بسم الله الرحمن الرحيم و نَحن أقربُ إليه مِن حَبل الوريد

بسم الله الرحمن الرحيم

نَحن أقرُب إليه ِمن َحبل الوريدو

Spontaneous Retroperitoneal Hemorrhage

by : Fereshteh SalimiDepartment of General & Vascular Surgery

Azar of 1392

e-mail: [email protected]

The retroperitoneum is defined as the space between the posterior envelopment of the peritoneum and the posterior body wall .

It is bounded superiorly by the diaphragm , posteriorly by the spinal column and iliopsoas muscle and inferiorly by the levator ani muscles.

The anterior border is quite convoluted , extending into the spaces in between the mesenteries of the small and large intestines.

Surgical Anatomy

Retroperitoneal Structures

Kidneys Ureters Bladde r Pancreas Duodenum (D2 and

D3) Adrenal gland Ascending colon Descending colon Rectum (upper two

thirds)

Aorta Inferior vena cava Iliac vessel Seminal vesicles Vas deferens Lymphatics (cysterna

chyli) Vagina (upper most) Ovaries Nerves (lumbar

sympathetics)

Retroperitoneal space are classified on an anatomic basis:

zone 1 is the central area, bounded laterally by the kidneys and extending from the diaphragmatic hiatus to the bifurcation of the vena cava and the aorta

zone 2 comprises the lateral area of the retroperitoneum, from the kidneys laterally to the paracolic gutters

zone 3 is the pelvic portion

Retroperitoneal space

Retroperitoneal Regions

Retroperitoneal regions

The location of a retroperitoneal

hematoma and mechanism of injury guide the decision to explore the hematoma.

The retroperitoneum is divided into three anatomic zones: the midline retroperitoneum (zone

1) the perinephric space (zone 2) the pelvic retroperitoneum (zone 3)

Retroperitoneal Hematoma

Any hematoma in zone 1 mandates exploration for both penetrating and blunt injury because of the high likelihood and unforgiving nature of major vascular injury in this area.

The transverse mesocolon is the dividing line between the supramesocolic and inframesocolic compartments.

A central supramesocolic hematoma presents behind the lesser omentum, pushing the stomach forward

Inframesocolic hematoma develops behind the root of the small bowel mesentery, pushing it forward in a configuration similar to that of a ruptured abdominal aortic aneurysm

Retroperitoneal Hematoma

A hematoma in zone 2 is the result of injury to the renal vessels or parenchyma and mandates exploration for penetrating trauma to assess the damage and repair the injuries.

A nonexpanding stable hematoma resulting from a blunt trauma mechanism is better left unexplored because opening Gerota's fascia is very likely to result in further damage to the traumatized renal parenchyma and subsequent loss of the kidney.

In the severely injured patient with a stable hematoma from a penetrating injury, it is advisable not to explore the injured kidney because the patient may not have the physiologic reserves to tolerate an elaborate and time-consuming repair.

Retroperitoneal Regions

A pelvic retroperitoneal hematoma (zone 3) secondary to penetrating trauma mandates exploration because of the likelihood of iliac vessel injury.

zone 3 hematomas resulting from blunt trauma are usually associated with pelvic fractures and are not explored because the effective management of this type of bleeding is based not on operative control but on external fixation or angiographic embolization of the bleeding vessels.

The only exception is a rapidly expanding hematoma in which the surgeon suspects a major iliac vascular injury that requires operative repair.

Retroperitoneal Regions

Precipitating factors: Anticoagulation Pre-existent benign adrenal cyst. Factor ix and x deficiency Von Willebrand disease Anti-phospholipid syndrome Patients on Clopidogril (plavix) Rupture of tumour (kidney) Rupture of aneurysm

Spontaneous Hemorrhage

Vague presentation , usually diagnosis is

delayed if clinician is unaware of this condition, hypotension , mild tachycardia which improves with IVF.

Back pain , lower abdominal pain , groin discomfort and swelling.

Collapse , fall in Hb Femoral neuropathy , causes groin pain , sever

pain in affected groin and hip. Radiation to anterior thigh and lumbar region.

