The clinical spectrum of retroperitoneal hematoma in anticoagulated patients

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.

Iatrogenic combined common iliac and lateral sacral artery perforation during coronary angiography: A case report and review of literature

Key Clinical Message

Arterial rupture is one of the rare but known and devastating complications of the angiogram, which can ultimately lead to loss of limb and life. Therefore, it is recommended that this complication be included in the consent form and that the operator and the logistics team be prepared for this scenario. Moreover, categorizing the patients based on risk factors to be more cautious during the procedure for high-risk patients can be considered a reasonable strategy.

Abstract

One of the rare but lethal complications of femoral artery catheterization for coronary angiography is arterial rupture, which can cause a range of negligible to massive retroperitoneal hemorrhage. This case presents a woman with unstable angina who underwent coronary catheterization. After arterial sheath placement, extravasation of blood from the right common iliac and lateral sacral arteries was seen, a diagnosis that has been reported rarely before. The bleeding was controlled with balloon inflation in the lateral sacral artery and a stent graft implantation in the right common iliac artery. The patient remained asymptomatic during the procedure and the short- and long-term follow-up. Interventional cardiologists and radiologists who access the femoral artery for any procedure should be aware of this possible event. Sometimes, this situation manifests with nonspecific symptoms such as weakness, lethargy, and pallor. Moreover, more logistical preparation and training are needed to overcome these unexpected conditions.

[Spontaneous retroperitoneal and rectus sheath hematomas and their interventional therapy: a review]

BACKGROUND

 Retroperitoneal and rectus sheath hemorrhage (RRSH) has been described as a potentially fatal condition with mortality rates of up to 30 % due to the risk of exsanguination in combination with often nonspecific clinical symptoms. Patients at risk are > 65 years of age as well as those receiving anticoagulation/antiplatelet medicine. Classifications based on etiology consist of trauma, surgery, and/or underlying vascular pathologies, though spontaneous occurrences without precipitating factors have been reported and are expected to increase with the high number of patients undergoing anticoagulant therapy.

METHOD

 Analysis, summary, and discussion of published review articles and expert recommendations.

RESULTS

 The most commonly described symptom during clinical examination is abdominal pain. However, depending on the volume loss, clinical symptoms may include signs of abdominal compartment and hemorrhagic shock. Computed tomography angiography (CTA) with high sensitivity and specificity for the presence of active bleeding plays an important role in the detection of RH and RSH. Therapy management is based on different pillars, which include surgical and interventional measures in addition to conservative measures (volume replacement, optimization of coagulation parameters). Due to its lower invasiveness with simultaneously high technical and clinical success rates, interventional therapy in particular has gained increasing importance.

CONCLUSION

 Diagnostic and therapeutic workup of the patients by an interdisciplinary team is essential for optimal patient care. In case of transcatheter arterial embolization, a standardized approach to the detection of bleeding sites within the vascular territory of the core hematoma appears to favorably influence success and patient outcome.

KEY POINTS

  · The clinical presentation of retroperitoneal and rectus sheath hematomas can be very heterogeneous and nonspecific. Quick diagnosis is essential due to the relatively high mortality rate (approx. 12-30 %).. · The main risk factors are age > 65 years and the intake of anticoagulants, the use of which has increased 2.5 times in the last 10 years. Coagulopathies, retroperitoneal masses, and hemodialysis are less common causes.. · Computed tomography angiography (CTA) has a high sensitivity and specificity for the presence of active bleeding and has replaced diagnostic subtraction angiography (DSA).. · Treatment should be performed in a multidisciplinary setting with the inclusion of internal medicine, radiology, and surgery. The main indications for embolization are the detection of active contrast extravasation on CTA and the presence of abdominal pain. In cases without active bleeding and with stable vital parameters, conservative treatment measures can be sufficient. Surgical treatment is often reserved for treatment-refractory bleeding with symptoms of abdominal compartment.. · A systematic standardized approach to the detection of bleeding on DSA seems to have advantages regarding technical and clinical success rates..

CITATION FORMAT

· Becker LS, Dewald CLA et al. Spontaneous retroperitoneal and rectus sheath hematomas and their interventional therapy: a review. Fortschr Röntgenstr 2024; 196: 163 - 175.

Iliopsoas Hematoma Progression to Abscess in the Setting of Diabetic Ketoacidosis

Iliopsoas hematomas (IPH) are defined as a spontaneous or traumatic retroperitoneal collection of blood involving the iliopsoas muscle. In some cases, intramuscular hematomas can progress to abscesses and put the patient at risk for further complications. Our objectives are: to describe the etiology of intramuscular hematoma and psoas abscess, to describe the clinical signs and treatment of intramuscular hematoma and psoas abscess, and to analyze the association between uncontrolled diabetes mellitus and psoas abscess progression, which we achieve through retrospective case analysis and associated literature review on symptom constellation. We present the case of a 40-year-old male patient with a history of diabetes mellitus and alcohol abuse who presented with three days of increasing back and left lower extremity pain, confusion, auditory hallucinations, and fever found to be in diabetic ketoacidosis. Six days prior, the patient presented to the Emergency Department (ED) after being struck by a motor vehicle while ambulating found to have bruising, weakness in his lower extremities, and an L2 vertebrae fracture found on CT. During the presentation, the patient was found to have decreased muscle strength, leukocytosis with elevated lactate, and CT findings suggestive of a left psoas abscess drained by interventional radiology. Vancomycin and Cefepime were used as an empiric antibiotic regimen. The culture of the wound was then found to grow Methicillin-susceptible Staphylococcus aureus (MSSA) bacteria and antibiotics were then adjusted to Vancomycin and Cefazolin. During the patient's hospital stay, he developed two more abscesses on his bilateral psoas muscles, which were promptly percutaneously drained by interventional radiology. This case describes an uncommon progression of an Iliopsoas hematoma to a psoas abscess, likely due to his immunocompromised status secondary to his uncontrolled diabetes mellitus. Uncontrolled diabetes mellitus has been shown in various studies to be an independent risk factor of intramuscular hematoma progress to psoas abscess. We suggest that patients displaying fever, chills, flank pain, limited hip movement, and indications of uncontrolled diabetes should be approached with a high degree of suspicion for a psoas abscess.

