Retroperitoneal Hematoma Research Articles

Contained Uterine Rupture Managed Conservatively after Vaginal Delivery

Background Uterine rupture in an otherwise unscarred uterus is a rare event, with most sources describing it on the order of 1/5700 to 1/20,000 deliveries [1]. Risk factors include high multiparity, use of uterotonics, advanced maternal age, macrosomia, malpresentation, placental invasion, and prolonged labor [2-3]. Historically, management of this complication involves exploratory laparotomy with surgical repair or hysterectomy. Few reports have been published that describe conservative management in the setting of uterine rupture. Objective(s) To describe the conservative management of contained uterine rupture. Study Design Case report Case Summary A 39-year-old gravida 5, para 4 with history of pre-eclampsia was admitted for induction of labor at 40 weeks 0 days. Her intrapartum labor was complicated by pre-eclampsia with severe features. She had a vaginal delivery after 20 hours of induction without immediate complications. Following delivery, the patient complained of severe right lower quadrant pain, which was treated with escalating pain regimen, but continued to worsen. A CT scan was obtained, which revealed a right retroperitoneal hematoma with findings suspicious for uterine rupture. The patient was taken to the operating room for exploratory laparotomy with findings of a right-sided broad ligament hematoma measuring 15 cm by 6 cm, extending into the retroperitoneal space. The surgery ended without additional procedures since the patient was hemodynamically stable, and the hematoma was non-expanding. Postoperatively, she was started on a multimodal pain regimen, and eventually discharged on postoperative day 3 after pain improved. Conclusion We describe a contained uterine rupture noted in the immediate postpartum period after an uncomplicated vaginal delivery. Our patient had several risk factors for uterine rupture such as advanced maternal aged, high multiparity, and macrosomia. Surgical exploration noted a large non-expanding hematoma overlying the site of suspected uterine rupture, which was stable. In an otherwise hemodynamically stable patient with contained uterine rupture, conservative management is a reasonable option.

Clinical data analysis of 117 patients with ruptured abdominal aortic aneurysm

Objective: To examine the perioperative clinical features and prognosis of patients with ruptured abdominal aortic aneurysms (rAAA) who received surgical repair. Methods: The clinical data of rAAA patients who underwent surgical repair and were admitted to the Surgical Intensive Care Unit of Beijing Anzhen Hospital, Capital Medical University from August 2005 to November 2020 were retrospectively analyzed, including the general clinical features, surgical mode, intraoperative conditions, postoperative complications, and fatality rate. Results: There were 117 patients with rAAA, with a median age of 68 (62,77) years, including 93 men (79.5%) and 24 women (20.5%). The main clinical manifestation was abdominal pain (n=115, 98.3%). Among them, 65 (55.6%) patients underwent endovascular aneurysm repair (EVAR), while 52 (44.4%) underwent open surgical repair (OSR). The common postoperative complications include acute gastrointestinal dysfunction (n=116, 99.1%), shock (n=89, 76.1%), acute respiratory distress syndrome (n=85, 72.6%), pancreatic injury (n=56, 47.9%), coagulation dysfunction (n=55, 47.0%), disseminated intravascular coagulation (n=46, 39.3%), acute kidney injury (n=39, 33.3%), infection/sepsis (n=28, 23.9%), gastrointestinal bleeding (n=17, 14.5%), and abdominal compartment syndrome (n=12, 10.3%). The overall postoperative in-hospital fatality rate was 10.3% (12/117). Preoperative use of vasopressors and inotropes, retroperitoneal hematoma, and postoperative abdominal compartment syndrome, gastrointestinal hemorrhage, acute kidney injury, and diffuse intravascular coagulation significantly increased the fatality rate [5/11, 6/24, 5/16, 6/12, 6/17, 23.1%(9/39), 19.6%(9/46), respectively]. Conclusion: The postoperative mortality of rAAA patients is still high in the era of EVAR, especially in patients with preoperative existence of shock and retroperitoneal hematoma, and with postoperative abdominal compartment syndrome, coagulation dysfunction, and acute kidney injury. It is necessary to strengthen perioperative monitoring and management of these patients to reduce the fatality rate.

Natural history of renal angiomyolipoma in a high-volume center: our experience during more than 15years of follow up.

