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Retroperitoneal bleeding

Retroperitoneal bleeding, also known as retroperitoneal hematoma, is the accumulation of blood in the retroperitoneal space, a potential anatomical compartment located posterior to the peritoneal cavity and anterior to the posterior abdominal wall, encompassing structures such as the kidneys, adrenal glands, aorta, and inferior vena cava.^[1] This condition is often occult and underrecognized, potentially leading to substantial morbidity and mortality due to insidious blood loss that can result in hemorrhagic shock before overt signs appear.^[1] It is classified into three zones based on anatomical location: zone I (central-medial, involving the aorta and major vessels), zone II (perirenal or lateral, around the kidneys), and zone III (pelvic, involving iliac vessels).^[1]^[2] The etiology of retroperitoneal bleeding encompasses traumatic, iatrogenic, and spontaneous mechanisms. Traumatic cases, which account for a significant portion, result from blunt abdominal or pelvic injuries in approximately 67-80% of instances (often from motor vehicle accidents) or penetrating trauma in 20-33%, comprising about 12% of stable abdominal trauma presentations.^[1]^[2] Iatrogenic bleeding occurs in roughly 0.06% of procedures like cardiac catheterization or anticoagulation therapy, with a 3.5-fold increase in mortality risk.^[1] Spontaneous retroperitoneal bleeding, with an incidence of about 0.6%, is frequently associated with anticoagulation use, coagulopathies, vascular malformations, or neoplasms, predominantly affecting older adults.^[1] Clinically, retroperitoneal bleeding manifests with nonspecific symptoms, including abdominal, flank, or back pain in 46-67.5% of cases, often accompanied by signs of hypovolemia such as tachycardia and hypotension.^[1] Other features may include abdominal distension, a palpable mass, or rare Grey Turner's sign (flank ecchymosis) in 1-6.5% of patients; in severe cases, it can lead to femoral neuropathy or shock from massive hemorrhage.^[1]^[2] Diagnosis relies on contrast-enhanced computed tomography (CT), which offers 100% sensitivity for detecting active bleeding and hematoma extent, supplemented by laboratory tests like complete blood count, coagulation profile, and type and crossmatch.^[1] Ultrasonography serves as an initial bedside tool in unstable patients, while exploratory laparotomy may be necessary for confirmation in trauma settings.^[2] Management prioritizes hemodynamic stabilization, with conservative observation suitable for stable patients without ongoing bleeding, while unstable cases require urgent intervention such as angioembolization or surgical exploration (mandatory for penetrating zone II injuries or expanding hematomas).^[1]^[2] In nontraumatic scenarios, reversal of anticoagulation is critical. Prognosis varies, with traumatic mortality at 6.5-18% and spontaneous cases carrying a 10% 30-day mortality rate, higher in those requiring intensive care; complications include infection, exsanguination, and abdominal compartment syndrome.^[1]^[2]

Introduction

Definition

Retroperitoneal bleeding, also referred to as retroperitoneal hematoma, is defined as the accumulation of blood within the retroperitoneal space, a potential anatomical compartment situated posterior to the peritoneal cavity and anterior to the posterior abdominal wall musculature.^[1] This condition arises from hemorrhage into this confined area, which can lead to significant hemodynamic instability if not promptly identified due to its often occult nature.^[1] The retroperitoneal space encompasses a variety of vital structures, including the kidneys, adrenal glands, pancreas (except its tail), portions of the duodenum, ascending and descending colon, aorta, inferior vena cava, and their major branches.^[3] Unlike intraperitoneal bleeding, which typically causes peritoneal irritation and more overt signs, retroperitoneal hemorrhage is contained within fascial planes, allowing blood to dissect along tissue planes without immediate peritoneal contamination.^[4] Retroperitoneal bleeding is broadly classified into traumatic and non-traumatic (spontaneous) categories based on etiology.^[1] Traumatic retroperitoneal bleeding results from direct injury, such as blunt or penetrating abdominal trauma, while spontaneous cases occur without evident external provocation, often linked to underlying coagulopathies, vascular anomalies, or iatrogenic factors.^[1] This distinction guides clinical management, with traumatic instances frequently requiring surgical exploration in specific zones of the retroperitoneum.^[5] The condition has historical roots dating back to the early 18th century for spontaneous forms, first described by Bonet in 1700 as Wunderlich syndrome, though recognition of traumatic retroperitoneal bleeding gained prominence in the early 20th century amid evolving trauma literature and pelvic fracture management.^[6]