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

PURPOSE

To 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 METHODS

Retrospective 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.

RESULTS

Pre-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.

CONCLUSION

Embolotherapy 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.

Spontaneous Retroperitoneal Haemorrhage: Efficacy of Conservative Management and Embolisation

PURPOSE

To assess the efficacy of conservative management and embolisation in patients with spontaneous retroperitoneal haemorrhage.

METHODS

Single-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.

RESULTS

A 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).

CONCLUSION

Conservative 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.

Management of Iatrogenic External Iliac Artery Perforation With a Self-Made Covered Stent

Retroperitoneal hemorrhage (RPH) following transfemoral arterial access is a dreaded complication needing immediate management. A 70-year-old female with inferior wall myocardial infarction developed hemodynamic instability following transfemoral percutaneous coronary intervention. The evaluation revealed an RPH due to an iatrogenic guidewire-related perforation of the external iliac artery. This was successfully managed with the deployment of a custom, a self-made covered stent. In this report, we describe our method of creating and deploying this self-made stent and discuss potential issues compared to commercially available covered stent systems.

Spontaneous Iliopsoas Muscle Hemorrhage-Predictors of Associated Mortality

RATIONALE AND OBJECTIVES

Spontaneous iliopsoas muscle hemorrhage (SIPH) is a rare clinical condition associated with high mortality. In this work we aimed to retrospectively investigate the predictors of mortality in a single-institution cohort of consecutive SIPH patients.

MATERIALS AND METHODS

Consecutive patients (n = 61, 30 men, 76 years [range 51-93]) with computed tomography (CT) confirmed diagnosis of SIPH were retrospectively included between January 2010 and April 2020. CT studies were assessed for signs of active bleeding, extramuscular retroperitoneal hematoma, visible sedimentation, and hematoma volume. Medication history, laboratory parameters, comorbidities, and disease management were also recorded. All parameters were subsequently examined with regard to their impact on outcome and survival. Univariate and multivariate Cox regressions were performed to identify variables associated with time to death.

RESULTS

The overall mortality was 22.9%. A total of 77% of patients received anticoagulant therapy prior to the onset of SIPH. Active bleeding in contrast enhanced CT (CECT) was the only independent variable associated with shorter survival (p = 0.01, hazard ratio 7.05 [1.45-34.20]). Hematoma volume or extramuscular retroperitoneal hematoma had no significant influence on short-term mortality.

CONCLUSION

Only active bleeding but not hematoma volume or extra-muscular bleeding is an independent risk factor for short-term mortality in patients with SIPH.

Unexpected tendency to bleeding in COVID-19 patients: A case of spontaneous retroperitoneal hematoma

While COVID-19 pandemic has become an enormous and devastating pandemic for today’s world, studies on the morbidity of the disease mainly show the disease’s progress with pneumonia and thromboembolic pathologies. In this disease with a predisposition to thromboembolism, findings of nontraumatic focused hemorrhages are unexpected. As spontaneous retroperitoneal hematoma is a serious condition with the absence of symptoms, creating a challenge for diagnosis, it should also be considered in COVID-19 which is thought to be predisposed to thromboembolism. Here, a 47-year-old woman with COVID-19 pneumonia diagnosis (diagnosed by computed tomography (CT) scan and approved by nasopharyngeal swab test) is presented with spontaneous retroperitoneal hematoma, and its management is reported. This case highlights the importance of considering both thromboembolic events and bleeding in cases with COVID-19 positivity. The balance between two sides of clotting mechanisms needs to be understood with novel research.

The way to a man's heart is through his stomach: a case of myocardial infarction mimic and pseudo-tamponade in a polytrauma patient

Background

There exists a therapeutic conflict between haemorrhage control and prevention of thromboembolic events following polytrauma and complications are not uncommon. Such opposing therapies can result in unexpected pathophysiology and there is a real risk of misdiagnosis resulting in harm. This case presents a previously unreported complication of prevention and management of thromboembolism- STEMI (ST elevation myocardial infarction) and tamponade mimic secondary to retroperitoneal haematoma.

Case presentation

We present a 50-year-old male polytrauma patient who following treatment for presumed pulmonary embolus demonstrated classical clinical findings of myocardial infarction and pericardial tamponade secondary to a retroperitoneal haematoma. This is an event not previously reported in the literature. The risk of adverse outcome by management along the standard lines of STEMI (ST elevation myocardial infarction) was averted through awareness for alternative aetiology via a multi-team approach which resulted in percutaneous drainage of the haematoma and complete resolution of symptoms.

