What is the management and treatment for spontaneous retroperitoneal hematoma?

Management of Spontaneous Retroperitoneal Hematoma

For spontaneous retroperitoneal hematoma, hemodynamically stable patients should undergo immediate CT angiography followed by super-selective angioembolization if active bleeding is identified, while unstable patients require urgent operative intervention. 1

Immediate Assessment and Diagnostic Imaging

Obtain CT abdomen/pelvis with IV contrast or CTA as the first-line imaging modality to rapidly diagnose, localize bleeding, and identify active extravasation. 1 CTA is superior when active bleeding is clinically suspected, detecting bleeding rates as slow as 0.3 mL/min and providing detailed vascular information. 1

• Use non-contrast CT alone only in patients with compromised renal function or when subsequent angiography may be needed to avoid additional contrast load. 1
• CT findings determine acuity: high attenuation indicates acute bleeding, mixed attenuation suggests rebleeding, and low attenuation indicates subacute to chronic blood products. 1
• Never use ultrasound for initial diagnosis due to limited acoustic windows and inability to reliably evaluate the entire retroperitoneum. 1
• Plain radiography has low sensitivity and is inappropriate as moderate-volume hematomas may not produce sufficient mass effect. 1

Risk Stratification by Hemodynamic Status

Hemodynamically Stable Patients

Most stable patients can be managed conservatively with fluid resuscitation, correction of coagulopathy, and blood transfusion. 2 This approach is particularly appropriate when no active extravasation is identified on imaging. 3

• Anticoagulation therapy is a major cause of spontaneous retroperitoneal bleeding, particularly with excessive anticoagulation. 4
• Reverse anticoagulation immediately in patients on warfarin, enoxaparin, or other anticoagulants. 5
• Be especially cautious in elderly patients, those with impaired renal function, and patients receiving concomitant oral anticoagulants. 5

Hemodynamically Unstable Patients

Hemodynamic instability unresponsive to volume resuscitation requires urgent operative intervention. 1 Do not delay surgical intervention in unstable patients. 2

Angioembolization Strategy

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 achieves cessation of bleeding in nearly 100% of cases when active bleeding is identified on angiography. 1
• Perform angioembolization 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
• Interventional radiology with intra-arterial embolisation or stent-grafting is the treatment of choice for most cases. 2

Operative Management Indications

Proceed to open surgery when:

• Pulsatile or expanding retroperitoneal hematoma is discovered during laparotomy. 1
• Uncontrollable life-threatening hemorrhage with renal pedicle avulsion or renal vein lesion without self-limiting hemorrhage occurs. 1
• Conservative or endovascular measures fail to control bleeding. 2
• Endovascular facilities or expertise is unavailable and the patient is unstable. 2

Open surgical repair is now rarely required and should be reserved for these specific scenarios. 2

Special Clinical Scenarios

Vascular Causes

• Ruptured aortic aneurysm requires urgent intervention. 4
• Spontaneous iliac vein rupture, especially in women aged >45 years with May-Thurner syndrome, should be considered when patients present with sudden lower abdominal or lumbar pain, leg swelling, anemia, and shock. 6
• Pancreaticoduodenal artery aneurysm rupture may require angioembolization but monitor closely for gastric outlet obstruction and obstructive jaundice requiring surgical haematoma evacuation. 7

Pelvic Fracture-Related Hematomas

• Retroperitoneal hematomas from pelvic fractures are associated with higher transfusion requirements. 1

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

Monitoring and Follow-up

• Perform follow-up CT to evaluate for rebleeding, changes in hematoma size, or complications such as infection and abscess formation. 1
• Close monitoring is necessary to identify early complications after initial treatment. 7
• Early diagnosis within the first 5 hours significantly improves outcomes. 1

Critical Pitfalls to Avoid

• Always consider spontaneous retroperitoneal hematoma in patients under anticoagulation therapy presenting with abdominal pain, flank pain, back pain, or hemodynamic instability. 5
• Do not delay CT imaging in stable patients with clinical suspicion. 1
• Diagnosis is often delayed as symptoms are nonspecific including diffuse abdominal pain, back pain, abdominal distension, and flank mass. 4
• If treated inappropriately, mortality remains high. 2
• Surgical interventions are associated with high mortality (16.7%) and morbidity (50%). 6
• Conservative therapy is safer than open surgical procedures in appropriate candidates. 6