What is the management of Hemoretroperitoneum (blood in the retroperitoneal space)?

Management of Hemoretroperitoneum

Hemodynamic status determines the management pathway for hemoretroperitoneum: unstable patients require immediate operative intervention or angioembolization, while stable patients should undergo CT imaging with contrast followed by selective intervention based on findings. 1

Initial Assessment and Resuscitation

Hemodynamic stability is the critical decision point that dictates all subsequent management. 1

• Establish IV access immediately and initiate fluid resuscitation with blood products as needed for unstable patients 2
• Perform E-FAST (Extended Focused Assessment with Sonography for Trauma) to identify bleeding sources, though be aware that E-FAST can produce false positives from suffusion of hemoretroperitoneum 3
• Obtain chest X-ray and pelvic X-ray for hemodynamically unstable patients to rule out extra-pelvic bleeding sources 3
• Minimize time between injury identification and definitive intervention 2

Management Algorithm Based on Hemodynamic Status

Hemodynamically Unstable Patients

Proceed directly to hemorrhage control without delay for CT imaging. 1

• Immediate operative management is indicated for uncontrollable life-threatening hemorrhage, pulsating/expanding retroperitoneal hematoma, or avulsion of renal pedicle 1
• Consider Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as a bridge to definitive procedures 1
• For pelvic fractures with retroperitoneal bleeding, perform pre-peritoneal pelvic packing (PPP) combined with external fixation 3, 1
• If pelvic ring disruption is present, immediate pelvic ring closure and stabilization is required, followed by angiographic embolization or surgical bleeding control 3
• When chest X-ray and E-FAST rule out extra-pelvic causes of hemorrhagic shock, proceed directly to angiography to visualize active arterial bleeding 3

Hemodynamically Stable Patients

Obtain thoraco-abdomino-pelvic CT scan with intravenous contrast as the primary diagnostic modality. 3

• CT with contrast has 93.9% positive predictive value and 77.8% negative predictive value for detecting active bleeding compared to angiography 3
• Pelvic X-ray is unnecessary in stable patients—proceed directly to CT imaging 3
• Non-operative management is appropriate for stable patients without signs of ongoing bleeding 1
• Serial physical examinations by experienced clinicians are reliable for detecting progression of injury 1
• Angiography with super-selective angioembolization is indicated for stable patients with arterial contrast extravasation, pseudoaneurysms, arteriovenous fistula, or non-self-limiting gross hematuria 1

Organ-Specific Management Considerations

Renal Injuries

• Most traumatic renal injuries are now managed non-operatively 1
• Percutaneous angioembolization is increasingly accepted for ongoing bleeding without surgical exploration 1

Bladder Injuries

• Retrograde cystography (CT or conventional) is essential for diagnosis 1
• Extraperitoneal ruptures (60% of cases) can be managed non-operatively with catheter drainage alone 1
• Intraperitoneal ruptures (30% of cases) require surgical repair 1

Urethral Injuries

• Associated with pelvic fractures 1
• Immediate goal is securing catheter drainage of the bladder 1

Critical Pitfalls to Avoid

• Do not rely solely on E-FAST to exclude retroperitoneal bleeding—it has limited sensitivity for retroperitoneal injuries and can show false positives from hemoretroperitoneum suffusion 3
• Do not delay intervention in unstable patients to obtain CT imaging—proceed directly to operative management or angiography 3, 1
• Penetrating injuries with retroperitoneal hematoma require exploration, especially if entering the peritoneal cavity 1
• Retroperitoneal hematoma discovered during laparotomy requires exploration if pulsatile or if it is the only cause of hemodynamic instability 1
• Diagnostic peritoneal lavage has poor sensitivity for retroperitoneal injuries and should not be relied upon for this diagnosis 3
• A negative E-FAST does not exclude early or slowly bleeding retroperitoneal injuries 2