Conclusions

This manuscript highlights the therapeutic conflict between haemorrhage control and prevention of thromboembolic events in critically injured, the importance of high index of suspicion in this patient cohort and the benefits of multidisciplinary decision making in the complex patient through a not previously published pathophysiologic phenomenon.

Iliopsoas Hematoma in Patients Undergoing Venovenous ECMO

BACKGROUND

Iliopsoas hematoma occasionally occurs in patients receiving anticoagulation therapy. It may be a life-threatening complication and can cause disseminated intravascular coagulation, which could develop into abdominal compartment syndrome. The incidence of and factors associated with iliopsoas hematoma during venovenous extracorporeal membrane oxygenation (ECMO) have not been well studied.

OBJECTIVES

To describe the incidence of iliopsoas hematoma and associated factors among patients undergoing venovenous ECMO.

METHODS

A retrospective cohort study was conducted at Nippon Medical School Hospital from April 2015 to October 2018. All patients (>18 years old) with iliopsoas hematoma received a diagnosis based on computed tomography.

RESULTS

During the study period, 54 patients were supported with venovenous ECMO. Iliopsoas hematoma occurred in 8 of those patients (15%), none of whom had disseminated intravascular coagulopathy or abdominal compartment syndrome develop. Univariate analysis indicated that management of ECMO while the patient was awake and mobilization beyond sitting on the edge of the bed were significantly different (P < .05) in patients with and patients without iliopsoas hematoma. Mortality, however, did not differ significantly between the 2 groups.

CONCLUSIONS

Our findings emphasize that recognizing factors associated with iliopsoas hematoma and detecting them early are crucial during venovenous ECMO in order to treat patients with iliopsoas hematoma appropriately.

Acute, major muscular hematoma associated with antithrombotic agents: A multicenter real-world cohort

BACKGROUND

There is little data on major muscular hematomas and the little there is has mainly focused on patients exposed to oral anticoagulants.

OBJECTIVE

To describe the clinical characteristics, management and outcomes of patients admitted to emergency department (ED) for major muscular hematoma associated with an antithrombotic agent, and to identify predictors of in-hospital mortality.

PATIENTS AND METHODS

Over a three-year period, all consecutive cases of adult patients admitted to the ED of 5 tertiary care hospitals for major muscular hematoma while exposed to an antithrombotic agent were prospectively collected and medically validated. Clinical and biological data, therapeutic management of the bleeding event, and in-hospital mortality were collected from the medical records and compared across five groups of hematoma locations. Potential confounders were taken in account using a multivariate binomial regression model.

RESULTS

Three hundred and seventy-five patients were included (mean age = 81.4 years): 271 were exposed to vitamin K antagonists, 58 to parenteral anticoagulants (heparin, LMWH, fondaparinux), 33 to antiplatelets, and 13 to direct oral anticoagulants. The muscular hematomas were located in the lower limbs (n = 198), the rectus sheath (n = 71), the iliopsoas (n = 45), the upper limbs (n = 33), or elsewhere (n = 28). Reversal therapy was prescribed for 48.5% of patients, red cell transfusions for 63.6%, surgery for 12.3% and embolization for 3.5%. For 84% of patients, hospitalization was required, with a median length of stay of 10 days. Overall, in-hospital mortality was 8.5%. Reversal therapy, the need for intensive care and mortality were significantly more frequent among patients with iliopsoas hematomas. The independent predictors of in-hospital mortality were: decrease in mean arterial pressure (RR = 1.84), decrease in hemoglobin level (RR = 1.37) and the iliopsoas location (RR = 3.06).

CONCLUSION

Frail elderly patients with major muscular hematomas linked to antithrombotic agents risk substantial morbidity and in-hospital mortality. The iliopsoas location was the most life-threatening bleeding site. Close observation of this population is warranted to ensure better outcomes.

Efficacy of transarterial embolisation in patients with life-threatening spontaneous retroperitoneal haematoma

AIM

To evaluate the technical and clinical success of embolisation in patients with life-threatening spontaneous retroperitoneal haematoma (SRH) and to assess predictors of clinical outcome.

MATERIALS AND METHODS

Thirty patients (mean age: 71.9±9.8 years) with SRH underwent digital subtraction angiography (DSA). All patients received anticoagulant or antiplatelet medication or a combination of both at the time the SRH occurred.

RESULTS

Pre-interventional computed tomography angiography (CTA) revealed active retroperitoneal bleeding in 28 of 30 (93.3%) patients. DSA identified active haemorrhage in 22 of 30 patients (73.3%). Twenty-nine of 30 (96.7%) patients underwent embolisation. n-Butyl-2-cyanoacrylate (NBCA) was used in 15 patients (51.7%), coils were used in 10 patients (34.5%), and both embolic agents were used in four patients (13.8%). The technical success rate was 100%. Pre-interventional haemoglobin levels increased significantly after embolotherapy from 70.9±16.1 g/l to 87±11.3 g/l (p<0.001), whereas partial thromboplastin time decreased from 58±38 to 30±9 seconds (p<0.001) after embolotherapy. The need for transfusion of concentrated red cells decreased from 3±2.2 to 1±1.1 units (p<0.001) after the intervention. Clinical success was achieved in 19 of 29 (65.5%) patients. No major procedure-related complications occurred. Seven patients (24.1%) died within 30 days after the procedure.

