Skip to main content

Advertisement

SpringerLink
Log in

Spontaneous non-aortic retroperitoneal hemorrhage: etiology, imaging characterization and impact of MDCT on management. A multicentric study

  • EMERGENCY RADIOLOGY
  • Published:
La radiologia medica Aims and scope Submit manuscript

Abstract

Purpose

The purpose of this multicentric study is to assess the usefulness of multiphasic Computed tomography in the identification of spontaneous non-traumatic retroperitoneal hematoma (SRH) and its management, with references to the role of interventional radiology.

Materials and methods

From January 2011 to June 2014, 27 patients with SRH were selected. Patients with aortic, traumatic, or iatrogenic source of bleeding were excluded. All the patients were studied with multiphasic MDCT after injection of intravenous contrast. Digital Subtraction angiography and percutaneous embolization treatment were performed.

Results

CT identified SRH in all cases (100 %), showing the source of bleeding in 11 cases (40 %) and pointing out the source of bleeding in 15 cases (55 %). In one case (5 %), the bleeding origin was recognized only at surgery as adrenal source. CT has identified a contrast medium extravasation in the arterial phase in 17 patients (63 %), treated successfully by percutaneous embolization in 13 and by open-surgery in two cases. Two patients died before undergoing intervention and surgery, respectively. Ten patients (37 %) were non-operatively treated successfully with clinical, laboratory, and imaging follow-up.

Conclusions

Multiphasic CT is the gold standard for the identification of a SRH. Recognition of CT signs of active bleeding is the crucial feature influencing the timing of therapeutic treatment. Urgent embolization should be performed in cases of arterial bleeding or contained vascular injuries supplying the retroperitoneal hematoma. Surgery is to be addressed in cases of actively bleeding hematomas associated with complication. Finally, an initial more conservative approach can be adopted in patients without signs of contrast extravasation or low-flow active bleeding. Technical skill, expertise, and recognition of CT signs of arterial active bleeding are critical features influencing patients management.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11

Similar content being viewed by others

References

  1. Sunga KL, Bellolio F et al (2012) Spontaneous retroperitoneal hematoma: etiology, characteristics, management, and outcome. J Emerg Med 43(2):e157–e161

    Article  PubMed  Google Scholar 

  2. Zhang JQ, Fielding JR, Zou KH (2002) Etiology of spontaneous perirenal hemorrhage: a meta-analysis. J Urol 167:1593–1596

    Article  PubMed  Google Scholar 

  3. Jordan E, Poder L, Courtier J et al (2012) Imaging of nontraumatic adrenal hemorrhage. AJR Am J Roentgenol 199(1):W91–W98

    Article  PubMed  Google Scholar 

  4. Lopez-Sanchez M, Gonzalez-Fernandez C, Valero-Diaz DLC et al (2005) Enoxaparin, retroperitoneal haematoma in the elderly and impaired renal function. Anaesth Intensive Care 33:689–695

    CAS  PubMed  Google Scholar 

  5. Buresta P, Freyrie A, Paragona O et al (2004) Ruptured pancreaticoduodenal artery aneurysm. A case report and review of the literature. J Cardiovasc Surg 45:153–157

    CAS  Google Scholar 

  6. Bonamigo TP, Erling N Jr, Faccini FP (2002) Rupture of a saccular renal artery aneurysm: report of a case. Surg Today 32:753–755

    Article  PubMed  Google Scholar 

  7. Chan YC, Morales JP, Reidy JF et al (2008) Management of spontaneous and iatrogenic retroperitoneal haemorrhage: conservative management, endovascular intervention or open surgery? Int J Clin Pract 62(10):1604–1613

    Article  CAS  PubMed  Google Scholar 

  8. Kruzel-Davila E, Frajewicki V, Kushnir D et al (2005) Retroperitoneal hematoma in a hemodialysis patient receiving low molecular weight heparin. Isr Med Assoc J 7:611–612

