Spontaneous Retroperitoneal Hemorrhage Research Articles

Spontaneous retroperitoneal haemorrhage after pulmonary endarterectomy surgery

Spontaneous retroperitoneal hematoma (SRH) is a rare complication of anticoagulation therapy. Presentation may vary from limb paresis to hypovolemic shock due to blood loss. The optimal treatment is controversial. It can be managed conservatively or surgically. We report a case of a 73-year-old man presenting with progressively worsening abdominal pain and severe pain radiating to his left lower limb twenty-five days after his pulmonary endarterectomy (PEA) surgery. He was on anticoagulation per our institutional protocol for PEA patients. Investigations revealed a large, spontaneously occurring iliopsoas hematoma. Our patient was treated conservatively, and the SRH stabilised.

Life Threatening Retroperitoneal Haemorrhage in COVID-19 Patient -Surgical Treatment: A Case Report

Coronavirus disease (COVID-19) is an infectious disease caused by the SARS-CoV-2 virus that emerged in late 2019. The COVID-19 pandemic has affected millions of people worldwide, causing severe respiratory distress, multi-organ failure, and death. Nevertheless, there are records of unusual presentations of COVID-19, which includes hemorrhagic complications. Retroperitoneal hemorrhage (RPH) is a rare but life-threatening complication that can occur in COVID-19 patients. In this paper, we present a case of a life-threatening spontaneous retroperitoneal haemorrhage who has successfully undergone an exploratory laparotomy and made a full recovery. We would like to highlight the importance of close monitoring and prompt recognition in patients with increased risk of bleeding.

Laparoscopic resolution of Wünderlich syndrome as a primary treatment

Background: Spontaneous Retroperitoneal Hemorrhage, named Wünderlich Syndrome (WS) is usually managed by emergency surgeons with a conventional laparotomy. The aim is to report a patient with WS successfully treated by a laparoscopic approach avoiding open surgery. Methods: A 50-year-old female was diagnosed with WS hemodynamic instability and flank pain. After a normal CT scan that discarded visceral injuries and stabilized, the patient underwent a laparoscopic renal exploration. Results: Laparoscopic approach was as standard transperitoneal renal access. Fortunately, the hematoma was within Gerota fascia meaning a non-complex surgery. Due to the high R.E.N.A.L. score, it was necessary to complete a radical nephrectomy. Surgical time was 120 minutes without perioperative complications and the renal unit was retrieved using a Pfannenstiel incision. Estimate blood loss was not quantified. Finally, the hospital stay was 24 hrs. Conclusion: Laparoscopic approach could be performed in selected patients with WS especially when are hemodynamic stabilized with no visceral injury associated. Immediately treatment could facilitate the procedure because it avoids adherences or fibrosis due to hematoma. Experience in the laparoscopic approach is necessary.

Spontaneous Pancreatic Hemorrhage: Successful Conservative Management in Two Cases.

BACKGROUND Spontaneous pancreatic and peripancreatic hemorrhage (SPH) is a rare subtype of spontaneous retroperitoneal hemorrhage. With diverse clinical manifestations and no specific presentations, early diagnosis of SPH becomes challenging. Patient-specific underlying causes and vital signs guide the SPH treatment approach. CASE REPORT Case 1: A 39-year-old man reported unexplained hypogastralgia at the emergency department (ED). An abdominal MRI revealed a mixed hematoma and cystic lesions between the pancreatic head and descending duodenum, attributed to ruptured mucinous cystic neoplasms. Extensive hematoceles were identified around the liver and abdominal pelvis on an enhanced CT scan. After undergoing fasting, rehydration, proton pump inhibitor and somatostatin intravenous injections, and peritoneal puncture, his condition improved. He was discharged nine days post-admission. Case 2: A 44-year-old man arrived at the ED with back pain and right upper quadrant pain. Enhanced CT indicated peritoneal fluid and a hematoma between the pancreatic head and descending duodenum. He initially received conservative treatment. However, on the eighth day, he reported recurrent abdominal pain. Follow-up CT showed an enlarged hematoma and gastric content accumulation. The patient was fasted and put on parenteral nutrition, and by the 37th day of hospitalization, he had fully recovered and was discharged. Both patients, having stable hemodynamics, fully recovered following conservative management, with no surgical intervention required. CONCLUSIONS Given its varied clinical presentations, SPH can easily be misdiagnosed. However, successful conservative management can lead to full recovery, as demonstrated in these case reports.

