Review Question - QID 104635

A patient on chronic anticoagulation presenting with flank/abdominal pain and hemodynamic compromise is most likely suffering a spontaneous retroperitoneal hemorrhage. CT scan of the abdomen/pelvis is useful to confirm the diagnosis, identify the extent of the bleed, and detect a specific cause that might be amenable to treatment.

Retroperitoneal hemorrhage/hematoma may occur as either spontaneous (most commonly in anticoagulated patients), traumatic, or iatrogenic (complication from percutaneous vascular access). Conservative treatment in patients who are hemodynamically stable include fluid resuscitation, reversal of anticoagulation/coagulopathy, and blood transfusion. However, in more severe cases, endovascular repair (embolization or stent) or open surgical repair may be required. However, with improvements in technologies in interventional endovascular procedures, open surgery is now rarely indicated.

Wigle et al. discuss guidelines on outpatient anticoagulation, specifically focusing on the use of warfarin. Coumadin is utilized in patients with venous thromboembolism as well as to prevent stroke in patients with atrial fibrillation/flutter or valvular disease. The agent should be stopped 5 days before surgery and can be resumed 12-24 hours post-operatively. Bridging the patient with a low-molecular weight heparin requires a risk-benefit analysis between the risk of thromboembolism versus that of bleeding.

Sunga et al. conduct a cohort study and discuss the etiology, presentation, and management of patients with spontaneous retroperitoneal hematoma. 66% of 89 patients presenting with spontaneous retroperitoneal hematoma were on anticoagulation, with 42% of that 66% taking coumadin. Spontaneous retroperitoneal hemorrhage can happen as either an outpatient with presentation to the emergency department, but is more commonly a complication of an inpatient admission. CT was the most effective imaging modality to identify the bleed. The mortality associated with this is quite high, as the study found an approximately 20% mortality at 6 months for these patients suffering from a retroperitoneal bleed.

Illustration A is a CT scan of a left-sided retroperitoneal hemorrhage (circled in white outline). Illustration B shows a "Grey-Turner" sign, bruising accompanying a retroperitoneal hematoma.

Incorrect Answers:
Answer 1: Although ultrasound may be used to detect a hematoma, it is often not precise enough to identify the extent of the bleed or a potential underlying cause. This patient presenting as an elderly, hypotensive male with abdominal pain might benefit from an abdominal ultrasound prior to a CT scan to rule out a ruptured abdominal aortic aneurysm; however an ultrasound of the right flank would not be helpful.
Answer 2: Radiographs may show signs suggestive of pathology in the abdominal or pelvic regions; however, these imaging studies typically are neither sensitive nor specific enough to diagnose a retroperitoneal bleed.
Answer 3: MRA may show the site of the bleed through extravascular leak of contrast; if a patient were unstable, angiography would be the correct choice in order to attempt to control the bleed through embolization or another interventional procedure. In this patient, CT is recommended first to confirm the diagnosis and evaluate the extent of bleeding.
Answer 4: Although MRI yields excellent imaging of the retroperitoneal structures, it is more expensive and takes more time. CT scan is a preferred imaging modality for retroperitoneal hematoma/hemorrhage.