To describe the natural history of AML, the clinical results and the need for treatment during long-term follow-up of renal AML. Retrospective study of patients diagnosed with AML by computed tomography or nuclear magnetic resonance between 2001 and 2019, with at least two follow-up images. Clinical and imaging variables, need for intervention, complications and follow-up time were recorded. Statistical analysis was performed using SPSS 22.0. 111 patients and 145 AML were included. The median follow-up was 6.17years (range 0.7-18.1, IQR 11.8-12.2). The median tumor size at diagnosis was 13mm (IQR 7.5-30), with 24 (16.4%) being ≥ 4cm. Most presented as an incidental finding (85.5%); in 3 (2.1%) cases, the presentation was as a spontaneous retroperitoneal hematoma. The main indication for intervention was size ≥ 4cm in 50%. Eighteen (12%) patients received a first intervention, being urgent in 3. Embolization was performed in 15 cases and partial nephrectomy in 3. The need for reintervention was recorded in five: two underwent partial nephrectomy and two total nephrectomy; one patient required a new urgent embolization. Of the non-operated patients, 43% decreased in size or did not change, while 57% increased, with the median annual growth being 0.13mm (IQR -0.11 to 0.73). There were no differences in the median growth in tumors measuring ≥ 4cm (0.16mm) at diagnosis vs. < 4cm (0.13mm) (p = 0.9). The findings of this study suggest that AML typically demonstrate a slow-progressing clinical course during long-term follow-up. Moreover, our observations, which cast doubt on tumor size as a reliable predictor of adverse clinical outcomes, advocate for a less intensive monitoring strategy in both monitoring frequency and choice of imaging modality.

Massive retroperitoneal hematoma caused by intercostal artery bleeding after blunt trauma: a case report

BackgroundThe occurrence of massive retroperitoneal hematoma caused by intercostal artery bleeding is exceedingly uncommon.Case presentationA middle-aged male presented to the hospital after a fall. Computed tomography scan revealed a massive retroperitoneal hematoma without any evidence of organ or major vessel rupture. The angiogram revealed extravasation from a branch of the twelfth intercostal artery, and successful transcatheter arterial embolization was performed on this specific artery.ConclusionsThe possibility of intercostal artery rupture should be considered in cases of retroperitoneal hematomas, and accurate diagnosis can be achieved through imaging studies. Transcatheter arterial embolization represents an effective treatment modality.

Staged repair of a ruptured thoracoabdominal aortic aneurysm: a case report

BackgroundA ruptured thoracoabdominal aortic aneurysm (rTAAA) represents a considerable challenge for surgeons. To date, endovascular procedures have not been able to completely replace open repair when debranching is required.Case presentationA 73-year-old man was admitted to our hospital after complaining of left lateral abdominal pain. Enhanced computed tomography revealed a left retroperitoneal hematoma and a large, ruptured Crawford type IV TAAA. We first performed emergency resuscitative surgery to close the lacerated foramen. A graft replacement was performed 1 month after the initial surgery when the patient had stabilized. At 5 years postoperatively, neither occlusion nor anastomotic pseudoaneurysm was noted on computed tomography.ConclusionsWe provide an update on the perioperative management of patients undergoing open rTAAA repair. This procedure can be considered to ensure complete repair of an rTAAA.

Outcomes and Predictors of Delayed Intervention After Renal Trauma.

Historically, a zone II hematoma mandated exploration after penetrating trauma, but this has been challenged given potentially higher nephrectomy rates and the advent of therapeutic endovascular and endoscopic interventions. We hypothesized penetrating mechanism was not a predictor for delayed intervention in the modern era. This single-center, retrospective study included renal trauma patients from 3/2019 to 6/2022. Our institutional practice is selective exploration of zone II hematomas for active bleeding and expanding hematoma only, regardless of mechanism. Descriptive statistics and multivariable logistic regression (MLR) were performed. One-hundred and forty-four patients were identified, with median age 32 years (IQR:23,49), 66% blunt mechanism, and injury severity score 17(IQR:11,26). Forty-three (30%) required operative intervention, and of the 20 that had a zone II exploration, 3 (15%) underwent renorrhaphy and 17 (85%) underwent nephrectomy. Penetrating patients more frequently underwent immediate operative intervention (67%vs10%,P < .0001), required nephrectomy (27%vs5%,P = .0003), and were less likely to undergo pre-intervention CT (51%vs96%,P < .0001) compared to blunt patients. Delayed renal interventions were higher in penetrating (33%vs13%,P = .004) with no difference in mortality or length of stay compared to blunt mechanism. Ureteral stent placement and renal embolization were the most common delayed interventions. On MLR, the only independent predictor for delayed intervention was need for initial operative intervention (OR 3.803;95%CI:1.612-8.975,P = .0023). Four (3%) required delayed nephrectomy, of which only one underwent initial operative intervention without zone 2 exploration. The most common delayed interventions after renal trauma were renal embolization and ureteral stent. Penetrating mechanism was not a predictor of delayed renal intervention in a trauma center that manages zone II retroperitoneal hematomas similarly regardless of mechanism.

