What is the management approach for a patient with a retroperitoneal hematoma?

Management of Retroperitoneal Hematoma

Management of retroperitoneal hematoma is determined primarily by hemodynamic status: hemodynamically unstable patients require immediate operative management or angioembolization, while stable patients should undergo CT/CTA imaging followed by selective angioembolization if active bleeding is identified. 1

Initial Assessment and Imaging

Hemodynamically Stable Patients

• CT abdomen/pelvis without and with IV contrast or CTA is the imaging modality of choice for initial evaluation, providing rapid diagnosis, localization of bleeding, and identification of active extravasation 1, 2
• CTA is superior when active bleeding is clinically suspected, as it can detect bleeding rates as slow as 0.3 mL/min and provides detailed vascular information 1, 3
• Non-contrast CT alone is appropriate in patients with compromised renal function or when additional contrast load is a concern if subsequent angiography may be needed 1
• CT findings help determine acuity: high attenuation indicates acute bleeding, mixed attenuation suggests rebleeding, and low attenuation indicates subacute to chronic blood products 1

Hemodynamically Unstable Patients

• Urgent aortography with simultaneous transcatheter arterial embolization (TAE) is indicated for patients who remain unstable despite volume resuscitation 1
• REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) may be used as a bridge to definitive hemorrhage control procedures 1
• Direct angiography allows both diagnosis and treatment, with detection of bleeding rates as low as 0.5-1.0 mL/min 1

Operative Management Indications

Absolute Indications for Surgery

• Hemodynamic instability unresponsive to volume resuscitation requires urgent operative intervention 1, 4
• Pulsatile or expanding retroperitoneal hematoma discovered during laparotomy mandates exploration 1
• Uncontrollable life-threatening hemorrhage with renal pedicle avulsion or renal vein lesion without self-limiting hemorrhage 1
• All penetrating injuries with retroperitoneal hematoma that have not been adequately studied should be explored, especially if entering the peritoneal cavity 1

Surgical Timing Considerations

• Most patients (approximately 75-84%) can be managed successfully with transfusion alone without surgery 4, 5
• Surgery is required in approximately 16-25% of cases, typically when hypotension develops unresponsive to volume resuscitation or when progressive hematocrit decline occurs 24-72 hours post-event 4, 5

Angioembolization Strategy

Indications for Angioembolization

• Super-selective angioembolization is indicated in hemodynamically stable or stabilized patients with arterial contrast extravasation, pseudoaneurysms, arteriovenous fistula, or non-self-limiting gross hematuria 1
• Angioembolization should be performed as selectively as possible to preserve organ function 1
• Blind angioembolization is NOT indicated in stable patients with negative angiography, regardless of arterial contrast extravasation on CT scan 1

Technical Success

• Angioembolization achieves cessation of bleeding in nearly 100% of cases when active bleeding is identified on angiography 1
• Technical success rates reach up to 95% with clinical success around 67% 3

Special Clinical Scenarios

Trauma-Related Hematomas

• Retroperitoneal hematomas from pelvic fractures (55% of blunt trauma cases) are associated with higher transfusion requirements 6
• Penetrating trauma with retroperitoneal hematoma requires exploration if not adequately studied preoperatively 1

Anticoagulation-Related Bleeding

• Anticoagulation is a major cause of spontaneous retroperitoneal hematoma, occurring in approximately 66% of cases 5
• However, one-third of spontaneous cases occur without anticoagulation therapy 5
• Reversal of anticoagulation should be initiated immediately in consultation with hematology 5

Renal Injuries

• Shattered kidney or pyelo-ureteral junction avulsion in hemodynamically stable patients does NOT mandate urgent surgical intervention 1
• Urine extravasation alone is not an indication for operative management in the acute setting 1
• Devascularized kidney tissue causing refractory hypertension may require delayed nephrectomy if conservative management fails 1

Critical Pitfalls to Avoid

• Misdiagnosis occurs in approximately 10% of initial encounters due to non-specific presentation (abdominal pain, back pain, leg pain, hip pain) 5
• Ultrasound is NOT appropriate for initial diagnosis due to limited acoustic windows and inability to evaluate the entire retroperitoneum reliably 1, 2
• Plain radiography has low sensitivity and is usually not appropriate, as moderate-volume hematomas may not produce sufficient mass effect 1
• Do not delay CT imaging in stable patients with clinical suspicion—early diagnosis (within first 5 hours) significantly improves outcomes 3

Monitoring and Follow-up

• Intensive care unit management is required in approximately 40% of cases 5
• Blood transfusion is needed in approximately 75% of patients 5
• Follow-up CT is appropriate to evaluate for rebleeding, changes in hematoma size, or complications such as infection and abscess formation 1
• Mortality is 5.6% within 7 days, 10.1% within 30 days, and 19.1% within 6 months, emphasizing the serious nature of this condition 5