Epidemiology

Retroperitoneal bleeding, encompassing both traumatic and non-traumatic forms, exhibits varying incidence rates depending on the underlying mechanism. In traumatic cases, which constitute the majority, retroperitoneal hematomas occur in approximately 12% to 30% of patients with abdominal-pelvic trauma, with blunt mechanisms accounting for 67% to 80% of instances compared to 20% to 33% for penetrating injuries.^[1]^[7] Among blunt abdominal trauma specifically, renal injuries—a common source of retroperitoneal bleeding—manifest in up to 10% of cases.^[1] Non-traumatic spontaneous retroperitoneal hematomas are rarer, with an estimated incidence of 0.6% to 6.6% among patients on therapeutic anticoagulation, though overall prevalence remains low at around 0.6% in broader cohorts.^[1]^[8] Demographic patterns highlight a predominance in males for traumatic cases, with a male-to-female ratio approaching 2:1 to 2.5:1, reflecting higher exposure to trauma and procedural risks in this group; spontaneous cases show a more balanced gender distribution.^[2]^[9] For traumatic retroperitoneal bleeding, incidence peaks in younger adults aged 30 to 50 years, often linked to high-energy incidents, while spontaneous cases more frequently affect the elderly (mean age around 72 years), particularly those on anticoagulants.^[1]^[7] In the United States, data from trauma registries indicate thousands of annual cases, underscoring its relevance in polytrauma scenarios.^[1] Global variations in incidence correlate with regional trauma burdens, particularly elevated in areas with high rates of motor vehicle accidents, where blunt abdominal trauma drives up to 79% of cases.^[10] For instance, road traffic injuries contribute disproportionately in low- and middle-income countries, amplifying retroperitoneal bleeding risks through increased blunt force exposures.^[11] Mortality rates for retroperitoneal bleeding vary by etiology and management. Traumatic cases carry an overall mortality of 20% to 40%, with rates up to 40-60% in severe polytrauma including associated pelvic fractures (reported as low as 19% in some series), though exclusion of concurrent head injuries lowers this to about 13%.^[12]^[7] In contrast, managed non-traumatic cases exhibit lower rates of 10% to 20%, with spontaneous hematomas showing 5.6% mortality at one week and up to 19.1% at six months, emphasizing the impact of early intervention.^[1]^[13]

Anatomy and Pathophysiology

Retroperitoneal Space

The retroperitoneal space is the anatomical region located posterior to the peritoneal cavity and anterior to the posterior abdominal wall, bounded superiorly by the diaphragm, inferiorly by the pelvic brim, and laterally by the flanks. It extends from the 12th thoracic vertebra to the sacrum and is separated from the peritoneal cavity by the posterior parietal peritoneum. This space serves as a compartment for various viscera and vascular structures, facilitating their protection and mobility within the abdomen.^[3] For clinical relevance, particularly in trauma and bleeding scenarios, the retroperitoneal space is divided into three zones based on anatomical boundaries. Zone 1, the central zone, spans from the diaphragm superiorly to the aortic bifurcation inferiorly and is subdivided into supramesocolic (above the transverse mesocolon) and inframesocolic (below) regions; it lies medial to the ascending and descending colons. Zone 2, the perirenal or flank zones, are bilateral spaces lateral to the psoas muscles, extending from the renal vessels medially to the lateral reflection of the posterior parietal peritoneum and from the diaphragm superiorly to the aortic bifurcation inferiorly, encompassing the pararenal areas. Zone 3, the pelvic zone, is located inferior to the aortic bifurcation and includes the presacral and perivesical regions. These divisions aid in localizing injuries and potential hemorrhage sites.^[1] The retroperitoneal space contains several critical structures, including the kidneys and ureters, adrenal glands, second to fourth parts of the duodenum, ascending and descending colon, abdominal aorta, inferior vena cava, and iliac vessels. These organs and vessels are embedded within adipose tissue and connective layers, providing structural support and allowing for physiological functions such as filtration, hormone production, and blood flow. The pancreas (except its tail) and portions of the inferior mesenteric artery also reside here, contributing to the space's complexity.^[3] Fascial planes within the retroperitoneal space organize its contents and influence compartmentalization. The renal fascia, historically termed Gerota's fascia, forms a sheath around each kidney, adrenal gland, and surrounding perirenal fat, consisting of anterior (prerenal) and posterior (perirenal) layers that fuse laterally and inferiorly. This fascia creates the perirenal space (Zone 2) and can contain or direct the spread of fluid or blood along interfascial planes, while the anterior and posterior pararenal spaces are bounded by other condensations of connective tissue. Additional planes, such as the lateroconal fascia, further delineate boundaries between compartments.^[14]^[15]