CONCLUSION

Embolotherapy in patients with life-threatening SRH leads to a high technical success rate and is a safe therapeutic option. The clinical success rate was acceptable and influenced by pre-interventional coagulation status and by the amount of transfused concentrated red cells.

Spontaneous Retroperitoneal Hematoma in the Setting of Myasthenic Crisis

Our case highlights a patient with spontaneous retroperitoneal hematoma without clear cause in the setting of myasthenic crisis. While myasthenia gravis (MG) has been reported in the literature to be associated with vascular pathology such as polyarteritis nodosa, its association with coagulopathy and spontaneous major bleed is currently unclear. The patient in this case developed a sudden unprovoked iliopsoas hematoma while in the ICU for the management of newly diagnosed MG. Acute anemia was the only clinical sign which was later confirmed by imaging findings.

Cross-sectional study of retroperitoneal hematoma after invasive intervention in a Chinese population: Prevalence, characteristics, management and outcomes

The present study aimed to explore the clinical characteristics and management of retroperitoneal hematoma (RPH) after invasive intervention during a 12-year period in China. A retrospective review of patients with RPH after various invasive interventions was conducted at the China National Center for Cardiovascular Diseases. A total of 42 patients with a mean age of 63.1±2.5 years were continuously recruited in the study between January 2007 and September 2018. The incidence, manifestations and management of RPH were analyzed. A total of 20 patients had punctures in the femoral arterial access under the inguinal ligament and 5 patients had punctures above the inguinal ligament. The majority of RPH occurred within 24 h after intervention, while some occurred after postoperative 24 h. Pain was the most common symptom in patients with RPH. All patients who underwent intervention presented a reduction in hemoglobin (HB) concentration. The overall incidence of nosocomial infection was 38.1% and mortality was 7.1%. The findings demonstrated that RPH is a rare complication after invasive intervention of cardiovascular diseases with non-specific clinical manifestations. The reduction of HB concentration was a vital manifestation for RPH. Most RPH cases could be treated by conservative treatment and blood transfusion. A puncture in the femoral arterial access under the inguinal ligament may result in RPH.

Pain in the hip: Spontaneous retroperitoneal hemorrhage in an elderly patient on apixaban

As many as 5% of patients using oral anticoagulants suffer from a major bleeding event annually. Spontaneous retroperitoneal hemorrhage is a rare but serious complication, with a mortality rate as high as 20%. Oral anticoagulants were responsible for 2.83 million office visits per quarter in 2014 and use is increasing, therefore, rapid recognition of life threatening complications is critical. We present a case of an 86-year-old female taking apixaban for atrial fibrillation who presented with right hip pain upon standing. Laboratory tests revealed leukocytosis and anemia. A CT scan of the right hip revealed a moderately sized retroperitoneal hematoma. She was transferred to the intensive care unit, treated with supportive care, and was discharged two days later without any invasive intervention needed. Due to vague presentations, spontaneous retroperitoneal hemorrhages can be misdiagnosed as a number of abdominal or pelvic processes. While our patient presented with hip pain, other presentations include abdominal masses, back pain, or hypotension. Some patients may progress to hemodynamic instability, femoral neuropathy, or abdominal compartment syndrome requiring rapid intervention to prevent further morbidity. In patients with vague abdominal or pelvic complaints who have risk factors such as advanced age and the use of anticoagulation therapy, spontaneous retroperitoneal hemorrhage should be considered to allow for early diagnosis before severe complications arise.

Warfarin-induced spontaneous retroperitoneal hemorrhage from the renal vein: A rare case with an uncommon etiology

The overall rate of major bleeding in patients with atrial fibrillation receiving warfarin therapy is approximately 4%. Among these 4% patients, spontaneous retroperitoneal hemorrhage (SRH) is a rare but potentially lethal complication with a nonspecific presentation that can lead to missed or delayed diagnosis. The current literature provides little direction for diagnosis and management of such cases. Anticoagulation-related SRH is associated with a high mortality rate (approximately 20%). Despite the vague presentation, prompt diagnosis is crucial to reverse the anticoagulation and prevent further bleeding. Contrast-enhanced computed tomography (CT) of the abdomen is the imaging modality of choice in suspected cases. Patients with SRH require aggressive treatment with blood transfusions, interventional radiological procedures, percutaneous drainage or surgical evacuation of the hematoma. We report a case of warfarin-induced SRH from the renal vein in a patient who presented to our emergency department with acute, nonspecific abdominal pain and shock. We diagnosed the patient with warfarin-induced SRH on the basis of clinical suspicion and characteristic CT findings. We initially treated the patient conservatively, followed by embolization of the right renal artery during the late course of hospital stay, and he was discharged with good recovery. SRH should be considered in the differential diagnosis of abdominal pain, hypotension, and/or decreased hemoglobin levels in patients receiving anticoagulation therapy, especially in those with preexisting end-stage renal disease.

Contemporary management of spontaneous retroperitoneal and rectus sheath hematomas

BACKGROUND

Retroperitoneal and rectus sheath hematomas can occur spontaneously. There is a lack of research about the disease progression, optimal treatment strategies and the need for surgical intervention. Our study investigated their outcomes and management.