Intraarterial embolizations in life-threatening spontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH): a three-center experience

PurposeTo retrospectively evaluate the technical and clinical success of interventional treatments employed in three University medical centers and to develop work-flow recommendations for intra-arterial embolizations in patients with life-threatening spontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH).Materials and methodsRetrospective evaluation of all patients with contrast-enhanced CT and digital subtraction angiography (DSA) for SRRSH from 01/2018 to 12/2022, amounted to 91 interventions in 83 patients (45f, 38m) with a mean age of 68.1 ± 13.2 years. Analysis of the amount of bleeding and embolized vessels, choice of embolization material, technical success, and 30-day mortality was performed.ResultsPre-interventional contrast-enhanced CT demonstrated active contrast extravasation in 79 cases (87%). DSA identified a mean of 1.4 ± 0.88 active bleeds in all but two interventions (98%), consisting of 60 cases with a singular and 39 cases of >1 bleeding artery, which were consecutively embolized. The majority of patients underwent embolization with either n-butyl-2-cyanoacrylate (NBCA; n=38), coils (n=21), or a combination of embolic agents (n=23). While the technical success rate was documented at 97.8%, 25 patients (30%) died within 30 days after the initial procedure, with mortality rates ranging from 25 to 86% between the centers, each following different diagnostic algorithms.ConclusionEmbolotherapy is a safe therapy option with high technical success rates in patients with life-threatening SRRSH. To maximize clinical success and survival rates, we propose a standardized approach to angiography as well as a low threshold for re-angiography.

Management of Spontaneous Retroperitoneal Haemorrhage Emphasises the Need for Nuanced Clinical Decision Making in Interventional Radiology

Management of Spontaneous Retroperitoneal Haemorrhage Emphasises the Need for Nuanced Clinical Decision Making in Interventional Radiology

Abstract No. 163 Patient Management Algorithms in Life-Threatening Spontaneous Retroperitoneal and Rectus Sheath Hemorrhage (SRRSH): Experiences from Three Centers

Abstract No. 163 Patient Management Algorithms in Life-Threatening Spontaneous Retroperitoneal and Rectus Sheath Hemorrhage (SRRSH): Experiences from Three Centers

Spontaneous Retroperitoneal Haemorrhage: Efficacy of Conservative Management and Embolisation

PurposeTo assess the efficacy of conservative management and embolisation in patients with spontaneous retroperitoneal haemorrhage.MethodsSingle-centre retrospective case–control study of patients with spontaneous retroperitoneal haemorrhage treated conservatively or with embolisation. Patients aged ≥ 18 years were identified from CT imaging reports stating a diagnosis of retroperitoneal haemorrhage or similar and images reviewed for confirmation. Exclusion criteria included recent trauma, surgery, retroperitoneal vascular line insertion, or other non-spontaneous aetiology.Datapoints analysed included treatment approach (conservative or embolisation), technical success, clinical success, and mortality outcome.ResultsA total of 54 patients met inclusion criteria, who were predominantly anticoagulated (74%), male (72%), older adults (mean age 69 years), with active haemorrhage on CT (52%). Overall mortality was 15%. Clinical success was more likely with conservative management (36/38) than embolisation (9/16; p < 0.01), and all-cause (1/38 vs 7/16; p < 0.01) and uncontrolled primary bleeding (1/38 vs 5/16; p < 0.01) mortality were higher with embolisation. However, embolised patients more commonly had active bleeding on CT (15/38 vs 13/16; p < 0.01), shock (5/38 vs 6/16; p < 0.04), and higher blood transfusion volumes (mean 2.2 vs 5.9 units; p < 0.01). After one-to-one propensity score matching, differences in clinical success (p = 0.04) and all-cause mortality (p = 0.01) remained; however, difference in uncontrolled primary bleeding mortality did not (p = 0.07).ConclusionConservative management of SRH is likely to be effective in most patients, even in those who are anticoagulated and haemodynamically unstable, with variable success seen after embolisation in a more unstable patient group, supporting the notion that resuscitation and optimisation of coagulation are the most vital components of treatment.

