Physical Examination for Retroperitoneal Hematoma
Physical examination has limited sensitivity for ruling out retroperitoneal hematoma and cannot reliably exclude this diagnosis—CT imaging is required for definitive evaluation. 1, 2
Key Clinical Findings to Assess
Hemodynamic Status (Critical Priority)
- Measure vital signs immediately, focusing on blood pressure and heart rate to detect hemodynamic instability (hypotension, tachycardia) which indicates significant blood loss and requires urgent intervention 3, 2
- Assess for signs of hypovolemic shock: altered mental status, cool extremities, delayed capillary refill, and orthostatic changes 4, 5
Abdominal and Flank Examination
- Palpate for flank or abdominal mass, though this finding has low sensitivity as moderate-volume hematomas may not produce sufficient mass effect 6, 2
- Assess for abdominal distension, which may indicate significant retroperitoneal bleeding but is nonspecific 6, 3
- Evaluate for peritoneal signs (guarding, rigidity, rebound tenderness) to assess for associated intraperitoneal injury or complications 7
Pain Assessment
- Document location and character of pain: diffuse abdominal pain, back pain, or flank pain are common but nonspecific presentations 6, 3
- Assess for lumbago (lower back pain), which can be a presenting symptom particularly in spontaneous cases 5
Skin and Soft Tissue Examination
- Inspect for ecchymosis in the flank (Grey Turner sign) or periumbilical area (Cullen sign), though these are late findings and rarely present acutely 6
- Examine groin access sites if the patient has undergone recent vascular procedures, as iatrogenic injury is a common cause 1, 3
Trauma-Specific Assessment
- Evaluate for pelvic instability by gentle compression of the iliac crests if trauma is suspected, as pelvic fractures account for 55% of traumatic retroperitoneal hematomas 6, 7
- Document mechanism of injury (blunt versus penetrating) as this guides subsequent management decisions 7
Critical Limitations and Pitfalls
The diagnosis of retroperitoneal hematoma is frequently delayed because physical examination findings are nonspecific and insensitive. 6 Clinical signs such as abdominal pain, back pain, and flank mass lack the sensitivity and specificity needed to rule out this diagnosis 6, 3.
Do not rely on physical examination alone—even in the absence of obvious physical findings, maintain high clinical suspicion in patients with risk factors (anticoagulation, trauma, recent procedures) and proceed directly to CT imaging 2, 8, 9.
Serial hematocrit measurements are essential in patients with suspected retroperitoneal bleeding, as a declining hemoglobin level may be the earliest objective indicator of ongoing hemorrhage, particularly in patients with altered mental status where physical examination is unreliable 4.
Immediate Next Steps
Proceed directly to CT abdomen/pelvis with IV contrast (or CTA if active bleeding is suspected) in any patient with clinical suspicion, as this is the diagnostic modality of choice and physical examination cannot exclude the diagnosis 1, 2. Early imaging within the first 5 hours significantly improves outcomes 2.