Mechanisms of Bleeding

Retroperitoneal bleeding arises from the disruption of blood vessels or parenchymal organs within the retroperitoneal space, leading to the accumulation of blood and formation of a hematoma. This disruption can occur through mechanical injury to vascular structures or organ rupture, allowing blood to extravasate into the potential spaces posterior to the peritoneum. The resulting hematoma expands progressively, often without immediate peritoneal irritation due to the space's capacity to accommodate significant volumes of blood—up to 4 liters—before clinical signs become evident.^[16] This substantial blood loss contributes to hypovolemic shock, characterized by hemodynamic instability, as the retroperitoneum acts as a hidden reservoir that delays recognition of the hemorrhage.^[1] The spread and containment of blood in retroperitoneal bleeding are influenced by the fascial planes and connective tissues that compartmentalize the space, directing blood flow along defined pathways rather than freely diffusing. Blood may track superiorly toward the diaphragm, inferiorly into the pelvis, or laterally into adjacent compartments, potentially causing delayed onset of symptoms as the hematoma enlarges insidiously. This propagation can exert mass effect on nearby structures, compressing neural elements such as the femoral nerve to produce neuropathy or obstructing ureters to induce hydronephrosis and renal compromise.^[1]^[17]^[18] Hemodynamic factors play a critical role in initiating and exacerbating retroperitoneal bleeding. In traumatic scenarios, shearing forces from deceleration or compressive injuries lacerate fixed retroperitoneal vessels, such as the renal arteries or iliac vessels. Non-traumatic erosion, as seen in aneurysmal rupture, involves progressive wall weakening and breach, releasing blood under arterial pressure. Coagulopathy, whether from underlying disorders or therapeutic anticoagulation, amplifies the bleed by impairing hemostasis, allowing unchecked expansion of the hematoma and worsening hypovolemia.^[1]^[19]

Etiology

Traumatic Causes

Traumatic retroperitoneal bleeding arises from physical injuries that disrupt the integrity of retroperitoneal structures, including major vessels, organs, and supporting tissues. These injuries are broadly categorized into blunt and penetrating mechanisms, each involving distinct forces that lead to hematoma formation in the retroperitoneal space.^[1] Blunt trauma accounts for the majority of cases and typically results from high-energy impacts or deceleration forces that cause shearing or compressive injuries to retroperitoneal vasculature and organs. Common scenarios include motor vehicle collisions, where rapid deceleration can avulse branches of the aorta or iliac arteries, leading to bleeding in Zone 1 (central retroperitoneum). Falls from height or crush injuries often produce renal lacerations or perirenal hematomas in Zone 2 (perirenal space), while pelvic fractures from blunt force commonly cause bleeding in Zone 3 (pelvic retroperitoneum) due to disruption of iliac vessels or sacral veins.^[1]^[2] Penetrating trauma involves direct violation of the retroperitoneal space by foreign objects, resulting in lacerations to vessels or solid organs based on the injury trajectory. Gunshot wounds to the flank or pelvis frequently injure the kidneys, ureters, or iliac vessels in Zones 2 and 3, with high-velocity projectiles causing cavitation and extensive tissue damage. Stab wounds, though lower energy, can selectively transect retroperitoneal structures such as the duodenum, colon, or major arteries in Zone 1, leading to contained hematomas that may expand if untreated.^[1]^[2]

Non-Traumatic Causes

Non-traumatic retroperitoneal bleeding arises from endogenous vascular weaknesses, organ pathologies, or systemic coagulation disorders without external injury. It includes spontaneous and iatrogenic mechanisms, with the latter involving complications from medical procedures. These causes are relatively rare but carry high morbidity and mortality due to the potential for massive blood loss in the expansive retroperitoneal space.^[1] Elderly patients are particularly susceptible, as age-related vascular fragility exacerbates these risks.^[1]

Iatrogenic Causes

Iatrogenic trauma occurs as a complication of invasive medical procedures, where inadvertent vascular injury leads to retroperitoneal hemorrhage. It has an incidence of approximately 0.06% following percutaneous interventions.^[1] Lumbar puncture can puncture lumbar arteries, causing hematoma formation in the psoas muscle or broader retroperitoneum, particularly in anticoagulated patients. Percutaneous nephrostomy tube placement risks renal capsular or vascular disruption, resulting in perirenal or extraperitoneal bleeding. Spinal surgeries, such as lumbar fusion or discectomy, may injure segmental arteries or the aorta during anterior approaches, leading to delayed retroperitoneal hematomas.^[20]^[21]^[22]

Spontaneous Causes

Spontaneous retroperitoneal bleeding, with an incidence of approximately 0.6%, is frequently associated with anticoagulation use, coagulopathies, vascular malformations, or neoplasms, predominantly affecting older adults.^[1] Vascular etiologies predominate among spontaneous causes and often involve rupture of weakened arterial structures. A ruptured abdominal aortic aneurysm (AAA) is a classic example, where the aneurysm's posterolateral wall breaches into the retroperitoneal space, leading to contained hemorrhage that can expand rapidly and cause hemodynamic instability.^[23] Similarly, iliac artery rupture or erosion from adjacent structures can produce extensive retroperitoneal bleeding, frequently presenting with acute flank pain and hypotension.^[1] Anticoagulation therapy, such as warfarin overdose or therapeutic heparin use, significantly heightens the risk by impairing hemostasis in these fragile vessels.^[24]^[25] Organ-related causes stem from intrinsic parenchymal or cystic disruptions within retroperitoneal structures. Spontaneous adrenal hemorrhage is a notable example, often linked to pregnancy-induced vascular changes, adrenal tumors like myelolipomas, or underlying infections, resulting in unilateral or bilateral bleeding that dissects into the retroperitoneum.^[26]^[27] Rupture of a pancreatic pseudocyst, typically a complication of chronic pancreatitis, can erode into surrounding vessels or directly breach into the retroperitoneal space, causing hemorrhagic shock through acute expansion of the hematoma.^[28] Coagulopathies represent another critical category, where impaired clotting mechanisms precipitate spontaneous bleeding from minor vascular insults. In hemophilia, particularly severe factor VIII or IX deficiencies, retroperitoneal hemorrhage arises from unchecked microvascular leaks, often requiring factor replacement to halt progression.^[29] Liver disease, such as cirrhosis, induces coagulopathy through reduced synthesis of clotting factors and thrombocytopenia, increasing susceptibility to retroperitoneal hematomas even without trauma.^[30] Post-transplant patients on immunosuppressants like corticosteroids may experience exacerbated bleeding due to combined effects on platelet function and fibrinolysis, underscoring the need for vigilant monitoring in these populations.^[1]

