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Summary
Retroperitoneal hematoma (RPH) is bleeding into the retroperitoneal space, which may occur spontaneously (most often in patients on anticoagulants), after blunt or penetrating trauma, or iatrogenically following procedures such as percutaneous coronary intervention. Patients may be asymptomatic or present with flank, back, abdominal, and/or leg pain. Significant bleeding can lead to hemodynamic instability. CT abdomen and pelvis with IV contrast is the diagnostic modality of choice and may demonstrate contrast extravasation if there is ongoing bleeding. Most spontaneous and iatrogenic RPHs can be managed conservatively with close observation, transfusions, and correction of coagulopathies (e.g., anticoagulant reversal). Angiographic embolization or surgery may be necessary if bleeding persists despite conservative treatment. Complications include hemorrhagic shock and abdominal compartment syndrome.
Epidemiology
- Traumatic RPH: found in ∼ 15% of patients who undergo laparotomy after blunt abdominal trauma [2]
- Spontaneous RPH: rare; most commonly occurs in older patients [3][4]
- Iatrogenic RPH: occurs in up to 0.9% of patients undergoing percutaneous coronary intervention [5]
Epidemiological data refers to the US, unless otherwise specified.
Etiology
- Traumatic RPH [2][6]
-
Spontaneous RPH [7][8]
- Malignancy (e.g., renal or adrenal tumors)
- Hereditary or acquired coagulopathies (e.g., antiplatelet or anticoagulant use)
- Leaking or ruptured abdominal aortic aneurysm
- Postpartum retroperitoneal hematoma (e.g., after uterine rupture)
-
Iatrogenic RPH [4][5]
- Endovascular procedures (e.g., cardiac catheterization)
- Surgical interventions (e.g., nephrectomy, retroperitoneal dissection)
- Postpartum retroperitoneal hematoma (e.g., uterine artery injury during Cesarean delivery)
Clinical features
Clinical features vary based on hematoma size, bleeding rate, and mass effect on nearby organs. Patients may be asymptomatic or present with nonspecific symptoms. [7][9]
- Abdominal, flank, and/or back pain
- Hip and/or leg pain
- Inguinal swelling and/or tenderness
- Ecchymosis (e.g., Grey Turner sign, Cullen sign) [10]
- Femoral neuropathy [11]
- Clinical features of shock (e.g., hemodynamic instability)
Diagnosis
For suspected traumatic RPH, see also “Urgent diagnostics for trauma patients.”
Approach
- Consider RPH in patients with abdominal, flank, and/or back pain and who have signs of shock.
- Obtain CT abdomen and pelvis with IV contrast.
- Obtain initial laboratory studies (e.g., CBC, coagulation studies, type and screen).
Imaging [12]
-
CT abdomen and pelvis with IV contrast (recommended) [6][7]
- To determine size and location of hematoma
- To evaluate for recent and/or active bleeding
-
MRI abdomen and pelvis [7]
- Comparable diagnostic accuracy to CT
- Limited by availability and study duration
-
Ultrasound abdomen and pelvis (not recommended) [12]
- Cannot evaluate the entire retroperitoneum
- Cannot detect active bleeding
- May miss small RPHs
FAST has limited sensitivity for RPH and should not be used in isolation when RPH is suspected. [13]
Management
Management depends on etiology and hemodynamic stability of the patient, with guidance largely based on expert consensus. A multidisciplinary approach (e.g., surgery, interventional radiology) is often required.
Approach [3][7][14]
- Stabilize hemodynamically unstable patients using the ABCDE approach.
- Initiate immediate hemodynamic support.
- Transfuse blood products as needed for hemorrhagic shock.
- Correct coagulopathy and consider anticoagulant reversal.
- Traumatic RPH
- Begin interventions for pelvic hemorrhage control as needed.
- Evaluate for indications for emergency exploratory laparotomy.
- Consult surgery and interventional radiology to evaluate need for surgical and/or interventional management.
- Admit patient for hemodynamic monitoring, serial hemoglobin and hematocrit, and repeat imaging.
Conservative management [3][14][15]
-
Indications
- Nontraumatic RPH: hemodynamically stable patients without active contrast extravasation on CT
- Traumatic RPH: blunt abdominopelvic trauma without other indications for exploratory laparotomy
-
General measures
- Monitor for changes in clinical status (e.g., vital signs, serial abdominal examinations).
- Serial laboratory studies (e.g., hemoglobin)
- Repeat imaging for RPH expansion
Surgical and interventional management [3][7][14]
-
Indications
- Hemodynamic instability not responsive to resuscitation
- Ongoing bleeding despite anticoagulant reversal
- Penetrating trauma with associated organ or vascular injury
- Expanding RPH on repeat imaging
- Compressive symptoms (e.g., femoral neuropathy)
-
Interventions
- Angiographic embolization (e.g., endovascular coiling)
- Open surgical exploration and hemorrhage control [16]
Complications
We list the most important complications. The selection is not exhaustive.
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