    PubMed  Google Scholar 

  9. Guttilla A, Crestani A, Cattaneo F et al (2013) Wunderlich’s syndrome: three cases of acute spontaneous renal bleeding, conservatively treated. Arch Ital Urol Androl 85(4):210–213

    Article  PubMed  Google Scholar 

  10. Malek-Marin T, Arenas D, Gil T et al (2010) Spontaneous retroperitoneal hemorrhage in dialysis: a presentation of five cases and review of the literature. Clin Nephrol 74:229–244

    Article  CAS  PubMed  Google Scholar 

  11. Tomic M, Ulamec M, Trnski D et al (2013) Renal adenocarcinoma presenting as a spontaneous perirenal hematoma in a patient on warfarin therapy—case report and literature review. Coll Antropol 37(2):629–632

    PubMed  Google Scholar 

  12. Parekh S, Jolapara M, Shah T et al (2014) Emergency embolization of actively bleeding renal angiomyolipoma in a patient of tuberous sclerosis. Ren Fail 21:1–5

    Google Scholar 

  13. Lu CY, Min PQ, Wu B (2012) Ct evaluation of spontaneously ruptured renal angiomyolipomas with massive hemorrhage spreading into multi-retroperitoneal fascia and fascial spaces. Acta Radiol Short Rep 1:18

    Article  Google Scholar 

  14. Hanna J, Spencer P, Cornelia S et al (2011) Spontaneous adrenal pheochromocytoma rupture complicated by intraperitoneal hemorrhage and shock. World J Emerg Surg 6:27

    Article  PubMed Central  PubMed  Google Scholar 

  15. Nakajo M, Onohara S, Shinmura K et al (2003) Embolization for spontaneous retroperitoneal hemorrhage from adrenal myelolipoma. Radiat Med 21:214–219

    PubMed  Google Scholar 

  16. Kavashima A, Sandler CM, Ernst RD et al (1999) Imaging of non traumatic hemorrhage of adrenal gland. Radiographics 19:949–963

    Article  Google Scholar 

  17. Sacerdote M, Johnson P, Fishman E (2012) CT of the adrenal gland: the many faces of adrenal hemorrhage. Emerg Radiol 19(1):53–60

    Article  PubMed  Google Scholar 

  18. Manganaro L, Al Ansari N, Barchetti F et al (2013) Bilateral adrenal hemorrhage in a patient with myelodysplastic syndrome: value of MRI in the differential diagnosis. Case Rep Radiol 2013:479836

    PubMed Central  PubMed  Google Scholar 

  19. Mohan IV, Stephen MS (2013) Peripheral arterial aneurysms: open or endovascular surgery? Prog Cardiovasc 56(1):36–56

    Article  Google Scholar 

  20. Balderi A, Antonietti A, Grosso M et al (2012) Endovascular treatment of visceral artery aneurysm and pseudoaneurysm: our experience. Radiol Med 117(5):815–830

    Article  CAS  PubMed  Google Scholar 

  21. Lee SM, Kim HD, Lee YK et al (2013) A case of rupture renal cortical arteriovenous malformation of the right vein in hemorrhagic fever with renal syndrome. Korean J Intern Med 28:365–369

    Article  PubMed Central  PubMed  Google Scholar 

  22. Boersma HE, Nap RH, Haanstra WP et al (2013) A rare cause of spontaneous perirenal haemorrhage in a patient with ANCA-associated vasculitis. Neth J Med 71(6):318–322

    CAS  PubMed  Google Scholar 

  23. Yang HC, Lee S, Kim W et al (2012) Spontaneous perirenal hematoma due to multiple renal artery aneurysms in a patient with presumed polyarteritis nodosa. Vasc Med 17(6):427–428

    Article  PubMed  Google Scholar 

  24. Saba L, Anzidei M, Lucatelli P et al (2011) The multidetector computed tomography (MDCTA) in the diagnosis of splenic artery aneurysm and pseudoaneurysm. Acta Radiol 52(5):488–498