Multiple Cerebral Infarctions after Treatment of Acquired Factor XIII Deficiency with Retroperitoneal Hematoma.

Multiple Cerebral Infarctions after Treatment of Acquired Factor XIII Deficiency with Retroperitoneal Hematoma.

A prospective randomized trial was conducted to evaluate the complication rate and patient comfort using three different vascular closure strategies following coronary angiography

Background: The use of vascular closure devices is now common in clinical practice for femoral artery puncture, although manual compression remains the current gold standard. The development and use of vascular closure devices are aimed at improving patient comfort and avoiding complications such as hematoma, pseudoaneurysm formation, and the need for blood transfusion in the event of significant bleeding or surgical revision at the puncture site. Aims: The aim of this study is to evaluate the complication rate after femoral arterial puncture using different closure techniques. Furthermore, patient comfort will also be measured. Material and Methods: In this prospective, two-centre study, 142 patients were randomized into three groups: the Vascular Closure Device (VCD, Cordis), manual compression (MC) and External Compression Device (ECD, Maquet). The primary endpoint is combined with the evaluation of hematoma greater than 5 cm, pseudoaneurysm formation, the need for blood transfusion or relevant bleeding with a hemoglobin drop greater than 2 g/dl, the occurrence of retroperitoneal hematoma, pressure ulcers greater than grade 2, ischemia of the ipsilateral limb, or nerve damage. Follow-up visits are scheduled at 24 hours, 7 days, and 30 days. Results: The ratio of gender and pre-existing conditions within the randomized groups is almost equal. Medication before coronary angiography is comparable. Significantly more interventions are performed in the VCD group. Correspondingly, the procedure time is longer, and dual antiplatelet therapy is prescribed more often. Compression time and time to first hemostasis were significantly longer in the VCD group. The number of rebleeds after primary hemostasis is significantly higher in the ECD group. None of the enrolled patients suffered major bleeding or required a blood transfusion. No retroperitoneal hematoma was observed. Overall, there is one AV fistula in the MC group, two pseudoaneurysms in the VCD group, and one pseudoaneurysm in the ECD group. Pain was reported at significantly higher rates in the MC group than in either device group. The highest level of pain is reported within 48 hours in the MC group, and voiding dysfunction is significantly more frequent in the MC group. The same results are observed for sleep quality. Patients in the MC group reported significantly fewer hematomas greater than 5 cm at 7 days compared to patients who received a VCD. Conclusion: Our results show no significant difference in the achievement of the combined primary endpoint of all three groups. However, the rate of rebleeding after primary hemostasis is significantly lower in the VCD group, even with prolonged procedure time. There was no difference in the incidence of MACCE. Patient pain and voiding dysfunction within 24 hours are highest in the MC group. No difference is reported between 7 and 30 days.

Prevention of Perioperative Bleeding in Patients With Chronic Limb-Threatening Ischemia

