Retroperitoneal hematoma

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Retroperitoneal hematoma
Retroperitoneal hematoma.
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]


Retroperitoneal hemorrhage and retroperitoneal hematoma are potentially life-threatening conditions. Common causes of retroperitoneal hemorrhage are cardiac catheterization and trauma.


The patient may complain of intense flank pain or back pain.


The patient may develop tachycardia and hypotension if the rate of hemorrhage is rapid.

Rarely, later in the course, the patient may develop a Grey-Turner's sign with bulging flanks, and a bluish discoloration in the region of the flank. Again, it should be emphasized that this sign appears 24 to 48 hours after a severe retroperitoneal bleed and should not be used to gauge whether a retroperitoneal bleed is present acutely.

Differentiating retroperitoneal heamatoma from other diseases

Disease Clinical feature Laboratory findings Imaging findings
Fever Weight loss Abdominal pain
Retroperitoneal hematoma _ _ Anemia MRI is the best radiologic tool to differentiate between retroperitoneal masses.
Retroperitoneal abscess _ Leukocytosis, positive inflammatory markers
Retroperitoneal tumors (.e.g. liposarcoma) positive tumor marker
Chronic pancreatitis _ DM type II, amylase and lipase levels may be slightly elevated

Classification of acute abdomen based

on etiology

Presentation Clinical findings Diagnosis Comments
Fever Rigors and Chills Abdominal Pain Jaundice Hypotension Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Common causes of


Spontaneous bacterial peritonitis + Diffuse Hypoactive
  • Ascitic fluid PMN>250 cells/mm³
  • Culture: Positive for single organism
Ultrasound for evaluation of liver cirrhosis -
Perforated gastric and duodenal ulcer + Diffuse + + + N
  • Ascitic fluid
    • LDH > serum LDH
    • Glucose < 50mg/dl
    • Total protein > 1g/dl
Air under diaphragm in upright CXR Upper GI endoscopy for diagnosis
Acute suppurative cholangitis + + RUQ + + + + ±
Acute cholangitis + RUQ + N Abnormal LFT Ultrasound shows biliary dilatation Biliary drainage (ERCP) + IV antibiotics
Acute cholecystitis + RUQ + Hypoactive Ultrasound shows gallstone and evidence of inflammation Murphy’s sign
Acute pancreatitis + Epigastric ± N Increased amylase / lipase Ultrasound shows evidence of inflammation Pain radiation to back
Acute appendicitis + RLQ + + Hypoactive Leukocytosis Ultrasound shows evidence of inflammation Nausea & vomiting, decreased appetite
Acute diverticulitis + LLQ ± + Hypoactive Leukocytosis CT scan and ultrasound shows evidence of inflammation
Hollow Viscous Obstruction Small intestine obstruction Diffuse + ± Hyperactive then absent Leukocytosis Abdominal X ray Nausea & vomiting associated with constipation, abdominal distention
Gall stone disease/Cholelithiasis ±
Volvulus - Diffuse - + - Hypoactive Leukocytosis CT scan and abdominal X ray Nausea & vomiting associated with constipation, abdominal distention
Biliary colic - RUQ + - - N Increased bilirubin and alkaline phosphatase Ultrasound Nausea & vomiting
Renal colic - Flank pain - - - N Hematuria CT scan and ultrasound Colicky abdominal pain associated with nausea & vomiting
Vascular Disorders Ischemic causes Mesenteric ischemia ± Periumbilical - - - Hyperactive Leukocytosis and lactic acidosis CT scan Nausea & vomiting, normal physical examination
Acute ischemic colitis ± Diffuse - + + Hyperactive then absent Leukocytosis CT scan Nausea & vomiting
Hemorrhagic causes Ruptured abdominal aortic aneurysm - Diffuse - - - N Normal CT scan Unstable hemodynamics
Intra-abdominal or retroperitoneal hemorrhage - Diffuse - - - N Anemia CT scan History of trauma
Gynaecological Causes Fallopian tube Acute salpingitis + LLQ/ RLQ ± ± N Leukocytosis Pelvic ultrasound Vaginal discharge
Ovarian cyst complications and endometrial disease Torsion of the cyst - RLQ / LLQ - ± ± N Increased ESR and CRP Ultrasound Sudden onset severe pain with nausea and vomiting
Endometriosis - RLQ/LLQ - +/- +/- N Normal Laproscopy Menstrual-associated symptoms, pelvic


