Massive spontaneous retroperitoneal hemorrhage

Case contributed by Dr Paul Clarke

Presentation

Acute abdominal pain and hypovolaemic shock while an inpatient at her local hospital for management of spontaneous bacterial peritonitis and atrial fibrillation (AF) for which she was commenced on therapeutic clexane

Patient Data

Age: 70 years
Gender: Female

Abdominal CT angiogram demonstrates a massive retroperitoneal hematoma measuring 183 x 221 x 350 mm and multiple sites of contrast blushes indicating active bleeding. 

DSA (angiography)

Angiography and Onyx embolization

Interventional angiogram identified her primary bleeding source from the left circumflex iliac artery a branch of the external iliac artery and also to a lesser degree from the left L4 and L5 lumbar arteries.

Case Discussion

The patient was emergently transferred to a tertiary center for endovascular embolization. Endovascular angiography revealed the above primary bleeding sources. Each artery received Onyx embolization. Immediate post embolization images showed satisfactory control however her time in ICU continued to be turbulent with dependency on vasoactive medications and continued transfusion of blood products. Repeat abdominal CT angiogram confirmed an increase in the size of her retroperitoneal hematoma. The patient continued to deteriorate falling into multiorgan dysfunction syndrome thought to be contributed by abdominal compartment syndrome. An emergency midline laparotomy was performed. The massive hematoma was evacuated with a rough calculated volume of 10 L. No active arterial bleeding was identified, perhaps from the massive hematoma achieving tamponade. Fortunately, the patient made a full recovery.

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Case information

rID: 69556
Published: 17th Jul 2019
Last edited: 20th Aug 2019
System: Vascular
Inclusion in quiz mode: Included

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