Clinical Presentation

Signs and Symptoms

Retroperitoneal bleeding commonly manifests with acute or insidious pain, which patients describe as a dull ache localized to the abdomen, flank, or lower back. This pain arises from irritation of surrounding tissues by the accumulating hematoma and may radiate to the groin, hips, or legs, particularly when the bleeding involves structures near neural pathways or compresses adjacent nerves. In retrospective studies, abdominal pain is reported in 46% to 67.5% of spontaneous cases, making it the most frequent initial complaint.^[1] Systemic symptoms often develop due to substantial blood loss into the retroperitoneal space, leading to hypovolemia and anemia. Patients may report fatigue, weakness, dizziness, or lightheadedness as early indicators of hemodynamic compromise, alongside tachycardia and hypotension in progressive cases. Shock is a hallmark of severe presentations, occurring in up to 26.5% of spontaneous cases and contributing to Lenk's triad of abdominal or flank pain, palpable mass, and signs of hypovolemic shock.^[1]^[31]^[32] When the bleeding originates from or affects the urinary tract, such as in renal or ureteral involvement, hematuria is a notable patient-reported symptom, present in approximately 40% of spontaneous retroperitoneal hemorrhages. In instances of duodenal perforation extending into the retroperitoneum, gastrointestinal complaints such as nausea and vomiting may occur.^[32]

Physical Examination Findings

Patients with retroperitoneal bleeding often exhibit subtle abdominal findings on physical examination due to the contained nature of the hemorrhage within the retroperitoneal space. Abdominal distension may be present without associated rigidity or guarding, as the bleeding does not typically irritate the peritoneal cavity. Ecchymosis can manifest as Cullen's sign, characterized by periumbilical bruising from tracking blood, or Grey Turner's sign, indicated by flank discoloration, though these are uncommon and have low sensitivity (approximately 1-6.5% in reported cohorts).^[1] A ballotable mass may be palpable in the flanks, particularly in cases of significant hematoma accumulation, such as spontaneous perirenal hemorrhage, where it forms part of Lenk's triad alongside shock signs.^[2] Vital signs frequently reveal hemodynamic instability, including hypotension, tachycardia, and oliguria, reflecting hypovolemic shock from blood loss.^[1] Neurological examination may disclose femoral neuropathy due to hematoma compression of the femoral nerve within the iliopsoas compartment, presenting as weakness in hip flexion, reduced patellar reflex, and sensory deficits in the anterior thigh.^[33]^[34]

Diagnosis

History and Physical Examination

The evaluation of retroperitoneal bleeding begins with a thorough history to identify risk factors and potential etiologies. In cases of suspected trauma, details regarding the mechanism—such as blunt force from high-speed motor vehicle collisions or penetrating injuries—along with the timing and circumstances of the event, are essential to assess the likelihood of retroperitoneal involvement.^[1]^[7] Medication history should include the use of anticoagulants like warfarin or antiplatelet agents, which significantly increase the risk of spontaneous bleeding, particularly in older adults or those with underlying coagulopathies.^[1] Comorbidities such as abdominal aortic aneurysm (AAA) or bleeding diatheses, including hemophilia, must also be elicited, as they predispose patients to non-traumatic hemorrhage.^[35] Red flags in the history include unexplained hypotension following invasive procedures like femoral cannulation or in patients on anticoagulation therapy, warranting heightened suspicion for retroperitoneal bleeding even without overt trauma.^[1]^[4] The physical examination follows advanced trauma life support (ATLS) protocols, starting with assessment of airway, breathing, and circulation (ABCs) to address any immediate life threats from hypovolemia or shock.^[1] A focused abdominal examination may reveal tenderness in the flank, lower quadrants, or back, though findings can be subtle or absent due to the retroperitoneal location; rare signs include flank ecchymosis (Grey Turner's sign) or umbilical bruising (Cullen's sign).^[35]^[36] Neurological screening is critical, particularly for lower extremity weakness or sensory changes suggestive of femoral neuropathy from psoas hematoma compression.^[35] Additional red flags encompass hemodynamic instability, such as tachycardia and hypotension without an obvious source, or pelvic instability indicating possible zone III hemorrhage.^[7]