Clinical presentation

Cullen Sign

Loss of psoas shadow U/S: retroperitoneal hematoma , free fluid

intraperitoneal in 16%. C.T Spiral is sensitive in diagnosis MRI: is very sensitive

Diagnostic Images

C.T

C.T

C.T

1. Conservative2. Endovascular3. Open surgery

Management

Admission to ICU Monitoring IVF Resuscitation Blood Transfusion Normalization of coagulation factors

Conservative

Selective intra-arterial embolization by coil,

gelatin or polyvinyl alcohol. It is indicated :

if > 4 units of blood is needed in 24 hrs or 6 units in 48 hrs

After lumbar sympathectomy injury After percutaneous nephrostomy After renal biopsy

Endovascular Treatment

Hemodynamics instability , in spite of fluid

resuscitation . Abdominal compartment syndrome due to

massive extension of hematoma. In this condition , laparostomy is done with

coverage of ant.abdomional wall defect by Bogota bag

Open surgery

Retroperitoneal

hematoma

Large RPH

Aortic Rupture

RPH w/Liver injury

Laparostomy

Spontaneous retroperitoneal hemorrhage is a

rare clinical entity which requires a high index of clinical suspicion. If treated inappropriately, retroperitoneal bleeding is associated with high morbidity and mortality. It should be suspected in elderly patients by anticoagulants or renal dialysis and those patients who have had an invasive procedure via the femoral artery or vein.

conclusion

Correction of underlying coagulopathy and

resuscitation with fluids and blood products is essential. Urgent high quality CT imaging is mandatory to document the type, site and extent of the hematoma.

Most patients with spontaneous or iatrogenic

retroperitoneal hematoma can be monitored closely and treated conservatively without further intervention. Emergency angiography with a view to embolise or stent-graft the bleeding vessel(s) is indicated if the CT examination shows active extravasation of contrast.

Surgery can have its place in very selective

cases, but removal of the hematoma may increase bleeding by removing the tamponade effect, and packing with large abdominal gauze may be the only surgical option, if no specific arterial bleed but general ooze can be identified per-operatively. Abdominal compartment syndrome may require decompression laparostomy.

A 28 years old woman, in 33 week of her first pregnancy, who was admitted to our department for severe right flank pain, detected in right hypochondrium, associated with nausea, vomiting, and irritative bladder symptoms.

Personal and familial histories were unremarkable. The patient was hemodynamically stable without

hematuria, lumbar pain or other urological symptoms. Physical examination revealed no specific findings, a good

general condition, an axillary temperature of 38°C, blood pressure of 120/75 mmHg and a heart rate of 78 bpm.

Abdominal palpation revealed no masses. The only pathological laboratory test parameter was the hemoglobin 8,7 g/dl and hematocrit of 25,5%, that required the transfusion of two red cell concentrate units.

Case Presentation

Abdominal ultrasound examination revealed a mass, with mixed echogenity, without acoustic shadowing well circumscribed, expanding at the upper pole of right kidney

The mass confirmed with MRI, measuring approximately 7 × 7 × 5 cm in size with evidence of recent extensive retroperitoneal bleeding, with right perirenal and intrarenal hematoma

After a couple of hours she was developed an episode of fetal bradycardia, hypotension, and a hematocrit continued to decline, despite repeated blood transfusion, which combined with symptoms of intense lumbar pain and hematuria.

Considering the hemodynamic instability of the patient, emergency cesarean delivery, under general anaesthesia, was undertaken, because of foetal distress.

Exploration of the retroperitoneal space after foetal extraction, confirmed the presence of a large haematoma and the renal mass., which occupied the intrarenal space

Right nephrectomy was performed, and the haemorrhaging contents was evacuated.

The histological study of the resected mass

revealed the presence of with admixture of mature adipose tissue, smooth muscle, and thick-walled blood vessels corrolated with Angiomyolipoma

Renal angiomyolipoma (AML) is a relatively infrequent

clinical entity observed in 0.3% of the general population and accounting for 3% of all solid renal masses.

AMLs are benign mesothelial tumors, with three histologic characteristics: mature adipose tissue, blood vessels, and smooth muscle cells.

