retroperitoneal haemorrhage

see also:

• The adult with back pain in the ED

• retroperitoneal bleeding can be life threatening and often diagnosis is delayed

• flank pain - often of sudden onset
• if forms a large psoas haematoma, may present with:
  • constipation
  • urinary frequency
  • femoral neuropathy
  • fever
• haematuria if aetiology is renal
• late, Cullen's sign (umbilical bruising), Gray-Turner's sign (flank ecchymosis), the shocked hypotensive patient

• coagulopathy
• renal or adrenal conditions:
  • renal angiomyolipoma
  • adrenal myelolipoma
  • phaeochromocytoma
  • adrenal haemangioma
  • ruptured visceral artery aneurysm
  • necrotizing arteritis
  • connective tissue (CT) disorders

• trauma
• ruptured abdominal aortic aneurysm (AAA)
• iatrogenic - femoral cannulation;

• CT abdomen
  • plain first to assess for other causes and should demonstrate the haemorrhage
  • THEN, if positive, contrast angiography to determine site of bleeding

• IV access
• send bloods for FBE, U&E, lipase, group and hold +/- X-match, coagulation profile
• resuscitate with iv fluids if haemodynamic compromise
• treat any underlying coagulopathy
• consider tranexamic acid (Cyclokapron)
• careful observation to detect deterioration early
• analgesia
• treat underlying cause as indicated
  • interventional radiology with intra-arterial embolisation or stent-grafting