Massive Spontaneous Retroperitoneal Hematoma

Abstract

Purpose: A 75-year-old man with hypertension, diabetes, dementia and atrial fibrillation on warfarin presented to ER with history of a fall at home from bed. He lived at home by himself. Upon arrival to ER, physical examination was unremarkable except for blood pressure of 150/90 mm Hg and mild paraspinal tenderness on the left side. Lumbosacral spine x-ray did not demonstrate a fracture. Laboratory tests revealed baseline hemoglobin level of 11.5 gm/dL and INR of 2.0. Patient was admitted for further evaluation and arrangement of appropriate social services. On Day 2, he complained of severe left lower quadrant abdominal pain. Physical examination revealed severe left lower quadrant tenderness and a palpable mass. Hemoglobin decreased from 11.5 gm/dL to 7.0 gm/dL. CT scan of abdomen without contrast showed 15.1 cm × 14.7 cm size hematoma in the left lower quadrant in the retroperitoneal space (Figure 1). Patient was hemodynamically stable. He was transferred to the intensive care unit and was transfused three units of packed red blood cells. Hemoglobin remained stable at 10.0 gm/dL for subsequent three days. An aortogram showed no extravasation of contrast. Patient was discharged to home with home services and for out patient follow up. Retroperitoneal Hematoma (RH) is a possibility even with minimal trauma in elderly patients especially while on anti coagulation. Several case reports have described development of RH with use of enoxaparin and after cardiac catheterization via the femoral artery. Back pain is often the only complaint. Physical examination may demonstrate a palpable, tender mass, discoloration of the abdominal skin and voluntary guarding. Although the diagnosis has become easier with CT scans, the management still remains confusing. Generally, non-traumatic RHs without obvious active hemorrhage do not require surgical intervention. In contrast, most RHs after a penetrating trauma require a surgical exploration. Transcatheter embolotherapy has shown safe and effective results for emergency treatment for retroperitoneal bleeding in hemodynamically unstable patients.Figure 1: Retroperitoneal hematoma.