What is the management of a retroperitoneal hematoma?

From the Guidelines

Management of retroperitoneal hematoma requires a tailored approach based on the etiology, size, and patient stability, with a focus on minimizing morbidity, mortality, and optimizing quality of life. For stable patients with small, contained hematomas, conservative management is recommended with close monitoring, bed rest, fluid resuscitation, and correction of any coagulopathy 1. Vital signs should be monitored frequently, with serial hemoglobin measurements every 6-8 hours initially. Patients on anticoagulants should have these medications held, and reversal agents administered if appropriate (protamine for heparin, vitamin K and prothrombin complex concentrate for warfarin, specific reversal agents for DOACs) 1. Pain control with appropriate analgesics is essential.

Key Considerations

• For unstable patients or those with expanding hematomas, surgical intervention is necessary, which may involve open surgery or endovascular techniques such as angioembolization if active bleeding is identified on CT angiography 1.
• The decision between conservative and interventional approaches depends on hemodynamic stability, hematoma size, and whether active bleeding is present 1.
• Patients with traumatic retroperitoneal hematomas often require a multidisciplinary approach involving trauma surgeons, interventional radiologists, and critical care specialists.
• Follow-up imaging with CT scan is typically performed at 24-48 hours to assess stability or resolution of the hematoma 1.

Diagnostic Approaches

• CT abdomen and pelvis is helpful for the diagnosis of retroperitoneal hematoma, given its speed, high spatial resolution, and noninvasiveness 1.
• CT angiography (CTA) is usually performed to detect the site of active retroperitoneal bleeding in cases of known or clinically suspected acute bleeding 1.
• Angiography of the abdomen and pelvis provides the benefit of being able to simultaneously diagnose active bleeding and treat retroperitoneal bleeding with transcatheter arterial embolization (TAE) 1.

Treatment Options

• Conservative management is recommended for stable patients with small, contained hematomas, while surgical intervention is necessary for unstable patients or those with expanding hematomas.
• Endovascular techniques such as angioembolization may be considered for patients with active bleeding identified on CT angiography 1.
• The choice of treatment should prioritize minimizing morbidity, mortality, and optimizing quality of life, taking into account the patient's overall clinical condition and the specific characteristics of the hematoma 1.

From the Research

Management Approaches

• The management of retroperitoneal hematoma can be approached through conservative management, endovascular intervention, or open surgery 2.
• Conservative management is suitable for hemodynamically stable patients and involves fluid resuscitation, correction of coagulopathy, and blood transfusion 2.
• Endovascular treatment, including selective intra-arterial embolization or stent-graft deployment, is increasingly important for managing retroperitoneal hematoma 2, 3.
• Open repair is typically reserved for cases where conservative or endovascular measures fail to control bleeding, or when endovascular facilities or expertise are unavailable, and in cases of patient instability 2, 4, 5, 6.

Diagnostic Methods

• Diagnosis of retroperitoneal hematoma often involves multi-slice CT and arteriography to identify the source and extent of bleeding 2.
• Systematic reviews have shown an increasing trend towards nonsurgical management of retroperitoneal injuries, emphasizing the importance of accurate diagnosis and treatment planning 3.

Treatment Considerations

• The decision to operate on a retroperitoneal hematoma depends on the mechanism of injury (blunt or penetrating), the location of the hematoma, and the patient's hemodynamic status 4, 5, 6.
• For penetrating trauma, most retroperitoneal hematomas are opened, except for isolated lateral perirenal hematomas that have been carefully staged by CT 4.
• In cases of blunt trauma, selected retroperitoneal hematomas in the lateral perirenal and pelvic areas may not require operation and should not be opened if discovered at operation 4.