Laboratory Investigations

Laboratory investigations are essential for supporting the diagnosis of retroperitoneal bleeding, particularly by detecting evidence of blood loss, organ dysfunction, and underlying coagulopathies. A complete blood count (CBC) often reveals decreasing hemoglobin and hematocrit levels, reflecting acute or ongoing hemorrhage into the retroperitoneal space.^[1] Coagulation studies, including prothrombin time (PT), international normalized ratio (INR), activated partial thromboplastin time (aPTT), and platelet count, are critical to identify coagulopathies that may contribute to or exacerbate the bleeding, especially in patients receiving anticoagulant therapy.^[35] Type and crossmatch should be performed to prepare for potential transfusion.^[1] Biochemical evaluation typically includes a comprehensive metabolic panel to assess for hypovolemia-induced prerenal azotemia, manifested as elevated blood urea nitrogen (BUN) and creatinine levels, which may also result from direct compression of renal structures by the hematoma.^[1] Serum lactate measurement is useful to evaluate for hypovolemic shock, with elevated levels indicating tissue hypoperfusion.^[35] Urinalysis may show microscopic or gross hematuria, suggesting concomitant renal injury or involvement in the bleeding process.^[1]

Imaging Modalities

Computed tomography (CT) scanning serves as the gold standard imaging modality for diagnosing retroperitoneal bleeding due to its high sensitivity, rapid acquisition, and ability to precisely localize hematomas and identify underlying causes. Non-contrast CT can detect hyperdense acute hematomas with densities typically ranging from 40 to 80 Hounsfield units, while intravenous contrast-enhanced CT reveals active extravasation as a hallmark of ongoing hemorrhage, often appearing as a "sentinel" blush or pooling of contrast within the hematoma. Multidetector CT further enhances visualization of retroperitoneal zones, distinguishing central (Zone I), perirenal (Zone II), and pelvic (Zone III) involvement, and assesses for associated vascular injuries or organ lacerations.^[1]^[37]^[4] Focused assessment with sonography for trauma (FAST) ultrasound provides a quick, non-invasive bedside option for initial evaluation in hemodynamically unstable patients, particularly in trauma settings, but it has limited utility for retroperitoneal bleeding due to the space's posterior location and acoustic shadowing from bowel gas or bone. FAST may detect free intraperitoneal fluid suggestive of associated injuries but often misses contained retroperitoneal hematomas, making it unreliable as a standalone diagnostic tool.^[1]^[37]^[4] Magnetic resonance imaging (MRI) offers superior soft tissue contrast for detailed assessment of hematoma chronicity, composition, and potential nerve compression in stable patients, with signal intensities varying by blood degradation stage—hyperintense on T1-weighted images for subacute methemoglobin and hypointense on T2 for hemosiderin. However, MRI is rarely used acutely due to its prolonged scan times, contraindications in unstable or claustrophobic patients, and lack of widespread availability in emergency settings.^[38]^[39] Angiography, including conventional catheter-based or computed tomography angiography (CTA), is valuable for vascular mapping and identifying arterial sources of bleeding, such as pseudoaneurysms or active extravasation not fully characterized on initial CT. CTA is preferred for its non-invasive nature and integration with CT protocols, while digital subtraction angiography facilitates both diagnosis and therapeutic embolization in cases requiring intervention. Limitations include invasiveness for conventional angiography, contrast risks, and radiation exposure similar to CT.^[1]^[37]^[4] Overall, imaging selection prioritizes CT for most patients, balancing diagnostic yield against radiation concerns, particularly in younger individuals or those needing serial exams.^[4]

Management

Initial Stabilization

Initial stabilization of retroperitoneal bleeding prioritizes the advanced trauma life support (ATLS) protocol to address life-threatening conditions through a systematic primary survey focusing on airway, breathing, and circulation (ABC). Airway patency is ensured first, followed by adequate ventilation and oxygenation support if compromised, such as via endotracheal intubation in cases of hemodynamic instability or altered mental status. Circulation is managed by controlling external hemorrhage through direct pressure and assessing for internal bleeding, with immediate intravenous access established using two large-bore peripheral lines to facilitate rapid fluid administration.^[1]^[7]^[40] Hemorrhagic shock, common in retroperitoneal bleeding, requires prompt resuscitation starting with crystalloid fluids like normal saline or lactated Ringer's in limited volumes to avoid dilutional coagulopathy, transitioning quickly to blood products including packed red blood cells, fresh frozen plasma, and platelets in a 1:1:1 ratio for massive transfusion protocols. Permissive hypotension is employed in trauma patients without traumatic brain injury, targeting a systolic blood pressure of approximately 90 mmHg to minimize re-bleeding from clot disruption while preserving perfusion. In non-traumatic cases, such as spontaneous retroperitoneal hemorrhage, anticoagulation reversal is critical: for warfarin, administer vitamin K and prothrombin complex concentrate (PCC); for direct oral anticoagulants, use specific reversal agents like idarucizumab for dabigatran or andexanet alfa for factor Xa inhibitors; and for heparin, protamine sulfate.^[41]^[40]^[1]^[42] Ongoing monitoring includes central venous access for pressure assessment and vasopressor administration if needed, continuous vital signs tracking, and serial hemoglobin/hematocrit measurements every 4-6 hours to gauge blood loss and response to resuscitation. Electrocardiographic monitoring detects arrhythmias from hypovolemia, and urine output is tracked via Foley catheter to ensure end-organ perfusion greater than 0.5 mL/kg/hour. These interventions aim to stabilize the patient hemodynamically before proceeding to definitive care, with close observation for signs of ongoing bleeding such as persistent hypotension or expanding hematoma on imaging. For traumatic cases, management should align with current guidelines such as the 2025 European Society for Vascular Surgery (ESVS) Clinical Practice Guidelines on vascular trauma.^[1]^[7]^[43]^[44]