Materials and methods: At stage I, we retrospectively studied histories and outpatient medical records of 766 patients with chronic limb-threatening ischemia (from 2006 to 2020) to identify hemorrhagic complications and potential risk factors for their development. We analyzed the effectiveness of different scores for assessment of the bleeding risk. Based on the obtained data, measures to prevent hemorrhagic complications in this cohort of patients were improved. During stage II, 114 patients with 1 or several risk factors for major bleeding underwent surgery between 2021 and 2023. We used the proposed and improved preventive measures for all the patients. Follow-up periods were during the hospital stay and in 6 and 12 months.Results: At stage I, 44 (5.74%) patients were found to have hemorrhagic complications in the early postoperative period: retroperitoneal hematoma, bleeding from an operating wound, and pulsating hematoma (15.9%); gastrointestinal hemorrhage (31.8%); gross hematuria (13.7%), and hemorrhagic stroke (6.8%). The most significant risk factors for bleeding were endovascular intervention using brachial and femoral approaches (P = .000), hybrid intervention (P = .000), dual antiplatelet therapy (P = .014), surgery duration above 60 minutes (P = .001), triple antithrombotic therapy (P = .001), and significant vascular calcification (P = .023). The PRECISE-DAPT score has proven to be of prognostic value (P = .073; odds ratio, 2.88). At stage II, due to the proposed preventive measures, bleeding that required blood transfusion was found in 5 (4.38%) of 114 patients: of them, 1 (0.9%) patient had acute coronary syndrome. There were no major amputations, whereas 3 (2.63%) patients underwent minor amputation. In 6 and 12 months of the follow-up, the total frequency of major cardiovascular complications (cardiac death, myocardial infarction), major and minor amputation was 0.9% and 2.6%, 0% and 1.75%, and 0.9% and 2.6%, respectively.Conclusions: Surgical treatment of patients with chronic limb-threatening ischemia and risk factors for hemorrhagic complications who underwent surgery with the proposed preventive measures demonstrated high efficiency in reducing the number of hemorrhages and associated cardiac complications and low frequency of major and minor amputations in the long-term follow-up.

Effect of lipiodol marking before CT-guided cryoablation on the outcome of sporadic renal cell carcinoma.

This retrospective study evaluates the impact of preoperative lipiodol marking on the outcomes of computed tomography (CT)-guided cryoablation for histologically diagnosed sporadic renal cell carcinoma (RCC). This study analyzed the data of 173 patients who underwent CT-guided cryoablation for histologically proven sporadic RCC at a single institution between April 2014 and December 2020. The local control rate (LCR), recurrence-free survival rate (RFSR), overall survival rate (OSR), changes in renal function, and complications in patients with (n = 85) and without (n = 88) preoperative lipiodol marking were compared. The 5-year LCR and 5-year RFSR were significantly higher in patients with lipiodol marking (97.51% and 93.84%, respectively) than in those without (72.38% and 68.10%, respectively) (P value <0.01, log-rank test). There were no significant differences between the two groups regarding the 5-year OSR (97.50% vs. 86.82%) or the deterioration in chronic kidney disease stage (12.70% vs. 16.43%). Grade ≥3 complications occurred in patients with lipiodol marking (n = 2, retroperitoneal hematoma and cerebral infarction in 1 patient each) and without (n = 5; urinary fistula in 2, colonic perforation in 2, urinary infection in 1). Lipiodol marking before CT-guided cryoablation for sporadic RCC is a feasible approach to improving local control and RFS while mitigating the decline in renal function. Additionally, it may help reduce complications.

Case of spontaneous hematoma of the renal compartment resulting in hemorrhagic shock: A unique presentation in urology

Hemorrhagic shock from spontaneous retroperitoneal hematoma of renal origin is a rare condition, and there are few publications on this subject. We present the case of a 60-year-old obese patient who experienced hemorrhagic shock from a right renal subcapsular hematoma that had ruptured into the retroperitoneum after initiation of anticoagulant treatment for acute pulmonary edema in the context of recurrent paroxysmal atrial fibrillation. The CT scan revealed a retroperitoneal hematoma and a possible hemorrhagic cyst in the right kidney. An emergency nephrectomy was necessary for hemostasis. The histology of the nephrectomy specimen confirmed the diagnosis of renal cell carcinoma.

A case of massive retroperitoneal hematoma secondary to hernia repair and review of the literature

Retroperitoneal hematomas are very rare and possibly fatal complications of hernia surgery. In this study, we report the case of a 24-year-old patient who developed a massive left preperitoneal and retroperitoneal hematoma following vessel injury during Shouldice hernia repair. Despite a packing during haemostasis surgery and being well resuscitated, the patient died in haemorrhagic shock. This case highlights the importance of early detection of signs of postoperative bleeding in the outcome of patients undergoing hernia repair.

Safety and Diagnostic Efficacy of Image-Guided Biopsy of Small Renal Masses.