WUNDERLICH'S SYNDROME IN A PATIENT WITH ADVANCED TUBEROUS SCLEROSIS COMPLEX WITH LARGE ANGIOMYOLIPOMA

Wunderlich's syndrome, or spontaneous non-traumatic retroperitoneal hemorrhage, can be a life-threatening event. Renal angiomyolipoma is a rare benign tumor that can occur sporadically, or in association with tuberous sclerosis. A case of spontaneous retroperitoneal hemorrhage in a patient with tuberous sclerosis and renal angiomyolipoma is presented. Tuberous sclerosis complex is a rare symptom complex and may have varied presentations.We present a case of hypovolemic shock due to spontaneous rupture of large angiomyolipoma in a 24-year-old male patient with tuberous sclerosis complex (TSC).The hemodynamic instability of our patient leads to an urgent surgery and right nephrectomy was done for the angiomyolipomas. Spontaneous hemorrhage in renal angiomyolipoma in a case of tuberous sclerosis and management are discussed.

A Retroperitoneal Hematoma in an Anticoagulated Patient

Aim Spontaneous retroperitoneal haemorrhage (SRH), a potentially fatal complication with an atypical presentation, is caused by anticoagulants. The present body of literature does not offer much guidance for diagnosing and treating these situations. This case report’s major goal is to give a general review of the condition’s clinical presentation and anticoagulant therapy in relation to spontaneous retroperitoneal haemorrhage. Case report In this case report, we have covered an instance of retroperitoneal bleeding brought on by anticoagulants. Due to abdominal pain, a computed tomography (CT) scan of the abdomen was performed on the patient, who was using an anticoagulant, and it diagnosed a retroperitoneal hematoma. Conclusion Spontaneous retroperitoneal bleeding is an uncommon occurrence. When patients taking anticoagulant medications appear with stomach pain and distension, retroperitoneal haemorrhage should always be considered a possibility. With this presentation, this is one such instance. An early diagnosis will aid in the proper treatment of the patient.

Our strategy in a patient with spontaneous retroperitoneal hemorrhage and deep venous thrombosis of the left lower extremity

Our strategy in a patient with spontaneous retroperitoneal hemorrhage and deep venous thrombosis of the left lower extremity

A Rare Case of Anemia Caused by Retroperitoneal Hematoma

Introduction: Retroperitoneal hemorrhage has been reported with enoxaparin therapy. İn this article, spontaneous retroperitoneal hemorrhage developed in a patient using enoxaparin due to deep vein thrombosis is discussed. Case Report: A seventy-six-year-old male patient was admitted to the emergency department with the complaint of fatigue. On deeper introspection, our patient had, in the recent past, been used enoxaparin for deep vein thrombosis. In the physical examination was natural except subcutaneous minimal hematoma in the upper extremity bilateral enoxaparin area. İn laboratory tests, hemoglobin: 4.6 g / dl, urea: 158 mg / dl and creatinine were determined as 1.86 mg / dl. Abdominopelvic computed tomography imaging were performed and retroperitoneal hemorrhage reaching a depth of 4 cm adjacent to the right psoas muscle was detected. The patient, who did not develop additional complications after FFP and erythrocyte suspension replacement during the intensive care follow-ups and did not need surgical treatment, was discharged on the 17th day of his hospitalization in good health. Conclusion: When patients under enoxoparine treatment present with the complaint of fatigue, major bleeding may be seen when anemia is detected. One should be vigilant in terms of retroperitoneal bleeding as the bleeding focus in these patients.