Definitive Treatment

Definitive treatment of retroperitoneal bleeding is tailored to the underlying etiology, hemodynamic stability, and extent of hemorrhage, escalating from conservative approaches for stable patients to invasive interventions as needed.^[1] Conservative management is appropriate for hemodynamically stable patients with self-limiting hematomas, involving close observation, serial imaging such as computed tomography (CT) to monitor hematoma size and stability, and supportive measures to correct coagulopathy or underlying anticoagulation.^[1] This approach has demonstrated efficacy in over 90% of spontaneous retroperitoneal hemorrhage cases, particularly when there is no ongoing active bleeding or expansion on follow-up scans.^[45] Interventional radiology techniques serve as a minimally invasive option for controlling vascular sources of bleeding, with angiographic embolization being the preferred method for targeted hemostasis in both traumatic and spontaneous retroperitoneal bleeds. Transcatheter arterial embolization (TAE) achieves technical success rates exceeding 90% and is associated with reduced morbidity compared to surgery, effectively occluding bleeding vessels using coils, particles, or glue under fluoroscopic guidance.^[46]^[47] For cases involving urinary tract obstruction secondary to hematoma compression, ureteral stenting can relieve hydronephrosis and prevent renal damage by bypassing the obstruction and restoring urine flow.^[48] Surgical intervention is reserved for massive or uncontrolled bleeding unresponsive to conservative or endovascular measures, often requiring exploratory laparotomy to access the retroperitoneum, evacuate the hematoma, and achieve direct hemostasis through vessel ligation or repair. In ruptured abdominal aortic aneurysms (AAA), open surgical repair involves graft placement to exclude the aneurysm sac, though this carries higher perioperative risks in unstable patients.^[1]^[49] For traumatic retroperitoneal injuries, damage control surgery employs abbreviated laparotomy with packing and temporary closure to rapidly control hemorrhage and contamination, followed by staged definitive repair once physiology is optimized.^[50] Additionally, AI-assisted angiography has emerged to improve detection of active bleeding during procedures, with convolutional neural networks enabling real-time identification of extravasation on digital subtraction images, potentially shortening procedure times and increasing diagnostic accuracy in mesenteric and celiac artery assessments applicable to retroperitoneal bleeding.^[51]

Complications and Prognosis

Potential Complications

Retroperitoneal bleeding can lead to several local complications due to the mass effect of the accumulating hematoma in the confined retroperitoneal space. One significant local issue is abdominal compartment syndrome, which arises from increased intra-abdominal pressure caused by the expanding hematoma, potentially compromising organ perfusion and requiring urgent decompression.^[1] Another local complication is renal failure resulting from compression of the kidneys or ureters by the hematoma, leading to obstructive uropathy and acute kidney injury, particularly in cases involving a solitary functioning kidney.^[52] Infection of the hematoma is also possible, especially in posttraumatic or postoperative settings, where bacterial superinfection can occur, leading to abscess formation or sepsis if not promptly addressed.^[1] Systemic complications from retroperitoneal bleeding often stem from hypovolemia, coagulopathy, or prolonged hospitalization. Multi-organ failure may develop secondary to severe blood loss and hypovolemic shock, affecting organs such as the kidneys, liver, and lungs through ischemia and inflammatory responses.^[1] Disseminated intravascular coagulation (DIC) can be triggered by massive hemorrhage, resulting in widespread microvascular thrombosis and further bleeding tendencies due to consumption of clotting factors.^[53] Thromboembolism, including deep vein thrombosis and pulmonary embolism, is a risk following immobility during conservative management or recovery, exacerbated by hypercoagulable states associated with trauma or underlying conditions. Treatment-related complications can arise from interventions aimed at controlling the bleed. Re-bleeding may occur after transarterial embolization, particularly if collateral vessels develop or the initial procedure fails to fully occlude the source, necessitating repeat interventions.^[1] Surgical management carries risks of wound complications, such as infection, dehiscence, or damage to adjacent structures like nerves and vessels, which can prolong recovery and increase morbidity.^[1]

