin checks

2. Hemodynamically Unstable Patients or Failed Conservative Management

• Establish large-bore IV access (at least two lines) 3
• Fluid resuscitation targeting systolic BP of 80-100 mmHg until bleeding is controlled 3
• Blood product transfusion as needed
• Interventional radiology approach:
  • Selective intra-arterial embolization for identified bleeding vessels 2, 4
  • Stent-graft deployment over punctured vessels (particularly for iatrogenic cases) 2

3. Indications for Surgical Intervention

• Failure of conservative and endovascular measures to control bleeding 2
• Persistent hemodynamic instability despite resuscitation 3
• Unavailability of endovascular facilities or expertise 2
• Significant free fluid identified on imaging with hemodynamic instability 3
• Expanding or pulsatile hematoma 5

Special Considerations

Etiology-Specific Management

1. Spontaneous retroperitoneal hemorrhage:

   • Often occurs in anticoagulated patients 2
   • Focus on correction of coagulopathy and supportive care 4
   • Even anticoagulated and initially unstable patients often respond to conservative management 4

2. Iatrogenic (post-catheterization) hematoma:

   • Highest frequency after coronary artery stenting (3%) 6
   • Most (84%) can be managed with transfusion alone 6
   • Only 16% require surgical intervention 6

3. Traumatic retroperitoneal hematoma:

   • May require more aggressive intervention depending on associated injuries
   • Pelvic fractures with retroperitoneal bleeding are associated with increased transfusion needs 1

Risk Factors for Poor Outcomes

• Female sex (for iatrogenic cases) 6
• Excessive anticoagulation 6
• Low platelet count 6
• Presence of active extravasation on imaging 4
• Shock at presentation 4

Monitoring and Follow-up

• Serial hemoglobin/hematocrit measurements
• Repeat imaging (CT) within 24-72 hours if there are concerns about expansion 3
• Monitor for signs of compartment syndrome or femoral neuropathy (particularly in iatrogenic cases) 6

Pitfalls and Caveats

• Diagnosis is often delayed due to nonspecific symptoms 2
• Large volume hematomas can be concealed in the retroperitoneal space and lead to hypovolemic shock 1
• Clinical signs to monitor: suprainguinal tenderness/fullness (100%), severe back and lower quadrant pain (64%), and femoral neuropathy (36%) 6
• Propensity-matched studies suggest that resuscitation and optimization of coagulation are the most vital components of treatment, even more than the specific intervention chosen 4