Most of AMLs are asymptomatic and found incidentally on imaging examinations.

To the best of our knowledge, during the past 10 years only three cases of massive retroperitoneal hemorrhage, resulting from rupture of a renal angiomyolipoma during pregnancy have occurred.

Angiomyolipoma

The majority of this kind of tumor, are often

solitary, the mean age of presentation is 43 years, 4 times more common in men and, interestingly, involve the right kidney

Palpable abdominal mass, hematuria or flank pain are the main symptoms, and acute abdominal or even shock are the results of spontaneous rupture of the tumor

The management of AML is widely discussed in the literature. Asymptomatic tumors smaller than 4 cm in size should be

subjected to periodic ultrasound and CT controls every 6 months .

Symptomatic, bilateral lesions should be treated with selective arterial embolization or partial nephrectomy.

Radical nephrectomy is required when the patient is hemodynamic unstable, due to retroperitoneal hemorrhage

In our patient, the life threatening hemodynamic profile, in combination with fetal pulse abnormality, required emergency caesarian section and at the same time control of retroperitoneum bleeding, with radical right nephrectomy

In conclusion, it seems that these tumors

show a greater growth index in pregnant women and the question that may be raised is when is the appropriate time for surgical interference.

The second trimester of pregnancy seems to be ideal since the risk of fetal organogenetic abnormalities decreases, even though the need of individualization of each case is necessary

Retroperitoneal hemorrhage presenting as a ruptured

ectopic pregnancy. Department of Surgery, University of Colorado Health Sciences

Center, Denver.Abstract A young woman presented with acute abdominal pain, anemia,

and a positive pregnancy test. At surgery a large retroperitoneal hematoma secondary to a ruptured right kidney was found. Pathological examination revealed a hematogenic necrosis of a choriocarcinoma of the kidney. The patient tolerated subsequent chemotherapy with no evidence of recurrent disease after ten months of follow-up care. The diagnosis of choriocarcinoma must always be entertained when a patient presents with a positive pregnancy test and normal pelvic examination.

Spontaneous Retroperitoneal Hematoma: A Rare Devastating Clinical Entity of a Pleiada of Less

Common Origins

Department for Surgical treatment of End Stage Heart Failure and Mechanical Circulatory Support, Evangelisches and Johanniter Hospital Duisburg, Duisburg, Germany

Journal of Surgical Technique and Case Report Definition of Wunderlich syndrome, also known as spontaneous

retroperitoneal hemorrhage (SRH), was first given in 1700 by Bonet and was more completely explained by Wunderlich.

Although SRH is commonly associated with Lenk's triad (acute flank pain,symptoms of internal bleeding, and upper and lower quadrant abdominal tenderness to palpation – costovertebral angle tenderness),

The most common signs and symptoms described are abdominal pain (67%), hematuria (40%), and shock (26.5%).

It is frequently found in conjunction with hypertension (33–50%) and atherosclerosis (80–87%).

Tumors, particularly renal cell carcinoma and angiomyolipoma, are the most common cause of SRH, occurring in 57–73% of cases

Aneurysms of the visceral circulation as a cause are rare, accounting for 0.1–10.4% in autopsy statistics.

Spontaneous hemorrhage can be seen with inflammatory erosive processes which explain the association with necrotizing arteritis in polyarteritis nodosa and rheumatoid arthritisSpontaneous

SRH among patients receiving anticoagulation therapy has been well described and related to warfarin, low-molecular-weight heparin, unfractionated heparin, or even clopidogrel

Idiopathic retroperitoneal

hemorrhage/hematoma is a relatively uncommon condition with a large variability and nonspecific presentation in most of the cases, which may lead to shock and even death unless it is promptly recognized and treated appropriately

Prompt diagnosis and treatment may spare the patient surgical intervention and improve outcome.

هوالبصیر

اللهم انی اعتذرالیک من مظلوم ظلم بحضرتی فلم انصره

خداوندا عذر می خواهم درباره مظلومی که در حضور من او را یاری نکرده ومن مورد ستم واقع شده

باشم. 

۳۸صحیفه سجادیه- دعای