Prognostic Factors

Prognostic factors for retroperitoneal bleeding significantly influence patient survival and recovery, with outcomes varying based on etiology, timeliness of intervention, and patient characteristics. Early diagnosis is a key positive predictor, as prompt recognition allows for timely stabilization and reduces the risk of hemodynamic collapse.^[36] Hemodynamic stability upon presentation also favorably impacts prognosis, with stable patients exhibiting lower mortality rates compared to those arriving in shock.^[7] Non-traumatic etiologies, such as spontaneous or iatrogenic bleeds, generally carry a better prognosis than traumatic cases, with spontaneous retroperitoneal hemorrhage showing a 30-day mortality of approximately 10%, lower than the 18% seen in penetrating trauma.^[1] Negative prognostic indicators include delayed intervention, which exacerbates blood loss and multiorgan failure, leading to high mortality in severe cases. Massive blood loss is associated with profound hypovolemia and a threefold increase in 30-day mortality.^[54] Comorbidities further worsen outcomes; advanced age over 70 years correlates with higher mortality due to reduced physiological reserve, while coagulopathy from anticoagulation or underlying disorders increases bleeding severity and complication rates.^[55]^[1] Scoring systems like the Injury Severity Score (ISS) provide quantitative prognostic insight, with mean ISS values above 37 strongly correlating with nonsurvival in retroperitoneal hematoma cases, contributing to an overall mortality of 20%.^[12] For abdominal aortic aneurysm (AAA)-related retroperitoneal bleeds, which often involve rupture, 5-year survival post-repair is approximately 41%, reflecting the high perioperative risks.^[56] In survivors, long-term sequelae such as chronic pain from unresolved hematoma fibrosis and renal impairment due to hypoperfusion or direct injury occur in a notable proportion, impacting quality of life.^[1]

