Management of Spontaneous and Iatrogenic Retroperitoneal Haemorrhage: Conservative Management, Endovascular Intervention or Open Surgery?

Y.C. Chan; J.P. Morales; J.F. Reidy; P.R. Taylor

Disclosures

Int J Clin Pract. 2008;62(10):1604-1613. 

In This Article

Spontaneous Retroperitoneal Bleed

Spontaneous retroperitoneal bleeding is a distinctive clinical entity that can present in the absence of specific underlying pathology or trauma.[15] Isolated case reports exist in the literature stating that spontaneous retroperitoneal haemorrhage may occur without any precipitating factors, such as spontaneous haemorrhage into a pre-existing benign adrenal cyst or bleeding from a left inferior phrenic artery.[16] Spontaneous bleed can occur in patients with factor IX or factor X deficiency,[17] in patients with von Willebrand disease,[18] or in patients with antiphospholipid syndrome.[19] Rarely, spontaneous retroperitoneal haematoma may develop if the patient is on clopidogrel.[20]

It is most commonly seen in association with patients with anticoagulation therapy, bleeding abnormalities, and haemodialysis,[21] and may represent one of the most serious and potentially lethal complications of anticoagulation therapy (Fig 1). The incidence of retroperitoneal haematoma has been reported at 0.6-6.6% of patients undergoing therapeutic anticoagulation.[3,22,23] Warfarin, unfractionated and low-molecular weight heparin have all been implicated.[24] The risk of bleeding during unfractionated heparin therapy has been estimated to be two- to fivefolds greater than that with warfarin.[25] In a review of 51 cases of patients receiving unfractionated heparin and developing spontaneous retroperitoneal haematoma, most of their coagulation parameters were in the therapeutic range.[26] The risk of low-molecular weight heparin causing retroperitoneal haematoma is often increased if the patient is also receiving long-term warfarin. The elderly patients, and those with renal failure on dialysis are also at risk.[27,28,29] In general, patients maintained on chronic haemodialysis have an increased incidence of spontaneous bleeding from various parts of the body, especially if they are receiving heparin or warfarin.[30]

Figure 1.

Spontaneous retroperitoneal haematoma in an anticoagulated patient with thrombophilia. CT scan showed large haematoma without obvious source of bleeding (A). Urgent aorto-iliac arteriogram did not show any active bleeding, but selective mesenteric views show active bleeding (black arrow) from branches of ileocolic vessels (B), which were successfully embolised with coils

The pathophysiology and pathogenesis of spontaneous retroperitoneal bleeding remain unclear. It has been hypothesised that diffused occult vasculopathy and arteriosclerosis of the small vessels in the retroperitoneum may render them friable and therefore prone to rupture, although such theories have not been substantiated on histology.[31] Qanadli et al.[32] postulated that spontaneous bleeding starts at the microvascular level, and large vessels become disrupted or stretched as the haematoma enlarges. Others have suggested that heparin- or anticoagulation- induced immune microangiopathy may be responsible, where unrecognised minor trauma in the micro-circulation in the presence of coagulation may lead to haemorrhage.[33] Although the term spontaneous implies the lack of observable injury, many authors have suspected that unrecognised trauma (such as minor trauma in sports and vomiting or coughing) may initiate blood loss which continues unabated when clotting factors are absent or depleted. In a retrospective study of 12 patients undergoing anticoagulation therapy who developed large rectus sheath haematoma, six patients had a history of coughing fits.[34] Such minor trauma is a recognised inciting factor in haemophilia-related spontaneous retroperitoneal bleed.[35,36,37]

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