Parenteral Anticoagulation and Retroperitoneal Hemorrhage in COVID-19: Case Report of Five Patients.

Since coronavirus disease 2019 (COVID-19) is associated with a hypercoagulable state, especially in critical patients, anticoagulation is used for thromboprophylaxis. Hemorrhagic complications, even uncommon ones such as retroperitoneal hemorrhage, can occur following anticoagulant administration. We present 5 patients with COVID-19 whose clinical course was complicated by spontaneous retroperitoneal hemorrhage. The patients were initially presented with respiratory manifestations of the infection. There was no history or evidence suggestive for traumatic injury. After hospitalization, the patients received supplemental oxygen, antibiotics, enoxaparin or heparin, interferon beta-1b (in three patients), and anticoagulation with subcutaneous injection of enoxaparin (three patients) or heparin (two patients). During the course of hospitalization, the patients showed sudden-onset abdominal pain (three cases), hypotension (three cases), and an acute drop in hemoglobin level. CT scan of the abdomen and pelvis revealed retroperitoneal hemorrhage. For one patient, owing to unstable vital signs and an expanding hematoma, surgical intervention was performed. Others were managed conservatively with discontinuation of anticoagulants, intravenous (IV) fluid resuscitation, and packed red blood cells transfusion. Three patients died due to worsening of the infection and respiratory failure. Retroperitoneal hemorrhage could be a potential complication in COVID-19 patients receiving anticoagulation. Careful monitoring of the vital signs and blood tests like hemoglobin level of such patients is essential.

WÜNDERLICH SYNDROME: A CASE OF HYPOVOLEMIC HEMORRHAGIC SHOCK

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Wünderlich syndrome (WS) is a rare presentation of hypovolemic hemorrhagic shock. It is a fatal disease described as a syndrome of spontaneous non-traumatic subcapsular and retroperitoneal hemorrhage. The etiology of WS is varied, with renal causes including malignancy being the most common, followed by renal vasculature abnormalities, vasculitis, cystic rupture, pyelonephritis, and idiopathic. The appropriate treatment depends on the accuracy of diagnosis and precise determination of its cause. To our knowledge, this is the first case report of WS due to acute pyelonephritis in a patient with congenital solitary kidney and Jehovah's Witness religious beliefs which impacted his care. CASE PRESENTATION: A 77 year old male with a two day history of flank pain accentuated on the right side, fevers, and confusion presented as critically ill and requiring vasopressor support. His medical history comprises prostate cancer in remission and atrial fibrillation on aspirin. He was diagnosed clinically with pyelonephritis, and culture positive urinary tract infection and sepsis with Escherichia coli. The initial hemoglobin was of 10.3 g/dL. Computed tomography (CT) of the abdomen showed nonspecific stranding and a solitary right kidney. He clinically deteriorated prompting repeat CT imaging that showed a large right perirenal hematoma with retroperitoneal blood. He underwent emergent coil angioembolization of a hemorrhagic branch of the inferior pole renal artery. His hemoglobin of 4 g/dL recovered with erythropoietin and intravenous iron. He briefly required hemodialysis for his acute kidney injury. The patient survived and the function of his congenital solitary kidney was preserved. DISCUSSION: The classic signs of WS include Lenk’s triad of flank pain, abdominal mass, and hypovolemic shock. However, in only 20% of cases, all three symptoms present. Acute onset of flank pain is the most common symptom. Although pyelonephritis is a rare cause of WS, in our case we believe that bleeding diathesis and etiology of WS was driven by cytokine induced endothelial damage from pyelonephritis along with aspirin induced platelet dysfunction. CT is preferred for the initial imaging workup. Angioembolization is a minimally invasive treatment modality for acute hemorrhage. Exploratory laparotomy or nephrectomy is typically recommended if malignancy is suspected. CONCLUSIONS: WS requires prompt recognition to prevent death from exsanguination. Shock is relatively common with WS, however, surgical exploration is not absolutely necessary with the advent of angioembolization. The unconventional treatment method with erythropoietin instead of blood may be considered in patients with Jehovah’s Witness religious beliefs. Reference #1: Katabathina VS, Katre R, Prasad SR, Surabhi VR, Shanbhogue AK, Sunnapwar A. Wunderlich syndrome: cross-sectional imaging review. J Comput Assist Tomogr. 2011;35(4):425-33. Reference #2: Chen YC, Lin YC. Wunderlich syndrome. QJM. 2013;106(2):187-8. Reference #3: Chamarthi G, Koratala A. Wunderlich syndrome. Clin Case Rep. 2018;6(9):1901-1902. DISCLOSURES: No relevant relationships by Francois Kaleta, source=Web Response No relevant relationships by Mitra Sahebazamani, source=Web Response No relevant relationships by Pratyaksha Sankhyan, source=Web Response