STUDY DESIGN

Adult patients admitted during a one-year period with non-traumatic retroperitoneal or rectus sheath hematomas were retrospectively identified. Biographical, hospital-course, and outcome data were extracted.

RESULTS

99 patients were included; median age was 73-years (IQR 61-80). 88 patients were on an anticoagulant or antiplatelet agent. Warfarin and intravenous heparin being the most commonly utilized agents (42% and 36.4%, respectively). All 99 patients were diagnosed by CT scan. 79 patients received some sort of blood product (79.8% PRBC, 43.4% FFP, 17% platelets), and 26 patients were in hemorrhagic shock. 17 patients underwent angiography and/or angioembolization. Neither anticoagulation in general nor any specific agent was associated with the need for blood product transfusion or angiography. 13 patients died but none were attributable to the hematoma.

CONCLUSION

Both hematomas are usually self-limiting and rarely require surgical intervention. A subset may require angioembolization.

Spontaneous ilio-psoas hematomas complicating intensive care unit hospitalizations

BACKGROUND

Ilio-psoas hematoma is a potentially lethal condition that can arise during hospital stay. However, neither the incidence nor the prognosis of patients whose stay in intensive care units (ICU) is complicated by a iatrogenic ilio-psoas hematoma is known.

METHODS

A bicentric retrospective study was conducted to compile the patients who developed an ilio-psoas hematoma while they were hospitalized in ICU between January 2009 and December 2016. Their biometric characteristics, pre-existing conditions, the circumstances in which the hematoma was diagnosed, the treatments they received and their prognosis were recorded.

RESULTS

Forty patients were diagnosed with an ilio-psoas hematoma during their ICU stay. The incidence of this complication was 3.8 cases for 1000 admissions, taking into account only patients who stayed more than three days in ICU. The median age of patients was 74 years old and the median time between admission and the diagnosis of ilio-psoas hematoma was 12.6 days. A large proportion of them was obese (42.5%) and/or under dialysis (50%) prior to developing their hematoma. Ninety-five percent of the patients had heparin at prophylactic or therapeutic doses. Only 10% of them were above the therapeutic range of anticoagulation. The ICU mortality rate was of 50% following this complication (versus a general mortality rate of 22% for the patients without IPH over the same period of time). Patients with IPH that were complicated by disseminated intravascular coagulopathy had a significantly higher mortality rate than those with IPH and no disseminated intravascular coagulopathy (OR 6.91, 95% CI [1.28; 58.8], p = 0.04).

CONCLUSION

Age, anticoagulation, a high body mass index and dialysis seem to be risk factors of developing an ilio-psoas hematoma in ICU. Iatrogenic ilio-psoas hematomas complicated by disseminated intravascular coagulopathies are more at risk of leading to death. It is noteworthy that activated partial thromboplastin time above the therapeutic range was not a good predictor of developing a hematoma for patients who received unfractioned heparin therapy.

The utility of transarterial embolization and computed tomography for life-threatening spontaneous retroperitoneal hemorrhage

PURPOSE

To assess the safety and efficacy of transarterial embolization (TAE) and to evaluate the utility of contrast-enhanced computed tomography (CE-CT) for life-threatening spontaneous retroperitoneal hemorrhage (SRH).

METHODS

Nineteen patients underwent TAE following CE-CT for life-threatening SRH. CE-CT and angiographic findings, technical successes, and clinical successes were evaluated. The diagnostic performance of CE-CT for the detection of active bleeding arteries was also assessed by two independent readers.

RESULTS

Active extravasation of contrast material was accurately observed in 78.9‒84.2% of the patients on CE-CT. Angiograms revealed active extravasation in 37 arteries of 15 patients (78.9%), and 4 patients showed no sign of active bleeding. Sensitivity, positive predictive value, and accuracy rate of CE-CT for the detection of active bleeding vessels was 59.5%, 62.9‒71.0% and 55.6‒60.0% respectively. The successful embolization of 48 intended arteries was achieved in all the patients, including empirical TAE in four patients. Hemodynamic stabilization was achieved in 17 patients (89.5%) with a significant decrease in transfusion (p < 0.001).

CONCLUSION

TAE is a technically safe and clinically effective treatment method for life-threatening SRH. CE-CT has moderate capability for accurate identification of active bleeding arteries. TAE including arteries that potentially distribute anatomic territory of the hematoma is essential.

Delayed retroperitoneal hemorrhage during veno-venous extracorporeal membrane oxygenation: a case report

Case

There are several reports of retroperitoneal hemorrhage induced by percutaneous femoral cannulation for extracorporeal membrane oxygenation (ECMO). However, there are no reports of delayed retroperitoneal hemorrhage, which develops a few days after ECMO initiation and is unrelated to the ECMO cannulation. Herein, we report a rare case of delayed retroperitoneal hemorrhage during veno‐venous extracorporeal membrane oxygenation (VV‐ECMO).

Outcome

A 54‐year‐old man was referred to our hospital because of severe acute respiratory distress syndrome. We initiated VV‐ECMO. The patient had severe delirium and was confined to a long‐term supine position to maintain circuit safety. On day 13, computed tomography unexpectedly revealed a large retroperitoneal hemorrhage spreading around the psoas muscle.

Conclusion

Delayed retroperitoneal hemorrhage can develop during VV‐ECMO management a few days after its initiation. Anticoagulant use and forceful muscular strain could be risk factors of delayed retroperitoneal hemorrhage.