Image-guided renal mass biopsy is gaining increased diagnostic acceptance, but there are limited data concerning the safety and diagnostic yield of biopsy for small renal masses (≤4 cm). This study evaluated the safety, diagnostic yield, and management after image-guided percutaneous biopsy for small renal masses. A retrospective IRB-approved study was conducted on patients who underwent renal mass biopsy for histopathologic diagnosis at a single center from 2015 to 2021. Patients with a prior history of malignancy or a renal mass >4 cm were excluded. Descriptive statistics were used to summarize patient demographics, tumor size, the imaging modality used for biopsy, procedure details, complications, pathological diagnosis, and post-biopsy management. A biopsy was considered successful when the specimen was sufficient for diagnosis without need for a repeat biopsy. Complications were graded according to the SIR classification of adverse events. A chi-squared test (significance level set at p ≤ 0.05) was used to compare the success rate of biopsies in different lesion size groups. A total of 167 patients met the inclusion criteria. The median age was 65 years (range: 26-87) and 51% were male. The median renal mass size was 2.6 cm (range: one-four). Ultrasound was solely employed in 60% of procedures, CT in 33%, a combination of US/CT in 6%, and MRI in one case. With on-site cytopathology, the median number of specimens obtained per procedure was four (range: one-nine). The overall complication rate was 5%. Grade A complications were seen in 4% (n = 7), consisting of perinephric hematoma (n = 6) and retroperitoneal hematoma (n = 1). There was one grade B complication (0.5%; pain) and one grade D complication (0.5%; pyelonephritis). There was no patient mortality within 30 days post-biopsy. Biopsy was successful in 88% of cases. A sub-group analysis showed a success rate of 85% in tumors <3 cm and 93% in tumors ≥3 cm (p = 0.01). Pathological diagnoses included renal cell carcinoma (65%), oncocytoma (18%), clear cell papillary renal cell tumors (9%), angiomyolipoma (4%), xanthogranulomatous pyelonephritis (1%), lymphoma (1%), high-grade papillary urothelial carcinoma (1%), and metanephric adenoma (1%), revealing benign diagnosis in 30% of cases. The most common treatment was surgery (40%), followed by percutaneous cryoablation (22%). In total, 37% of patients were managed conservatively, and one patient received chemotherapy. This study demonstrates the safety and diagnostic efficacy of image-guided biopsy of small renal masses. The diagnostic yield was significantly higher for masses 3-4 cm in size compared to those <3 cm. The biopsy results showed a high percentage of benign diagnoses and informed treatment decisions in most patients.

Retroplacental hematoma: A case report

Background: Retroperitoneal hematomas during pregnancy arising from ovarian vessels are rare. Thiscondition is usually associated with hemorrhagic shock and can lead to serious maternal-fetal morbidityor mortality. Carrying a pregnancy to term when the condition is diagnosed in early pregnancy istherefore not guaranteed.Case presentation: A 39-year-old para 4+1 presented at 26 weeks of gestation with a 2-day history ofright lower abdominal pain after a fall on her farm two weeks before admission. She was anemic, andabdominal ultrasound revealed a hypoechoic mass in the right lower quadrant of the abdomen, which,upon explorative laparotomy, turned out to be a large nonexpanding zone III retroperitoneal hematoma.Conservative management without opening the hematoma was performed, and she was serially imagedto assess the etiology and to rule out any further bleeding. The patient carried the pregnancy to term anddelivered vaginally. Postpartum exploration of the abdomen during tubal ligation revealed resolution ofthe hematoma.Discussion: Retroperitoneal hematomas can occur spontaneously or can be caused by blunt orpenetrating trauma. Patients mostly present with abdominal pain, hypovolemia, or anemia. Fordescriptive purposes, the retroperitoneum is divided into three zones: central, perirenal, and pelvic. Forspontaneous or blunt trauma hematomas in the pelvic zone, conservative management without openingthe hematoma is advised.Conclusion: Retroperitoneal hematoma should be a differential diagnosis in a patient presenting with anacute abdomen during pregnancy. Although associated with morbidity and mortality during pregnancy,patients with this condition can still carry their pregnancy to term and deliver normally.

Aortobifemoral Bypass in Kidney Transplant Candidates: A Ten-Year Experience.