Warfarin-induced Spontaneous Retroperitoneal Hemorrhage in a Patient With Metallic Mitral Valve–Dilemmas in Management

We report a 70-year-old gentleman who attended the emergency department with a 1 day history of sudden onset right-sided flank pain. He was on warfarin due to metallic mitral valve. On presentation, he was hemodynamically stable, but his international normalized ratio was deranged at 4.7. An initial noncontrast computed tomography (CT) scan of abdomen showed a large right retroperitoneal hematoma and subsequent CT renal angiogram revealed evidence of active bleeding. There were dilemmas whether or not to reverse the effect of warfarin, proceed with angioembolization or explore the patient surgically. Here, we have addressed these issues.

Spontaneous Retroperitoneal Hemorrhage Secondary to Chronic Celiac Axis Compression Treated with Embolization Utilizing Cone Beam CT

Median arcuate ligament syndrome (MALS) is a rare and often misdiagnosed vascular pathology. In this paper, we discuss a 51-year-old female with MALS presenting with hypotension due to retroperitoneal hemorrhage. Currently, there is no consensus regarding the optimal treatment approach for such patients. This case report demonstrates the utility of conventional mesenteric angiography, cone beam CT with 3D reconstruction, and selective mesenteric transarterial embolization as an effective treatment approach for patients with spontaneous aneurysm rupture in MALS.

Retroperitoneal Hepatocellular Carcinoma Rupture Mimicking an Adrenal Hematoma

The retroperitoneum is a posterior space of the peritoneum, which has many visceral and vascular structures. Spontaneous retroperitoneal hemorrhages have variable causes, the most common of which are diseases of retroperitoneal organs. However, retroperitoneal hemorrhages may be caused by bare area injury. In this case study, a bare area was observed in the right upper quadrant (RUQ) of the retroperitoneum, the posterosuperior region of Couinaud liver segment 7 (bare area) is directly connected to the anterior pararenal space. The rupture or exophyte of the hepatocellular carcinoma on the bare area could invade the retroperitoneum, which may lead to inaccurate diagnosis of the condition. When the mass or the hemorrhage in the RUQ of the retroperitoneum is observed in computed tomography images, it is possible that ruptured hepatocellular carcinoma or a mass on the bare area of the liver, looks like a spontaneous retroperitoneal hemorrhage in the RUQ area for example a right adrenal hemorrhage. Keywords: adrenal hematoma, hepatocellular carcinoma rupture, spontaneous retroperitoneal hermorrahge

SUN-197 Giant Adrenal Myelolipoma Associated with Prolonged ACTH Elevation in a Patient with Congenital Adrenal Hyperplasia (CAH)