Retroperitoneal Bleeding: An Experience During Prophylactic Anticoagulation in a Patient With Nephrotic Syndrome

The association between nephrotic syndrome (NS) and a hypercoagulable state has been demonstrated. Controlling the blood clotting activity may therefore be attractive for patients with nephrosis in terms of thromboembolism prophylaxis. We herein report a 75-year-old woman with minimal change disease who developed pains in the right back, groin, and thigh because of retroperitoneal bleeding during prophylactic anticoagulation with unfractionated heparin. Although this procedure has not been accepted as the standard of care for patients with nephrosis, pharmacologic prophylaxis may already be practiced empirically, as in the present patient. We believe that our experience highlights the pitfalls of such a management in patients with nephrosis, implying the need for a diagnostic strategy for identifying those patients with NS who can benefit from prophylactic anticoagulation. Several concerns that emerged in this case are also discussed.

Antiplatelet Therapy and Spontaneous Retroperitoneal Hematoma: A Case Report and Literature Review

Patient: Male, 66

Final Diagnosis: Spontaneous retroperitoneal hematoma seconday dual antiplatelet therapy

Symptoms: Anemia • knee joint pain

Medication: —

Clinical Procedure: None

Specialty: Cardiology

Ilio-psoas hematoma in the intensive care unit: a multicentric study

Background

Clinical features and outcomes of patients with spontaneous ilio-psoas hematoma (IPH) in intensive care units (ICUs) are poorly documented. The objectives of this study were to determine epidemiological, clinical, biological and management characteristics of ICU patients with IPH.

Methods

We conducted a retrospective multicentric study in three French ICUs from January 2006 to December 2014. We included IPH diagnosed both at admission and during ICU stay. Surgery and embolization were available 24 h a day for each center, and therapeutic decisions were undertaken after pluridisciplinary discussion. All IPHs were diagnosed using CT scan.

Results

During this period, we identified 3.01 cases/1000 admissions. The mortality rate of the 77 included patients was 30 %. In multivariate analysis, we observed that mortality was independently associated with SAPS II (OR 1.1, 95 % CI [1.013–1.195], p = 0.02) and with the presence of hemorrhagic shock (OR 67.1, 95 % CI [2.6–1691], p = 0.01). We found IPH was related to anticoagulation therapy in 56 cases (72 %), with guideline-concordant reversal performed in 33 % of patients. We did not found any association between anticoagulant therapy type and outcome.

Conclusion

We found IPH is an infrequent disease, with a high mortality rate of 30 %, mostly related to anticoagulation therapy and usually affecting the elderly. Management of anticoagulation-related IPH includes a high rate of no reversal of 38 %.

[Clinical spectrum of patients with spontaneous retroperitoneal hematomas]

INTRODUCTION AND OBJECTIVE

Spontaneous retroperitoneal hematoma (SRH) is a potentially fatal clinical entity requiring immediate recognition and intervention.

MATERIAL AND METHODS

The clinical records of 18-year-old and older patients admitted to the University Hospital Marqués de Valdecilla from 2003 to 2013 were reviewed. "Spontaneous" was defined as unrelated to trauma, invasive procedures or bleeding due to aortic aneurysm rupture.

RESULTS

Thirty-four patients with SRH (44% were on anticoagulant drugs). One-third of cases had chronic renal insufficiency. Abdominal pain was the most common symptom both in anticoagulated and non-anticoagulated patients (80% in anticoagulated and 89% in non-anticoagulated patients). About one half of the patients developed shock. A CT scan was the most commonly performed diagnostic test, followed by abdominal ultrasound. Most cases were managed conservatively (80%). More than half of the patients (66%) restarted anticoagulation therapy after the acute event with a mean delay of 19 days (range 2-90 days). None of them suffered a new bleeding episode.

CONCLUSION

Restarting the anticoagulation treatment after hematoma resolution seems to be a safe practice. There is an increasing frequency of SRH in non-anticoagulated patients.

Spontaneous presacral haematoma mimicking rectal malignancy--an unusual consequence of anticoagulation

An 81-year-old man on warfarin was admitted to hospital after 3 days of constipation, straining and mild rectal bleeding. A large, boggy mass was felt posteriorly on direct rectal examination. Investigations revealed a normocytic anaemia and a supratherapeutic international normalised ratio (INR). Fearing a late presentation of malignancy, an urgent CT of abdomen and pelvis was arranged which showed a homogeneous mass arising between the sacrum and the rectum. Given the anaemia in the presence of anticoagulation, and subsequent widespread perineal and scrotal ecchymosis, the patient was diagnosed with atraumatic presacral haematoma. Following resuscitation, the patient was managed non-operatively and was discharged several days later following stabilisation of the haemoglobin and INR. At 3 months, he had complete clinical and radiological resolution of this haematoma.

Spontaneous retroperitoneal hematoma: etiology, characteristics, management, and outcome

BACKGROUND

Spontaneous retroperitoneal hematoma (SRH) can be fatal, requiring immediate recognition and intervention. Current literature is limited, providing little direction in patient care.

OBJECTIVE

To describe clinical characteristics of patients with SRH during an 8-year period.