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Anticoagulant therapy with heparin precipitated a massive spontaneous atraumatic retroperitoneal hemorrhage (with international normalized ratio 2.4), which ...
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Nov 15, 2024 · Adrenal hemorrhage is a relatively uncommon condition with a variable and nonspecific presentation that may lead to acute adrenal crisis, shock, and death
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Spontaneous adrenal hemorrhage. Report of two cases and review ...
Jun 11, 2018 · Hereby we present two cases of spontaneous adrenal hemorrhage associated with extensive retroperitoneal bleeding and hemodynamic instability.Spontaneous Adrenal... · Case Report 1 · Case Report 2
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Spontaneous Hemorrhage into the Pseudocyst of the Pancreas ...
Aug 29, 2024 · The hemorrhagic pseudocyst might rupture into the retroperitoneum, causing retroperitoneal hemorrhage; into the peritoneum, causing hemosuccus ...
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Giant Retroperitoneal Hematoma-A Life-Threatening Complication ...
Jan 17, 2022 · Abstract. Spontaneous retroperitoneal hemorrhage is a rare complication in patients with severe type A hemophilia. The diagnosis is made based ...Missing: liver | Show results with:liver
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Spontaneous Retroperitoneal Hematoma: A Deadly Complication ...
Dec 14, 2022 · Background: Patients with end-stage liver disease (ESLD) are at increased risk for hemorrhage and spontaneous retroperitoneal hematoma ...
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Spontaneous retroperitoneal haemorrhage from pancreatoduodenal ...
Oct 17, 2022 · SRH may present with vague symptoms, including abdominal, back or groin pain; blue-grey discolouration of the flank (Grey Turner's sign); ...
[30]
A case report on spontaneous retroperitoneal hemorrhage - PMC
Jul 20, 2021 · The typical clinical manifestations of SRH are Lenk triad: abdominal pain, shock, and non-pulsating abdominal mass. The nature of the abdominal ...
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Spontaneous Retroperitoneal Hemorrhage Caused by Segmental ...
Spontaneous retroperitoneal hemorrhage is a rare clinical entity; signs and symptoms include pain, hematuria, and shock. Spontaneous retroperitoneal hemorrhage ...Missing: definition | Show results with:definition<|control11|><|separator|>
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Valentino's Syndrome (with Retroperitoneal Ulcer Perforation)
Less often, ulcers can cause severe symptoms such as melena and hematemesis [7]. Perforation of these ulcers is considered a surgical emergency with ...
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Grey Turner's and Cullen's signs induced by spontaneous ... - NIH
Grey Turner's and Cullen's signs generally suggest a large retroperitoneal hematoma, such as hemorrhagic pancreatitis.Case Report · Fig. 2. Cullen's Sign Around... · Discussion
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Compressive femoral neuropathy caused by anticoagulant therapy ...
Retroperitoneal hematomas can cause severe pain in the groin, quadriceps femoris muscle weakness, hemodynamic instability, and abdominal distension.
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Femoral neuropathy following retroperitoneal hemorrhage - PubMed
We present a series of four cases of femoral nerve palsy due to retroperitoneal hematoma managed by surgical decompression.
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Retroperitoneal haemorrhage • LITFL • CCC Trauma
Nov 3, 2020 · Retroperitoneal haemorrhage is bleeding into the retroperitoneal space, either occurring spontaneously or secondary to an injury or illness.
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Retroperitoneal Hemorrhage - an overview | ScienceDirect Topics
Retroperitoneal hemorrhage is a result of a poor access technique that fails to identify the CFA, causing unsafe cannulation and sheath insertion.
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Rhabdomyolysis - StatPearls - NCBI Bookshelf - NIH
Rhabdomyolysis may be associated with dark reddish-colored urine due to myoglobinuria. Clinically, rhabdomyolysis can range from mild elevation in creatinine ...Missing: retroperitoneal | Show results with:retroperitoneal
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https://pmc.ncbi.nlm.nih.gov/articles/PMC9972597/
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Chronic expanding hematoma in the retroperitoneal space: a case ...
Nov 18, 2013 · Although MRI is inferior to CT in identifying calcification or spatial resolution, MRI is more sensitive than CT in the diagnosis of hematomas.
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Feb 28, 2023 · Spontaneous retroperitoneal hematoma is defined as bleeding in the retroperitoneal space without any triggers such as trauma, invasive procedures, and ...
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[PDF] Damage Control Resuscitation, 29 Aug 2023 - Joint Trauma System
Aug 29, 2023 · Instead, current ATLS recommendations for bleeding patients are for early administration of blood products, including plasma and platelets, ...
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Hemorrhagic Shock - StatPearls - NCBI Bookshelf
The aim is to achieve a systolic blood pressure of 90 mmHg in order to maintain tissue perfusion without inducing re-bleeding from recently clotted vessels.
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Spontaneous retroperitoneal hematoma induced by vitamin K ...
Spontaneous retroperitoneal hematoma is one of the rare complications of anticoagulation therapy, which needs to be recognized early and managed promptly.
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Initial management of trauma in adults - UpToDate
May 8, 2025 · Life-threatening hemorrhage must be controlled. A combination of manual pressure, proximal compression with either a tourniquet or a manual ...
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Jan 31, 2023 · This study showed that conservative management of SRH may be effective in most patients, even in those who are haemodynamically unstable but ...
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Angiographic Embolization for Intraperitoneal and Retroperitoneal ...
AE is a safe and effective method for controlling bleeding after blunt and penetrating intra- and retroperitoneal injuries.
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Spontaneous retroperitoneal hematoma treated with transarterial ...
May 25, 2024 · Meta-analysis of pooled proportions showed an overall 56.7% of males (95% CI, 21.29–86.12; I2 66.95%). The mean age across the included studies ...
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Massive retroperitoneal hematoma as an acute complication of ... - NIH
We here describe our experience with a patient who developed a huge periureteral hematoma after RIRS with holmium laser lithotripsy.
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Spontaneous retroperitoneal hematoma: a case report
Feb 28, 2023 · Spontaneous retroperitoneal hematoma is defined as bleeding in the retroperitoneal space without any triggers such as trauma, invasive procedures, and ...Abstract · Discussion And Conclusions · Author Information
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Retroperitoneal packing as part of damage control surgery in a ...
Retroperitoneal packing is a very simple and potentially lifesaving procedure, all surgeons who receive trauma patients should be able to perform it correctly ...
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Feasibility and Safety of Endovascular Aneurysm Repair (EVAR) in ...
Oct 29, 2024 · Background: Endovascular aneurysm repair (EVAR) represents a pivotal advancement in the treatment of abdominal aortic aneurysm (AAA).
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Artificial Intelligence for Identification of Images with Active Bleeding ...
Mar 26, 2024 · In this study, we explored the application of AI in mesenteric and celiac artery angiography for detecting active bleeding. The results of ...
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Retroperitoneal hematoma compressing a single functioning kidney
Retroperitoneal hematoma resulted in shock, progressive anemia and obstructive renal failure, related to renal pelvic compression.
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Disseminated Intravascular Coagulation (DIC) - Merck Manuals
Patients with hemophilia bleed into tissues (eg, hemarthroses, muscle hematomas, retroperitoneal hemorrhage). The bleeding can be immediate or occur slowly ...
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[PDF] Retroperitoneal Hematoma - Children's Mercy Kansas City
Jun 2, 2020 · Retroperitoneal hematoma is defined as bleeding into the retroperitoneal space. This clinical entity is often occult and.
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Delayed presentation of shock due to retroperitoneal hemorrhage ...
Hematoma and bleeding in the retroperitoneal space are observed in 44% of patients with blunt abdominal trauma. Injuries missed during the in-hospital ...Missing: percentage | Show results with:percentage
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Retroperitoneal Hemorrhage After Percutaneous Coronary ...
Feb 14, 2018 · Retroperitoneal hemorrhage (RH) is a rare bleeding complication of percutaneous coronary intervention, which can result as a consequence of femoral access or ...
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Spontaneous Retroperitoneal and Rectus Sheath Hemorrhage ...
Although overall mortality was 22%, spontaneous retroperitoneal and rectus sheath hematoma-related mortality was 6%. ... Age >70 years and systolic blood ...
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Life expectancy and causes of death after repair of intact and ...
Five-year survival expectancy was 65% for intact AAA and 41% for ruptured AAA (P < .001). Cardiovascular deaths unrelated to the AAA occurred in 35% and cancer- ...