Cyst rupture - RLQ / LLQ - +/- +/- N Increased ESR and CRP Ultrasound Sudden onset severe pain with nausea and vomiting
Pregnancy Ruptured ectopic pregnancy - RLQ / LLQ - - - N Positive pregnancy test Ultrasound History of missed period and vaginal bleeding
Functional Irritable Bowel Syndrome - Diffuse - - - - N

Clinical diagnosis


Diagnostic Findings

Images courtesy of RadsWiki

Patient #1

Hematoma in Psoas muscles

Hematoma in Psoas muscles

Patient #2

MRI demonstrates a right sided retroperitoneal hematoma

MRI demonstrates a right sided retroperitoneal hematoma

MRI demonstrates a right sided retroperitoneal hematoma

Patient #3

Retroperitoneal hematoma: The first sign was hypotension after cardiac catheterization

Retroperitoneal hematoma: The first sign was hypotension after cardiac catheterization

Retroperitoneal hematoma: The first sign was hypotension after cardiac catheterization

Retroperitoneal hematoma: The first sign was hypotension after cardiac catheterization

Retroperitoneal hematoma: The first sign was hypotension after cardiac catheterization

Retroperitoneal hematoma: The first sign was hypotension after cardiac catheterization


Medical Therapy


Discontinuation of anti-coagulation

If possible, anticoagulation therapy including both anti-thrombins and anti-platelet agents should be discontinued. One exception is if the patient has had a coronary stent placed, in which case dual anti-platelet therapy should be continued if at all possible. If Clopidogrel must be discontinued, then low dose aspirin should be continued in a patient with a fresh stent.

Reversal of anti-coagulation


If the patient has received unfractionated heparin, protamine can be used to reverse the heparin. Protamine does partially reverse enoxaparin as well. Bivalirudin has a fairly short half-life, and does not require reversal.


If the antiplatelet effects must be overcome acutely, then a platelet transfusion can be administered. However, if the antiplatelet agents on board do not bind avidly to the platelets, then these agents can then bind to the new platelets that have just been transfused. Small molecule 2b3a inhibitors such as eptifibatide and Aggrastat are examples of these types of agents. Agents that permanently inhibit the platelet such as aspirin and Clopidogrel can take up to five days to reverse (the time that it takes for new platelets to form).


After blunt trauma, selected retroperitoneal hematomas in the lateral perirenal and pelvic areas do not require operation and should not be opened if discovered at operation. Midline, lateral paraduodenal, lateral pericolonic not associated with pelvic, and portal hematomas are opened after proximal vascular control has been obtained, if appropriate.

Retrohepatic hematomas without obvious active hemorrhage are not opened. After penetrating trauma, most retroperitoneal hematomas are still opened. Exceptions include isolated lateral perirenal hematomas that have been carefully staged by CT and some lateral pericolonic hematomas. As with blunt trauma, retrohepatic hematomas without obvious active hemorrhage are not opened.


  • Petersen JL, Mahaffey KW, Hasselblad V, Antman EM, Cohen M, Goodman SG, et al. Efficacy and Bleeding Complications Among Patients Randomized to Enoxaparin or Unfractionated Heparin for Antithrombin Therapy in Non–ST-Segment Elevation Acute Coronary Syndromes: A Systematic Overview. JAMA 2004 Jul 7; 292(1): 89-96.
  • Jeong TK, Jeong GH, Park BS, Ma SK, Kim SW, Kim NH, et al. Dalteparin-sodium associated retroperitoneal hematoma in a patient with diabetic nephropathy. Korean J Med 2003 64: 322-7.
  • Collet JP, Montalescot G, Fine E, Golmard JL, Dalby M, Choussat R, et al. Enoxaparin in unstable angina patients who would have been excluded from randomized pivotal trials. J Am Coll Cardiol 2003 Jan 1; 41(1): 8-14.
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