Spontaneous retroperitoneal hematoma associated with anticoagulation therapy and antiplatet therapy: two centers experiences

A fatal retroperitoneal bleeding from iliolumbar artery following open reduction and internal fixation of an unstable pelvic ring injury: A case report

RATIONALE

Retroperitoneal bleedings are the result of injury to parenchymal tissue or vascular structures within retroperitoneal cavity. This may arise spontaneously, as a result of trauma or iatrogenically. Patients usually do not manifest clinically apparent signs and symptoms until a substantial amount of blood loss has occurred. Therefore, it is associated with high morbidity and mortality. Herein we present and discuss a case of fatal iatrogenic retroperitoneal bleeding following open reduction and internal fixation of an unstable pelvic ring injury.

PATIENT CONCERNS

A 66-year-old female patient presented to the Level I regional trauma center with severe pelvic pain after a pedestrian collision by a car.

DIAGNOSES

In initial radiography and computed tomography, she was diagnosed with unstable pelvic ring injury.

INTERVENTIONS

Definitive surgery for open reduction and internal fixation through the anterior approach to the sacroiliac joint and anterior intrapelvic approach was performed on the 8th day after the injury.

OUTCOMES

Patient died 3 days after the surgery due to a massive retroperitoneal bleeding from iliolumbar artery.

LESSONS

Insidious retroperitoneal bleeding from the small vessel may lead to fatal massive retroperitoneal hematoma. Therefore, active retroperitoneal bleeding should be suspected in cases of unexplained unstable hemodynamic status following orthopedic pelvic and acetabular surgery.

ACR Appropriateness Criteria® Suspected Retroperitoneal Bleed

The initial diagnosis of retroperitoneal bleeding can be challenging by physical examination and clinical presentation. Prompt imaging can make the diagnosis and be lifesaving. When selecting appropriate imaging for these patient's, consideration must be made for sensitivity and ability to image the retroperitoneum, as well as speed of imaging.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Spontaneous Retroperitoneal and Rectus Sheath Hemorrhage-Management, Risk Factors and Outcomes

BACKGROUND

Spontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH) is associated with high mortality in the literature, but studies on the subject are lacking. The objective of this study was to identify early predictors of the need for angiographic or surgical intervention (ASI) in patients with SRRSH and define risk factors for mortality.

METHODS

We conducted a retrospective cohort study at a tertiary academic hospital. All patients with computed tomography-identified SRRSH between 2012 to 2017 were included. Exclusion criteria were age below 18 years, possible mechanical cause of SRRSH, aortic aneurysm rupture or dissection, and traumatic or iatrogenic sources of SRRSH. The primary outcome was the incidence of ASI and/or mortality.

RESULTS

Of 100 patients included (median age 70 years, 52% males), 33% were transferred from another hospital, 82% patients were on therapeutic anticoagulation, and 90% had serious comorbidities. Overall mortality was 22%, but SRRSH-related mortality was only 6%. Sixteen patients underwent angiographic intervention (n = 10), surgical intervention (n = 5), or both (n = 1). Flank pain (OR 4.15, 95% CI 1.21-14.16, p = 0.023) and intravenous contrast extravasation (OR 3.89, 95% CI 1.23-12.27, p = 0.020) were independent predictors of ASI. Transfer from another hospital (OR 3.72, 95% CI 1.30-10.70, p = 0.015), age above 70 years (OR 4.24, 95% CI 1.25-14.32, p = 0.020), and systolic blood pressure below 110 mmHg at the time of diagnosis (OR 4.59, 95% CI 1.19-17.68, p = 0.027) were independent predictors of mortality.

CONCLUSIONS

SRRSH is associated with high mortality but is typically not the direct cause. Most SRRSHs are self-limited and require no intervention. Pattern identification of ASI is hard.

Case Report: Spontaneous Iliac Intramuscular Bleed After Orthotopic Heart Transplant

This case report describes an unusual case of spontaneous iliac intramuscular hematoma after a heart transplant secondary to valvular cardiomyopathy. A spontaneous retroperitoneal hematoma occurring after a heart transplant is rare, but can occur when the patient is on immunosuppressive medications. This could be secondary to the medications' ability to suppress the immune system and cause antiplatelet therapylike effects. Spontaneous retroperitoneal hematomas can cause significant patient morbidity, sometimes even causing immobility; however, a high index of suspicion with early recognition and immediate intervention can reduce the sequelae. Although the occurrence of a spontaneous retroperitoneal hematoma after a heart transplant is rare; there should be a high index of suspicion in cases where the patient is elderly, has experienced rejection episodes, and is taking immunosuppressants, or in cases where the patient is additionally on anticoagulation and antiplatelet therapy.