METHODS

Observational cohort study of all consecutive patients 18 years and older with SRH from January 2000 to December 2007. SRH was defined as unrelated to invasive procedures, surgery, trauma, or abdominal aortic aneurysm.

RESULTS

Of 346 patients screened, 89 were eligible. Median age was 72 years; 56.2% were male. Overall, 66.3% were anticoagulated: 41.6% on warfarin, 30.3% heparin, and 11.2% low-molecular-weight heparin; 30.3% were on antiplatelet therapy; 16.5% were taking both anticoagulant and antiplatelet medications; 15.3% were taking neither. Primary presentation to the Emergency Department was seen in 36%; 64% developed SRH during inpatient anticoagulation therapy. The most common symptom was pain: abdominal (67.5%), leg (23.8%), hip (22.5%), and back (21.3%); 10.1% were misdiagnosed upon their initial encounter. Computed tomography (CT) was performed in 98.8%, ultrasound in 22.1%, and magnetic resonance imaging in 3.5%. Of all subjects, 40.4% were managed in an intensive care unit; 24.7% underwent interventional radiology (IR) procedures and 6.7% surgical evacuation; 75.3% received blood transfusion. Mortality was 5.6% within 7 days, 10.1% within 30 days, and 19.1% within 6 months.

CONCLUSIONS

SRH is uncommon but potentially lethal, with a non-specific presentation that can lead to misdiagnosis. One-third of the cohort was not taking anticoagulants. CT was effective at identification. Most patients received aggressive management with transfusion or IR procedures.

Fatal retroperitoneal bleeding caused by metastasis of a sigmoid carcinoma

Retroperitoneal bleeding is relatively rare and a potentially life-threatening condition with significant mortality. Early recognition requires a high index of suspicion. Increased life expectancy, the widespread use of anticoagulants, and the rise of endovascular interventions have caused an increase in the incidence of retroperitoneal bleeding. We present a case of a 74-year-old woman who died because of retroperitoneal bleeding caused by retroperitoneal metastasis of a sigmoid carcinoma with angioinvasive growth into a lumbar artery. In addition we discuss etiology, diagnostic management, and treatment strategy.

Abdominal compartment syndrome due to spontaneous retroperitoneal hemorrhage in a patient undergoing anticoagulation

Spontaneous retroperitoneal hemorrhage is one of the most serious and often lethal complications of anticoagulation therapy. The clinical symptoms vary from femoral neuropathy to abdominal compartment syndrome or fatal hypovolemic shock. Of these symptoms, abdominal compartment syndrome is the most serious of all, because it leads to anuria, worsening of renal failure, a decrease in cardiac output, respiratory failure, and intestinal ischemia. We report a case of a spontaneous retroperitoneal hemorrhage in a 48-year-old female who had been receiving warfarin and aspirin for her artificial aortic valve. She presented with a sudden onset of lower abdominal pain, dizziness and a palpable abdominal mass after prolonged straining to defecate. Computed tomography demonstrated a huge retroperitoneal hematoma and active bleeding from the right internal iliac artery. After achieving successful bleeding control with transcatheter arterial embolization, surgical decompression of the hematoma was performed for management of the femoral neuropathy and the abdominal compartment syndrome. She recovered without any complications. We suggest that initial hemostasis by transcatheter arterial embolization followed by surgical decompression of hematoma is a safe, effective treatment method for a spontaneous retroperitoneal hemorrhage complicated with intractable pain, femoral neuropathy, or abdominal compartment syndrome.

Dizzy and confused: a step-by-step evaluation of the clinician's favorite chief complaint

This article covers the general approach to patients who present to the emergency department with a complaint of dizziness or vertigo, and altered mentation. Patients' histories and physical examination findings are discussed first, then a pertinent differential diagnosis, ranging from neurological causes and poor perfusion states to toxicologic causes, is described along with the distinguishing features and potential diagnostic pitfalls of each problem. Case scenarios are presented and the treatment and disposition of patients from the emergency department are discussed.

Local and systemic consequences of large retroperitoneal clot burdens

BACKGROUND

There is a paucity of data regarding the impact of retroperitoneal hematoma (RPH) volumes, as detected by computed tomography (CT) scanning, on patient morbidity and mortality. Therefore, we wanted to determine the natural history of RPHs and the effect of size on local and systemic outcomes.

METHODS

We performed a volumetric analysis of CT-documented RPHs managed at our institution between 1985 and 2006 along with a retrospective chart review.

RESULTS

We included 81 cases of RPH in this study. The mean Acute Physiology, Age, and Chronic Health Evaluation II (APACHE II) score was 12.8 +/- 0.72 (score +/- SE). By univariate analysis, the size of the hematoma showed a significant correlation with the development of local mass effects, delayed mass effects, 6-month mortality, major morbidity, pulmonary complications, fluid overload, and the requirement for operative evacuation (p < 0.05). Receiver operating characteristic analysis revealed that a size > or = 1600 cm(3) was > 80% sensitive and specific for predicting a delayed mass effect or an increase in 6-month mortality. Multivariate analysis controlling for factors such as APACHE II and packed red blood cells transfused showed that the volume of the RPH was an independent predictor for the development of local mass effects, pulmonary insufficiency, and fluid overload.

CONCLUSIONS

Large RPHs are clearly associated with worse patient outcomes. Surgical intervention may be warranted for the treatment of RPHs > or = 1600 cm(3).