In patients with severe aorto-iliac calcifications, vascular reconstructions can be performed in order to allow kidney transplantation. The aim of this study was to analyze the outcomes of kidney transplant candidates who underwent an aortobifemoral bypass (ABFB) for aorto-iliac calcifications. A retrospective study including all kidney transplant candidates who underwent an ABFB between 2012 and 2022 was performed. Primary outcome was 30-day morbidity-mortality after ABFB. Secondary outcome was accessibility to kidney transplant waiting list. Twenty-two ABFBs were performed: 10 ABFBs in asymptomatic patients presenting severe aorto-iliac circumferential calcifications without hemodynamic consequences, and 12 ABFBs in symptomatic patients in whom aorto-iliac calcifications were responsible for claudication or critical limb threatening ischemia. Overall 30-day mortality was 0%. Overall 30-day morbidity was 22.7%: 1 femoral hematoma and 1 retroperitoneal hematoma requiring surgical drainage in the asymptomatic group, and 2 digestive ischemia requiring bowel resection and 1 femoral hematoma requiring surgical drainage in the symptomatic group. Among the 22 patients, 20 patients could access to kidney waiting list and 8 patients underwent a kidney transplantation, including 3 living-donor transplantations. Aorto-iliac revascularization can be an option to overcome severe calcifications contraindicating kidney transplantation.

Accuracy of FAST in detecting intraabdominal bleeding in major trauma with pelvic and/or acetabular fractures: a retrospective cohort study

PurposeThe Focused Assessment with Sonography for Trauma (FAST) is a tool to rapidly detect intraabdominal and intrapericardial fluid with point-of-care ultrasound. Previous studies have questioned the role of FAST in patients with pelvic fractures. The aim of the present study was to assess the accuracy of FAST to detect clinically significant intraabdominal hemorrhage in patients with pelvic fractures.MethodsWe included all consecutive patients with pelvic and/or acetabular fractures treated our Level 1 trauma center from 2009–2020. We registered patient and fracture characteristics, FAST investigations and CT descriptions, explorative laparotomy findings, and transfusion needs. We compared FAST to CT and laparotomy findings, and calculated true positive and negative findings, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).ResultsWe included 389 patients. FAST had a sensitivity of 75%, a specificity of 98%, a PPV of 84%, and a NPV of 96% for clinically significant intraabdominal bleeding. Patients with retroperitoneal hematomas were at increased risk for laparotomy both because of True-negative FAST and False-positive FAST.ConclusionFAST is accurate to identify clinically significant intraabdominal blood in patients with severe pelvic fractures and should be a standard asset in these patients. Retroperitoneal hematomas challenge the FAST interpretation and thus the decision making when applying FAST in patients with pelvic fractures.

Ruptura pankreasne pseudoaneurizme kao posledice hroničnog pankreatitisa - prikaz slučaja

Abstract: Introduction: Pseudoaneurysms of the pancreaticoduodenal arcade are rare, accounting for approximately 2% of all visceral artery aneurysms. They typically arise as complications of chronic pancreatitis, peptic ulcer disease, trauma, pancreatic and biliary surgery, or pancreas transplantation. Diagnosis often occurs only after rupture, leading to life-threatening internal bleeding. Bleeding may occur within a pseudocyst, with blood passing through the Vater's papilla into the digestive tract, or may result in the formation of a retroperitoneal hematoma that can rupture into the abdominal cavity, causing hemoperitoneum. The cell-saver is a tool that can be utilized for intraoperative blood cell salvage and autologous transfusions. Case Report: Our patient, a 54-year-old male, an untreated alcoholic with no prior medical history or documented treatment, presented to the Clinic for Emergency Surgery at the University Clinical Center of Serbia with a sudden onset of upper abdominal pain. A quick ultrasound of the abdomen was performed, followed by an urgent CT scan of the chest and abdomen, revealing a hematoma extending from the right retroperitoneum and mesentery of the intestine, measuring 150x109x180mm in diameter, with signs of active bleeding in the region beneath the pancreas, indicative of hemoperitoneum. Due to hemodynamic instability, accompanied by a drop in arterial blood pressure and hemoglobin levels, an urgent laparotomy was performed. Active bleeding was identified from a ruptured pseudoaneurysm originating from the pancreaticoduodenal arcade. Hemostasis was achieved followed by tamponade, and the tampons were removed 30 hours post-surgery. The patient remained hemodynamically stable thereafter, recovered well from the surgery, and was discharged home in good general condition. Intraoperatively, we utilized the Cell-saver to collect the patient's blood and subsequently administered autologous transfusion. Conclusion: In patients with chronic pancreatitis presenting with sudden abdominal pain and hemodynamic instability accompanied by a drop in arterial pressure, hemoglobin, and hematocrit levels, the possibility of a ruptured pseudoaneurysm in the pancreatic or peripancreatic region should be considered. Timely diagnosis and prompt surgical intervention are crucial for a successful outcome. Effective collaboration among radiologists, anesthesiologists, and surgeons is essential. The utilization of the Cell-saver system significantly aids in maintaining cardiac output and hemodynamic stability in these patients.

