Retroperitoneal hematoma is a hemorrhage into the retroperitoneal space. Pathology occurs with abdominal trauma, accompanied by rupture of parenchymal or hollow organs, damage to retroperitoneal blood vessels. The condition manifests itself with increasing shock, signs of an “acute abdomen”, intestinal paresis. To diagnose this type of injury, ultrasound, computed tomography, angiography and a complex of laboratory tests are performed. Treatment tactics are determined by the severity of the injury and the volume of blood loss: conservative therapy, emergency surgery in the volume of laparotomy.
ICD 10
S36.8 Injury to other intra-abdominal organs
Meaning
Retroperitoneal hematoma (RH) is one of the most common complications that occurs in 25% of patients with closed abdominal injuries and in 50% of those who died from this type of injury. According to medical terminology, it is more correct to call such a condition “retroperitoneal hemorrhage”, since only 20% of cases are accompanied by the formation of blood clots in the space behind the peritoneum. The remaining 80% are manifested by the impregnation of retroperitoneal tissue with blood, therefore they cannot be called hematomas in the usual sense of the word.
Causes
The formation of retroperitoneal hematoma is associated with non-penetrating abdominal injuries. Pathology occurs when structures that have access to the retroperitoneal space are affected. These vessels include the aorta and portal vein, pelvic venous plexus, branches of the internal iliac artery. Retroperitoneal hemorrhages occur when the liver, kidneys and adrenal glands, pancreas and duodenum are damaged.
The causes of blunt abdominal trauma, which is accompanied by retroperitoneal hematoma, are diverse. Most often, serious damage is observed when the victim falls from a height or in a serious car accident. Traumatization occurs with a direct blow to the abdomen, compression of the body by fallen fragments or large parts of the car. In such situations, retroperitoneal hematoma occurs as one of the components of polytrauma.
In rare cases, pathology is observed in the absence of mechanical damage. Spontaneous hematomas are the result of rupture of the vessel wall, obstetric coagulopathy, complications of anticoagulant therapy. In this case, hemorrhage occurs against the background of changes in hemodynamics, a decrease in vascular resistance and an increase in cardiac output. Predisposing factors include arteriovenous malformations, Ellers-Danlos syndrome, neurofibromatosis.
Pathogenesis
The pathophysiology of disorders in retroperitoneal hematoma consists of several factors: a sharp decrease in the volume of circulating blood, irritation of nerve receptors, ingestion of the contents of hollow organs into the retroperitoneal zone. The amount of blood in the hematoma ranges from 500 ml to 3 liters. If more than 2 liters of blood is poured out due to injury, the hematoma spreads to the peritoneal tissue and can penetrate into the free abdominal cavity.
In the acute period, hemolymphatic disorders primarily occur, which lead to small foci of necrosis in the kidneys, ureters, and other abdominal organs. Within 6 hours, severe disorders of the motor function of the gastrointestinal tract develop, which is associated with damage to the abdominal nerves and sympathetic trunks. At the same time, complications of primary abdominal trauma are increasing, which caused hemorrhage into the retroperitoneal space.
Classification
In international traumatology, the systematization of injuries according to the AATS scale (American Association of Trauma Surgeons) is generally accepted. According to it, there are 5 degrees of the disease according to the severity and extent of the injury. In practical medicine, the classification of retroperitoneal hematomas by localization is of great importance, in which 3 types of trauma are distinguished:
- Type I is central. The hematoma is located in the central part of the retroperitoneal space. It most often occurs with vascular injuries: injuries of the aorta, portal vein of the inferior vena cava. Less often, this type of injury is observed with damage to the duodenum or pancreas.
- Type II – lateral. The hemorrhage is localized in the retroperitoneal space, which is limited by the lateral part of the diaphragm and the crest of the ilium. Most often, lateral hematomas are associated with kidney injuries.
- Type III – pelvic. The rarest type of RH, which are located in the pelvic cavity and occur mainly with rupture of the iliac vessels. Such an injury is often associated with obstetric pathology.
There are other variants of classifications, but they are less common. According to the anatomical location, hematomas can be parietal, renal visceral of the upper and lower floors of the abdominal cavity. According to the volume of hemorrhages, there are local, widespread and total. According to the composition of the pouring fluid, simple hematomas, urogematomas, fermentohematomas, chemigematomas and biliohematomas are isolated.
Symptoms
There are 3 syndromes in the clinical picture: shock, internal bleeding, “acute abdomen”. These signs overlap with each other, causing the general serious condition of the patient and complicating diagnosis. The shock reaction is observed in 70% of the victims, differs in duration and complexity in treatment. The shock is caused not only by a large blood loss, but also by irritation of the receptor field in the retroperitoneal space, which causes vascular reflexes to be disrupted.
General manifestations are represented by a sharp decrease in blood pressure, rapid and weak pulse, frequent shallow breathing. The patient looks sluggish and sleepy, may answer questions at random or not respond to speech at all. The level of consciousness varies from mild stun to coma, which depends on the severity of blood loss and the presence of concomitant injuries. On external examination, pale skin is observed, cold sweat may appear.
