A 23-year-old female with a past medical history of hip dysplasia presents with 2 days of non-positional/non-prodromal syncope, severe central lower back pain, and self-reported anemia. Seven days ago, she underwent a periacetabular osteotomy, which she describes as follows: “They broke my pelvis in a few places to realign it with my femur, and placed screws between it and my new acetabulum.”
She reports several days of downtrending hemoglobins in the postoperative period which improved without requiring transfusions. Besides a few X-rays of her hip, she was never re-imaged postoperatively. Since discharge, her primary care physician has been monitoring her hemoglobin, which seems to have settled around 8.5.
When she started syncopizing without warning yesterday, she went to a different ED where she was fluid-resuscitated and discharged home with instructions to increase her dietary iron consumption. Because the episodes persisted and in fact became more frequent today, she presented to this ED.
She denies fevers, nausea/vomiting, diarrhea, constipation, urinary symptoms, bowel/bladder incontinence, or a history of seizures. Her mother and aunt, both of whom are RNs and at the bedside, deny any family history of sudden unexplained death, anemia, arrhythmias, seizures, or CNS disease.
The patient’s vital signs on arrival were: afebrile, BP 107/70, HR 80, RR 12, O2 saturation 100% on room air. Notable exam findings included: a tricuspid systolic murmur (which she was not aware she had), acceptable perfusion per the skin/peripheral pulse exams, no midline or paraspinal back tenderness to palpation, no rashes or ecchymoses, a well-healing surgical site in the right groin, nausea and lightheadedness on sitting up, no diaphoresis or pallor, and suprapubic tenderness to palpation.
At this time, the differential included valvular disease, arrhythmia, retroperitoneal hematoma with or without hemorrhage, and orthostasis.
The patient’s EKG was negative for WPW, AV block, Brugada, bifascicular block, LVH, epsilon waves, or repolarization abnormalities.
A bedside echocardiogram was negative for pericardial effusion or signs of right heart strain, and demonstrated a normal-appearing ejection fraction. This was followed by a formal echocardiogram, which was unremarkable with the exception of trace tricuspid regurgitation.
CT of the abdomen and pelvis was generally reassuring, and specifically excluded hematoma or active hemorrhage. Her CBC revealed a hemoglobin of 6, for which she received 1 unit of packed red blood cells. Her chemistry, coagulation studies, urinalysis, and beta hCG were all unremarkable. She was ultimately admitted to the medical service for syncope.
Although retroperitoneal hemorrhage wasn’t the ultimate answer in this case, I didn’t consider that diagnosis in the differential right away... so let’s review it!
Retroperitoneal hematomas/hemorrhages fall into 3 categories: spontaneous, traumatic, and post-procedural. For each category, note the typical risk factors:
Spontaneous: coagulopathy, bleeding dyscrasias, vasculopathy, hemodialysis dependence
Traumatic: injury (typically blunt more than penetrating) to the retroperitoneal organs, pelvic fracture with blood loss from the site (sometimes due to a disrupted pelvic venous plexus)
As a reminder, the retroperitoneal organs can be remembered using the mnemonic SAD PUCKER:
Suprarenal (adrenal) gland
Aorta/IVC, duodenum (segments 2-4)
Pancreas (all segments except for the tail)
Ureters
Colon (ascending/descending)
Kidneys
Esophagus
Rectum.
Post-procedural: after endovascular or percutaneous (ie femoral access/IR cannulation) procedures
The history and exam for retroperitoneal hematoma can vary widely, which makes this diagnosis particularly difficult if you don’t consider it in the first place. The history may (or may not) include back/groin/flank/abdominal pain, a palpable mass/swelling, shock due to acute blood loss, and hematuria. Note that the psoas hematoma, a special case, may also present with constipation, urinary frequency, femoral nerve compressive neuropathy, and/or fever.
The physical exam may (or may not) include lower extremity paresis, anterior thigh (i.e. femoral nerve) hypoesthesia, Cullen’s/Grey-Turner signs (which are notably late findings), and abdominal compartment syndrome (which may suggest impending renal failure). My patient had none of these exam findings.
The diagnostic studies you may consider include:
CBC
lipase (if you suspect pancreatic or duodenal injury)
urinalysis (if you suspect genitourinary system injury)
coagulation studies
CT abdomen/pelvis with IV contrast (to find the suspected bleeding source).
The general management strategy of this pathology revolves around finding the source of the bleeding. If the patient is hemodynamically unstable or tenuous, ICU admission is best. Manage pain aggressively and resuscitate with blood products as well as anticoagulant reversal when indicated. In extreme cases, patients may require percutaneous drainage, embolization, or even surgical decompression of the hematoma.
Take-Away #1:
Remember the 6 compartments where patients can experience hemorrhage secondary to trauma (retroperitoneum, pelvis, long bones, chest, abdomen, street)... and that surgery qualifies as trauma.
Take-Away #2:
The history and exam in retroperitoneal hemorrhage is unreliable. CT imaging with IV contrast is key.
Take-Away #3:
Resuscitate appropriately (i.e. don’t treat acute blood loss anemia with LR).
References
Edited by Bassam Zahid, MD