Background: Myelolipomas are rare benign tumours which consist of adipose tissue and mature hematopoietic tissue. The incidence ranges from 0.08 to 0.4% and they constitute 15% of adrenal incidentalomas. We report the case of a massive adrenal myelolipoma in a patient with CAH. Clinical Case: A 51year old man with salt losing CAH due to 21 hydroxylase deficiency presented to the emergency department with abdominal pain. CT scan of the abdomen revealed a 15 x 16 x 19cm mass in the left adrenal gland. There were concerns about malignancy, however expert radiology review diagnosed a massive adrenal myelolipoma. The patient was diagnosed to have salt losing CAH during infancy and managed with cortisone acetate and fludrocortisone during childhood, then dexamethasone 0.5mg nocte, 0,25mg mane as an adult. At 27 years he was reviewed and found to be Cushingoid with abdominal striae, obesity and hypertension. A CT scan of the abdomen done at that time showed a normal left adrenal gland with nodular right adrenal gland. While he was on dexamethasone, his 17-OHP was 14 nmol/l (NR: 0–6.0 nmol/l). His dexamethasone was reduced, then he was transferred on to prednisolone and then to hydrocortisone. 17-OHP level and ACTH levels have risen with each change in medication. At the time of referral with abdominal pain, he was on hydrocortisone 10 mg mane, 10 mg midday and 5mg at 1700h and his biochemistry showed: ACTH 486ng/l (NR 7.2–63.3), 17-OHP 101.1nmol/l (0–6.0nmol/l), renin 5.5 nmol/l/hr (NR 0.2–3.3) and androstenedione 26.6 nmol/l (NR 0–7.8). He underwent laparoscopic hand-assisted left adrenalectomy with the removal of a 2030 gram adrenal myelolipoma. He made an uneventful recovery with remarkable clinical improvement in general wellbeing. Histology confirmed adrenal myelolipoma. Conclusion: Chronic exposure to high ACTH levels causes metaplasia of adrenocortical cells, but a direct causal relationship for myelolipomas is not established. The role of ACTH in development of myelolipomas is supported by the increased incidence in patients with Addison’s disease, Nelson’s syndrome and ACTH dependent Cushing Disease. Our case supports the role of ACTH as the myelipoma developed after the reduction of patient’s glucocorticoid treatment and ACTH levels were high for years. Myelolipomas are usually asymptomatic but can present with abdominal pain, spontaneous rupture, and spontaneous retroperitoneal haemorrhage. There are no set guidelines but for large and rapidly growing tumours, surgery may be considered..

Nephron sparing surgery for giant renal angiomyolipoma; a viable option?

Angiomyolipomas (AML) are most common benign tumors of the Kidney. It may be an incidental diagnosis or in symptomatic patients it may cause flank pain,hematuria or renal mass. Also, sometimes renal AML may present initially as spontaneous retroperitoneal hemorrhage secondary to rupture (Wunderlich syndrome). AML &gt;10 cm in size is known as giant AML and the data available on this entity is sparse. Herein, we report a case of a 28-year-old homemaker who had left flank pain for 3 months, on evaluation elsewhere, Ultrasonography, and Contrast Computed Tomography Scan - Kidney Ureter Bladder showed a left giant renal AML. This patient came to our centre for further management. Subsequently, this patient underwent left open Partial Nephrectomy; specimen was 21.5 cm x 16 cm x 14 cm in size and weighed 1330 g. Histopathological analysis showed AML. It is important to contemplate a primary nephron sparing approach even in a case of giant renal AML, as it may turn out to be a correct choice with a positive outcome.

Asymptomatic retroperitoneal hemorrhage in a hemodialysis patient: a case report

Hemostasis is deteriorated in patients with end-stage chronic kidney disease and dialysis. Therefore, these patients tend to bleed. Spontaneous retroperitoneal hemorrhage almost always occurs with obvious clinical symptoms and findings. Here we aimed to present our patient with SRH whose course was in an atypic fashion.