    Article  PubMed  Google Scholar 

  25. Basheer A, Rajan J, Toomas A et al (2013) Bilateral iliopsoas hematoma: case report and literature review. Surg Neurol Int 4:121

    PubMed Central  PubMed  Google Scholar 

  26. Sasson Z, Mangat I, Peckham KA (1996) Spontaneous iliopsoas hematoma in patients with unstable coronary syndromes receiving intravenous heparin in therapeutic doses. Can J Cardiol 12:490–494

    CAS  PubMed  Google Scholar 

  27. Dauty M, Sigaud M, Trosseart M et al (2007) Iliopsoas hematoma in patients with hemophilia: a single center study. Joint Bone Spine 74:179–183

    Article  PubMed  Google Scholar 

  28. Shu C, Hu X, Luo M et al (2011) A review of SA aneurysms with a small subsection on aneurysms arising from a splenomesenteric trunk. Int Angiol 30(5):395–407

    CAS  PubMed  Google Scholar 

  29. Pavlis T, Seretis C, Gourgiotis S et al (2012) Spontaneous rupture of splenic artery aneurysm during the first trimester of pregnancy: report of an extremely rare case and review of the literature. Case Rep Obstet Gynecol 2012:528051

    PubMed Central  PubMed  Google Scholar 

  30. Akkary E, Cramer T, Patel M et al (2010) Superior mesenteric artery aneurysm: an uncommon disease with potentially serious complication. W.V Med J. 106(7):10–14

    PubMed  Google Scholar 

  31. Seo PW (2013) Surgical treatment of rupture renal artery aneurysm: a report of two cases. Korean J Thorac Cardiovasc Surg 46:467–470

    Article  PubMed Central  PubMed  Google Scholar 

  32. Flood K, Nicholson AA (2013) Inferior pancreaticoduodenal artery aneurysm associated with occlusive lesions of the celiac axis: diagnosis, treatment options, outcomes, and review of the literature. Cardiovasc Intervent Radiol 36(3):578–587

    Article  PubMed  Google Scholar 

  33. Brocker JA, Maher JL, Smith RW (2012) True pancreaticoduodenal aneurysms with celiac stenosis or occlusion. Am J Surg 204(5):762–768

    Article  PubMed  Google Scholar 

  34. Gonzalez C, Penado S, Llata L et al (2003) The clinical spectrum of retroperitoneal hematoma in anticoagulated patients. Medicine 82:257–262

    PubMed  Google Scholar 

  35. Chenaitia H, Abrous K, Louis F et al (2011) Relevance of sonography for retroperitoneal hematoma. Am J Emerg Med 29(7):827–828

    Article  PubMed  Google Scholar 

  36. Scialpi M, Scaglione M, Angelelli G et al (2004) Emergencies in the retroperitoneum: assessment of spread of disease by helical CT. Eur J Radiol 50(1):74–83

    Article  CAS  PubMed  Google Scholar 

  37. Furlan A, Fakhran S, Federle MP (2009) Spontaneous abdominal hemorrhage: causes, CT findings and clinical implication. AJR Am J Roentgenol 193:1077–1087

    Article  PubMed  Google Scholar 

  38. Zissin R, Ellis M, Gayer C (2006) The CT findings of abdominal anticoagulant-related hematomas. Smin Ultrasound CT MR 27:117–125

    Article  CAS  Google Scholar 

  39. Federle MP, Pan KT, Pealer KM (2007) CT criteria for differentiating abdominal hemorrhage: anticoagulation or aortic aneurysm rupture? AJR Am J Roentgenol 188:1324–1330

    Article  PubMed  Google Scholar 

  40. Ibukuro K, Oishi A, Tanaka R et al (2006) Signal flare phenomenon as active bleeding in retroperitoneal hematoma with hematocrit effect on dynamic CT scan: three clinical cases and experimental study based on a specific gravity theory. J Comput Assist Tomogr 30(5):787–790