Transcatheter arterial embolisation in anticoagulant-related haematoma--a current therapeutic option: a report of four patients and review of the literature

The aim of this study is to present the computed tomography (CT) and angiographic findings of life-threatening extraperitoneal haemorrhage complicating anticoagulant therapy, treated with transcatheter arterial embolisation (TAE). CT and angiographic studies of four consecutive patients with large, extraperitoneal anticoagulant-related haematomas (ACH) treated by TAE were retrospectively reviewed. Attention was directed to the location of the haematoma and to the possible presence of active arterial extravasation on CT. Four women (mean age 70 years) with large extraperitoneal ACH's demonstrated on CT as extended rectus sheath haematoma in three and expanding iliopsoas haematoma in one, were successfully treated by TAE of the inferior epigastric (n=3) and lumbar artery (n=1). Two patients were diagnosed by contrast-enhanced CT as having active arterial bleeding within the haematoma requiring TAE. The other two were referred to angiography because of haemodynamic instability. We also reviewed the imaging findings of 26 patients with extraperitoneal ACH's requiring TAE described in the literature. In the reviewed cases, a female predominance was found, the retroperitoneum was the most frequent site and most patients recovered. To conclude, unenhanced CT has proved an excellent modality for the diagnosis of ACH's. TAE has been shown to be an effective and safe method for managing such haematomas when conservative treatment is insufficient. We suggest that whenever a large extraperitoneal ACH is seen on unenhanced CT, a subsequent contrast-enhanced dynamic scan should be performed, unless contraindicated. Enhanced CT has a supplementary role in detecting active bleeding that provides an indication for angiographic therapy. Awareness of this optional treatment improve patient's outcome.

CT Criteria for Differentiating Abdominal Hemorrhage: Anticoagulation or Aortic Aneurysm Rupture?

OBJECTIVE

The purpose of our study was to test the hypothesis that CT criteria would allow accurate diagnosis of the specific cause of abdominal hemorrhage in patients with coagulopathy or abdominal aortic aneurysm.

CONCLUSION

Attention to specific CT criteria allows accurate diagnosis of the specific cause of spontaneous abdominal hemorrhage even in patients who have both coagulopathy and an abdominal aortic aneurysm.

Massive retroperitoneal hematoma during enoxaparin treatment of pulmonary embolism after primary total hip arthroplasty: case reports and review of the literature

In light of the increasing use of enoxaparin for both prophylaxis and treatment of thromboembolic disease, the number of potential complications from this anticoagulant will also continue to increase. This article presents the first case of massive retroperitoneal hematoma during enoxaparin treatment of pulmonary embolism after a primary total hip arthroplasty and discusses several unique sequelae of the retroperitoneal hematoma. Retroperitoneal hematomas are often fatal, and treatment involves aggressive fluid resuscitation with possible surgical decompression.

Two cases of retroperitoneal haematoma caused by interaction between antibiotics and warfarin

Several commonly prescribed antibiotics are known to interact with warfarin, increasing its anticoagulant effect by different mechanisms. Retroperitoneal bleeding with consequent haematoma is recognised as a complication of over-anticoagulation. Consequences, which are potentially fatal, include hypovolaemic shock and compression of retroperitoneal structures such as the ureter and inferior vena cava.

Major vascular injury after laparoscopic tubal ligation

Laparoscopy has become an established approach with diverse applications in both diagnostic and therapeutic surgical procedures. In general, the procedure is safe and effective and offers the advantage of being less invasive than conventional surgery. Complications after laparoscopy are uncommon but among them major vascular injury is potentially the most fatal, with recognition or mortality typically occurring intra-operatively or in the immediate post-operative period. We report the case of a delayed emergency department presentation of a major vascular injury after an elective laparoscopic tubal ligation. The prevalence, diagnosis, pathophysiolgy and management of major vascular injury after laparoscopic surgery is discussed.

A Retroperitoneal Bleed Induced by Enoxaparin Therapy

Retroperitoneal bleeding is one of the most serious, potentially lethal complications of antico-agulation therapy. Although well documented in fully heparinized and coumadinized patients, there are only few reports of life-threatening hemorrhages in low-molecular-weight heparin (LMWH)-treated patients. We present a case of almost fatal spontaneous retroperitoneal bleeding in a 71-year-old woman with pneumonia and acute coronary syndrome. After receiving combination therapy with Lovenox (enoxaparin), aspirin, and Plavix for 5 days, she developed acute hemorrhagic shock and possible intra-abdominal compartment syndrome. Urgent computed tomography scan of the abdomen and pelvis was performed and showed a left retroperitoneal hematoma. The patient's condition continued to deteriorate, which prompted emergent exploration. After evacuating 3 L of free blood from the peritoneal cavity, we managed to stabilize the patient. Our case of spontaneous retroperitoneal bleeding adds to the growing number of cases in which enoxaparin has been associated with severe bleeding. A high index of suspicion is necessary if the patient displays any of the signs and symptoms that suggest major hemorrhage. It appears that those at highest risk receive doses approaching 1 mg/kg subcutaneously every 12 hours, have renal impairment, are of advanced age, and receive concomitant medications that can affect hemostasis. On average, a retroperitoneal hematoma occurs within 5 days of therapy with enoxaparin. In high-risk patients, enoxaparin activity (anti-factor Xa) should be carefully monitored.