Acquired Hemophilia A Diagnosed Based on Gross Hematuria: A Case Report and Literature Review

Acquired hemophilia A (AHA) is an acquired bleeding disorder caused by neutralizing antibodies (inhibitors) against Coagulation Factor VIII (FVIII:C), causing sudden hemorrhagic symptoms (i.e., subcutaneous bleeding, intramuscular bleeding, and hematuria). Herein, this study is aimed at presenting a case of AHA diagnosed based on hematuria and reviewing patients who were diagnosed with AHA due to hematuria. A 67‐year‐old woman was referred to Atsugi City Hospital with painless gross hematuria that began 4 weeks before presentation. Contrast‐enhanced computed tomography (eCT) revealed an approximately 2 cm mass in the right renal pelvis, and the patient’s activated partial thromboplastin time (APTT) was elevated (61.4 s). The day after the endoscopic biopsy, the patient was in shock due to a large retroperitoneal hematoma. Although her condition stabilized after intravenous radioembolization, she underwent emergency surgeries several times because of rebleeding within the next 3 weeks. At that time, APTT was more prolonged at 106.4 s, and the FVIII:C level was 2%. Mixing tests showed an upwardly convex curve after 2‐h incubation, indicating the presence of an inhibitor. Factor VIII inhibitor titer was ≥5.1 Bethesda unit (BU)/mL. A combined product of Plasma‐Derived Factors VIIa and X (pd‐FVIIa/FX), as second‐line hemostatic therapy, as well as cyclophosphamide (CYP), were administered after Recombinant Activated Factor VIIa (rFVIIa) had been ineffective. Following this, the Factor VIII inhibitor titer was undetectable, FVIII:C levels were restored, and APTT decreased to within the normal range. Gross hematuria was significantly alleviated. However, the patient died of cytomegalovirus and fungal infections due to prolonged immunosuppressive therapy. Although AHA diagnosed based on hematuria may have a better prognosis than others, there have been occasional cases with severe outcomes. APTT, detected upon initial hematological testing in patients with hematuria, may be a potential indicator of an existing AHA.

Ultrasound-guided percutaneous nephrostomy: Analysis of early complications in a prospective descriptive cross-sectional study at a tertiary care center

Background: Percutaneous nephrostomy (PCN) is a crucial intervention for urinary obstruction. Understanding indications, complications, and materials used enhances its clinical application. Objective: This study aims to identify PCN indications, assess tube types/materials, evaluate early complications, and determine PCN success rates, fostering improved outcomes and procedural refinement. Materials and Methods: This study was carried out in the interventional radiology suite of the Department of Radiodiagnosis and Imaging, Tribhuvan University Teaching Hospital (TUTH) on 74 patients for one year. Patients of all age groups who underwent PCN were included in the study. Indications for PCN were identified before the procedure using various imaging modalities like Ultrasonography (USG), Computed Tomography (CT) scan, and more. The type of approach, calyx punctured, the size of the tube chosen, and the type of the drain material were all recorded during the procedure or in the post-procedure note. The patients were evaluated daily, and USG was done in every patient after 48 hours of the procedure to evaluate in terms of any complications. Results: Ninety-eight PCNs were done on 74 patients, of whom 58 were males and 40 were females. The main reasons for PCN were calculus disease with hydronephrosis (44.9%), calculus disease with pyonephrosis (22.4%), and obstructive uropathy due to bladder or cervix carcinoma. The success rate for PCN on the first attempt was 89.8%, while 6.1% required two attempts and 4.1% needed more than two attempts. Complications included tube dislodgement (8.2%), urinoma (5.1%), major bleeding (3%), and retroperitoneal hematoma (1%). No new cases of sepsis occurred post-procedure. Conclusion: Percutaneous nephrostomy is a safe and simple procedure with low morbidity and no life-threatening complications.

Spontaneous hematomas in COVID-19 patients. Literature review

A brief literature review presents the main classifications, clinical manifestations and methods of diagnosis of spontaneous retroperitoneal and rectus sheath hematomas in patients with COVID-19. The direct and indirect ultrasound criteria, stages of resolution and treatment strategy of the spontaneous hematomas are discussed