    Article  PubMed  Google Scholar 

  41. Roy-Choudhury SH, Gallacher DJ, Pilmer J et al (2007) Relative threshold of detection of active arterial bleeding: in vitro comparison of MDCT and digital subtraction angiography. AJR Am J Roentgenol 189(5):W238–W246

    Article  PubMed  Google Scholar 

  42. Angle JF, Siddiqi NH, Wallace MJ et al (2010) Quality improvement guidelines for percutaneous transcatheter embolization: Society of Interventional Radiology Standards of Practice Committee. J Vasc Interv Radiol 21(10):1479–1486

    Article  PubMed  Google Scholar 

  43. Guzzardi G, Fossaceca R, Carriero A et al (2014) Endovascular treatment of spontaneous extraperitoneal haemorrhage: immediate and long-term clinical efficiency. Radiol Med 119(2):121–127

    Article  PubMed  Google Scholar 

  44. Pathi R, Voyvodic F, Thompson WR (2004) Spontaneous extraperitoneal haemorrhage: computed tomography diagnosis and treatment by selective arterial embolization. Australas Radiol 48(2):123–128

    Article  PubMed  Google Scholar 

  45. Anderson SW, Hirsch EF, Soto JA et al (2007) Blunt splenic trauma: delayed-phase CT for differentiation of active hemorrhage from contained vascular injury in patients. Radiology 243(1):88–95

    Article  PubMed  Google Scholar 

  46. Uyeda J, Anderson SW, Soto JA et al (2010) Pelvic CT angiography: application to blunt trauma using 64MDCT. Emerg Radiol 17(2):131–137

    Article  PubMed  Google Scholar 

  47. Anderson SW, Hirsch EF, Rhea JT et al (2008) Blunt trauma: feasibility and clinical utility of pelvic CT angiography performed with 64-detector row CT. Radiology 246(2):410–419

    Article  PubMed  Google Scholar 

  48. Pinto A, Niola R, Tortora G et al (2010) Role of multidetector-row CT in assessing the source of arterial haemorrhage in patients with pelvic vascular trauma. Comparison with angiography. Radiol Med (Torino) 115(4):648–667

    Article  CAS  Google Scholar 

Download references

Conflict of interest

The authors declare no conflict of interest

Author information

Authors and Affiliations

  1. Diagnostica per Immagini, USL2 Lucca, Presidio Ospedaliero San Luca, Via Guglielmo Lippi Francesconi, 55100, Lucca, Italy

    Oliviero Caleo, Giorgio Bocchini & Sonia Paoletta

  2. Interventional Radiology Department, Radiology Unit, Uninsubria, Viale Borri 57, 21100, Varese, Italy

    Anna Maria Ierardi & Gianpaolo Carrafiello

  3. Radiologia Universitaria I, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy

    Alessandra Scionti

  4. Radiologia pronto soccorso, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy

    Michele Tonerini

  5. Department of Radiology, PO Pineta Grande, Castel Volturno, Italy

    Franco Guida, Alessandra Perillo & Mariano Scaglione

  6. UO Radiologia, Ospedali Riuniti della Valdichiana, Stabilimento Ospedaliero di Nottola, Montepulciano, Siena, Italy

    Giacomo Sica

Authors
  1. Oliviero Caleo
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Giorgio Bocchini
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sonia Paoletta
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Anna Maria Ierardi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Alessandra Scionti
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Michele Tonerini
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Franco Guida
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Giacomo Sica
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Alessandra Perillo
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Gianpaolo Carrafiello
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Mariano Scaglione
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Oliviero Caleo.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Caleo, O., Bocchini, G., Paoletta, S. et al. Spontaneous non-aortic retroperitoneal hemorrhage: etiology, imaging characterization and impact of MDCT on management. A multicentric study. Radiol med 120, 133–148 (2015). https://doi.org/10.1007/s11547-014-0482-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11547-014-0482-0

Keywords

Search

Navigation