Retroperitoneal hematoma is characterized by various manifestations of “acute abdomen”. The main complaint of patients is dull pain, which is most pronounced in the area of hemorrhage and in most cases subsides within 24 hours. Due to intestinal paresis, the patient has no stool, bloating is observed. Characterized by local muscle tension, the area of dulling percussion sound, which does not change the size and location (a symptom of Joyce).
If the hematoma is not diagnosed in time, after 1-2 days, cyanotic spots appear on the side walls of the abdomen. They are caused by the spread of blood through the retroperitoneal space to the muscles of the abdominal wall. With hemorrhage in the ileum, symptoms of femoral neuropathy, spasms of the iliac muscle and sciatica are possible. Pelvic hematomas may cause difficulties during hip flexion and knee extension.
Complications
Retroperitoneal hematomas are accompanied by local and general consequences. Of the local complications, the most important is paresis of the gastrointestinal tract, which causes constipation and increased gas formation. If bile, enzymes or stomach contents enter the abdominal cavity, peritonitis may develop. Common complications of the disease include secondary bacterial pneumonia, kidney failure, respiratory failure.
Diagnostics
The examination of patients is carried out by a traumatologist or surgeon. During the initial examination, the conditions of injury are clarified, the general condition of the victim is assessed, and external signs of damage are revealed. Although retroperitoneal hematomas are widespread, their preoperative diagnosis is difficult due to the severe condition of the patient and the blurred clinical picture. The following methods are used to make a diagnosis:
- Abdominal ultrasound. Ultrasound diagnostics has a sensitivity of more than 73% percent when performed in the first 2 hours after injury. By the end of the first day of retroperitoneal hematoma development, the informativeness of this method increases to 100%. With the help of echosonography, the impregnation of fiber with blood or the formation of a cavity with blood clots in it is determined.
- Abdominal CT. Computed tomography is recognized as the most informative and accurate method of diagnosis, which shows a hematoma in 100% of cases. With the help of CT, injuries to internal organs and blood vessels are visualized, the severity of injury to retroperitoneal structures is determined, indications for surgery are found out.
- Angiography. If the vascular etiology of hemorrhage is confirmed, it is necessary to study the arterial and venous bed with the use of a contrast agent. According to the indications, embolization of the damaged vessel is performed during the diagnosis in order to block the bleeding zone and avoid complications of a strained hematoma.
- Diagnostic laparotomy. If other diagnostic methods were not informative enough, the patient is referred for surgery as soon as possible. Surgical intervention is prescribed for the revision of the retroperitoneal space, isolation of the affected organs and vessels, carrying out therapeutic measures, if necessary.
- Laboratory tests. Diagnosis is prescribed to assess the general health of the patient and timely diagnosis of complications. The basic methods include a clinical blood test, a urine test, a biochemical blood test and a coagulogram.
Differential diagnosis
Upon admission of the patient, it is necessary to differentiate retroperitoneal hematoma with isolated closed injuries of the abdominal organs. If the victim is unconscious and doctors cannot get information about what happened, differential diagnosis is carried out with acute surgical pathologies: peritonitis, thrombosis of mesenteric vessels. In women, it is necessary to exclude ectopic pregnancy and other gynecological pathologies.
Treatment
Emergency care consists in stabilizing the patient’s condition and hospitalizing him to the intensive care unit as quickly as possible. With hemorrhage within 500 ml and the absence of severe surgical pathology, conservative therapy is possible. It includes infusion solutions, painkillers, antispasmodics and other medications, taking into account the symptoms. To quickly stop bleeding, endovascular embolization of the injured vessel is performed.
In other situations, an emergency laparotomy is indicated. It is recommended to perform the operation in the first 6 hours after a closed injury to prevent the development of dangerous complications. Surgical intervention is aimed at detecting the source of bleeding and eliminating the ongoing blood loss. The technique of the operation depends on the nature of the injury and is selected individually. According to indications, repeated reconstructive operations are performed after 3-4 months.
Prognosis and prevention
Despite the ongoing therapeutic measures, the mortality rate for extensive retroperitoneal hematomas is 15%. The causes of death of the victims are shock and blood loss, bronchopulmonary complications, acute renal failure. Primary prevention measures include preventive work to reduce injuries. Secondary prevention consists in early and complete diagnosis of victims with abdominal injuries in order to exclude or detect a hematoma in time.
Literature
- Kasotakis G. Retroperitoneal and rectus sheath hematomas. Surg Clin North Am. 2014 Feb;94(1):71-6. – link
- Daly KP, Ho CP, Persson DL, Gay SB. Traumatic Retroperitoneal Injuries: Review of Multidetector CT Findings. Radiographics. 2008 Oct;28(6):1571-90. – link
- Feliciano DV. Management of traumatic retroperitoneal hematoma. Ann Surg. 1990 Feb;211(2):109-23.
- Sunga KL, Bellolio MF, Gilmore RM, Cabrera D. Spontaneous retroperitoneal hematoma: etiology, characteristics, management, and outcome. J Emerg Med. 2012 Aug;43(2):e157-61. – link
