What is the management of a retroperitoneal bleed?

Management of Retroperioneal Bleed

For hemodynamically stable patients with suspected retroperitoneal bleeding, obtain CT abdomen/pelvis with IV contrast or CTA immediately, followed by super-selective angioembolization if active extravasation is identified; for hemodynamically unstable patients unresponsive to volume resuscitation, proceed directly to urgent operative intervention or emergent aortography with transcatheter arterial embolization. 1

Initial Diagnostic Approach

Hemodynamically Stable Patients

• CT abdomen/pelvis without and with IV contrast or CTA is the imaging modality of choice, providing rapid diagnosis, bleeding localization, and identification of active extravasation 2, 1
• CTA is superior when active bleeding is clinically suspected, detecting bleeding rates as slow as 0.3 mL/min compared to 0.5-1.0 mL/min for conventional angiography 2, 1
• Non-contrast CT alone is appropriate when renal function is compromised or additional contrast load is concerning if subsequent angiography may be needed 2, 1
• CT findings 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 of the abdomen and pelvis is appropriate for patients with hemodynamic instability and high clinical suspicion, allowing simultaneous diagnosis and treatment with transcatheter arterial embolization 2
• This approach is best reserved for known active arterial bleeding or contained vascular injury amenable to concomitant diagnosis and treatment 2

Imaging Modalities to Avoid

• Ultrasound is NOT appropriate for initial diagnosis due to limited acoustic windows and inability to reliably evaluate the entire retroperitoneum 1
• Plain radiography has low sensitivity and is usually not appropriate, as moderate-volume hematomas may not produce sufficient mass effect 1

Management Strategy Based on Hemodynamic Status

Conservative Management (Stable Patients Without Active Bleeding)

• Fluid resuscitation, correction of coagulopathy, and blood transfusion for hemodynamically stable patients without evidence of active extravasation 3
• Most patients can be managed successfully with transfusion alone when stable 4
• Conservative management should only be reserved for patients who remain stable 3

Angioembolization (Stable or Stabilized Patients With Active Bleeding)

• Super-selective angioembolization is indicated for 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
• This technique achieves cessation of bleeding in nearly 100% of cases when active bleeding is identified on angiography 1, 5
• Blind angioembolization is NOT indicated in stable patients with negative angiography, regardless of arterial contrast extravasation on CT scan 1
• Embolization materials include coils and N-butyl-2-cyanoacrylate, with technical success rates of 100% 5

Operative Management (Unstable Patients)

• Hemodynamic instability unresponsive to volume resuscitation requires urgent operative intervention 1
• 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 requires urgent operative intervention 1
• A subset of patients (approximately 16%) who develop hypotension unresponsive to volume resuscitation require urgent operation 4
• Open surgery should be reserved for cases when there is failure of conservative or endovascular measures, or when endovascular facilities or expertise is unavailable 3

Special Clinical Scenarios

Trauma-Related Bleeding

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

Anticoagulation-Related Bleeding

• Anticoagulation therapy is a major cause of spontaneous retroperitoneal bleeding, particularly with excessive anticoagulation 6
• Low-molecular-weight heparin (enoxaparin) can cause life-threatening retroperitoneal bleeding, typically occurring within 5 days of therapy 7
• Highest risk patients receive doses approaching 1 mg/kg subcutaneously every 12 hours, have renal impairment, are of advanced age, and receive concomitant medications affecting hemostasis 7

Iatrogenic Causes

• Retroperitoneal bleeding after cardiac catheterization occurs in 0.5% of cases overall, with highest frequency (3%) after coronary artery stenting 4
• Predictors include female sex, nadir platelet count, and excessive anticoagulation 4

Clinical Presentation Recognition

• Suspect retroperitoneal bleeding in patients with suprainguinal tenderness and fullness (100% of cases), severe back and lower quadrant pain (64%), or femoral neuropathy (36%) following interventional procedures 4
• Nonspecific symptoms include diffuse abdominal pain, back pain, flank pain, abdominal distension, and hemodynamic instability with hypotension in severe cases 1, 3
• Diagnosis is often delayed due to the inaccessibility of the retroperitoneum to physical examination and nonspecific clinical signs 2, 6

Critical Pitfalls to Avoid

• Do not delay CT imaging in stable patients with clinical suspicion—early diagnosis (within first 5 hours) significantly improves outcomes 1
• Do not perform blind angioembolization in stable patients with negative angiography 1
• Do not rely on ultrasound or plain radiography for initial diagnosis 1
• Mortality remains high if treated inappropriately, particularly in unstable patients 3, 5

Monitoring and Follow-up

• Follow-up CT is appropriate to evaluate for rebleeding, changes in hematoma size, or complications such as infection and abscess formation 1
• Four of 16 patients (25%) in one series died within 1 month of embolotherapy, highlighting the need for close monitoring 5