What is Retroperitoneal Bleeding?
Retroperitoneal bleeding is a medical condition where blood leaks into the space located directly behind the inner lining of the belly, known as the abdominal peritoneum. This space contains many important organs, including the esophagus (food pipe), aorta (large artery), inferior vena cava (a large vein carrying deoxygenated blood to the heart), kidneys, adrenal glands (small glands located on top of each kidney), rectum, and certain parts of the duodenum (first part of the small intestine), pancreas, and colon. It’s often hard to diagnose this condition as the symptoms and causes can vary widely.
Common symptoms may include pain in the stomach, back, side of the body, or groin area, a noticeable lump in the abdominal area, and shock, which means your body isn’t getting enough blood flow.
Effective treatment relies on a swift diagnosis of the bleed, regular check-ups, and stabilizing the patient’s condition. Computerized tomography (CT) scans, which use X-rays and computers to create images of the body, may be used for a more detailed diagnosis. If the bleeding continues, a procedure known as angioembolization, which blocks the blood vessel, may be performed. In severe cases, or when certain injuries are involved, open surgery may be necessary.
Retroperitoneal bleeding is a life-threatening condition with a mortality rate ranging between 6% to 22% among those affected. Therefore, timely diagnosis and treatment by experienced medical personnel are crucial for the patient’s survival.
What Causes Retroperitoneal Bleeding?
Retroperitoneal bleeding, or bleeding in the space behind the stomach and intestines, can be difficult to diagnose because there are so many possible causes. The first detail doctors usually look at is whether the bleeding was caused by some kind of trauma, like a serious injury to the stomach or pelvic area.
If the bleeding wasn’t caused by trauma, there are two other categories: spontaneous bleeding (it happens without any clear cause) and non-spontaneous bleeding (there is a known cause).
Spontaneous bleeding often varies and could be due to several reasons including certain medications that thin the blood, inflammation and bleeding of the pancreas, kidney or adrenal gland cancers, complications in female reproductive health, and bulges in the aorta (the main blood vessel) or kidney arteries.
Non-spontaneous causes might include injury from medical procedures, like inserting a tube into the aorta or femoral artery, or a direct injury during surgery in the stomach or pelvis area.
Risk Factors and Frequency for Retroperitoneal Bleeding
Damage to the area behind the abdominal cavity, also known as the retroperitoneum, is quite common after an abdominal trauma. Studies show that 20-33% of patients with penetrating injuries and 44-80% of patients with blunt force injuries might have this type of damage. These injuries also have a high associated death rate, falling between 18% and 60%.
However, it’s important to mention that spontaneous bleeding in this area, not caused by an injury, is quite rare. Clinical studies show it can happen in 0.6% to 6.6% of patients who are treated with blood-thinning medications, with about 20% of these cases being fatal. In a related study, unintentional bleeding in the retroperitoneum occurred in 0.57% of patients after a non-surgical procedure to open up blocked coronary arteries, with a death rate of just over 10%.
- Abdominal trauma commonly damages the retroperitoneum, with 20-33% of penetrating injuries and 44-80% of blunt force injuries affecting this area.
- The injury-related death rate for this type of damage ranges from 18-60%.
- Spontaneous retroperitoneal bleeding is rare but can occur in 0.6-6.6% of patients on blood-thinners. Around 20% of these cases result in death.
- In a specific study, accidental retroperitoneal bleeding occurred in 0.57% of patients after a non-surgical procedure to treat blocked arteries, and the death rate was slightly over 10%.
Signs and Symptoms of Retroperitoneal Bleeding
Retroperitoneal bleeding is a severe condition that can pose a risk to life. Diagnosing it can be a challenge because the symptoms can vary and might not be immediately obvious. Accurate diagnosis needs a meticulous review of the patient’s medical history and a thorough physical examination. Key factors that clinicians should look for include recent trauma or surgery, a history of aneurysm disease, ongoing pancreatitis, use of blood thinners, and known cancer.
Most people with this condition experience abdominal or side pain, with some also having hip nerve paralysis, which can trigger pain radiating into the groin or pelvis. As the condition progresses, the patient might show signs of anxiety and elevated heart rate, confusion, low blood pressure, and eventually, a drop in body temperature. In some cases, a condition known as “Wunderlich syndrome” may be detected, characterized by pain in the abdomen, back, side or groin, a noticeable mass in the abdomen, and shock.
- Abdominal or side pain
- Radiating pain into groin or pelvis
- Anxiety and increased heart rate
- Confusion and low blood pressure
- Drop in body temperature
- Detectable abdominal mass in some cases
There are several specific signs linked to internal bleeding in the abdomen, which are named after the doctors who first described them. Grey-Turner’s sign refers to a hematoma on the side of the abdomen. Cullen’s sign is a bruise around the belly button. Fox’s sign is a bruise on the inner thigh. Bryant’s sign is a bruised and blood-filled scrotum. Stabler’s sign refers to a hematoma and bruising over the groin ligament.
In some cases, these signs might be absent, especially if the patient has other distracting injuries, like in the case of trauma. In some cases, the bleeding might lead to urinary system involvement, showing as blood in the urine, or reduced urine output due to compression from a growing mass of blood. Also, if the duodenum–the first part of the small intestine–is involved, it can result in gastric outlet obstruction, which is a blockage that keeps stomach contents from moving into the small intestine.
Testing for Retroperitoneal Bleeding
If your doctor suspects that you might be experiencing internal bleeding in your abdominal area (known as retroperitoneal bleeding), they might order some lab tests. The most common one is a test to measure the level of hemoglobin in your blood, which can decrease if you’re bleeding. But, it’s important to note that it might take a while to detect this drop. Other helpful tests can look at clotting time and if you’re taking anticoagulants (blood thinners). A urine test may also be conducted to check if the urinary tract is affected. If the doctor suspects that the bleeding might be serious, they will also test your blood type in case you need a blood transfusion.
Sonography (ultrasound) is a common tool used to diagnose and manage abdominal trauma. This technique, known as the Focused Assessment with Sonography for Trauma (FAST), has changed how doctors deal with abdominal injuries. However, it has some limitations. For example, it can’t effectively assess the retroperitoneal space (the area behind the general area of the abdomen located near the back). So while it’s great for detecting fluid in the abdominal area, it can’t reliably confirm or rule out retroperitoneal bleeding. The FAST exam also can’t identify smaller volumes of fluid (less than 200 mL) in the abdomen or distinguish between different types of fluids, such as blood, urine, or stool.
In a trauma setting, doctors often perform X-rays of the neck, chest, and pelvis. A pelvic X-ray may be the first hint for the doctor that the area behind the abdomen might be affected. However, X-rays aren’t typically as helpful outside of a trauma situation. For investigating retroperitoneal bleeding, a CT scan (computed tomographic scan) with a special dye injected into the veins is usually the best option. CT scans can quickly and repeatedly pinpoint the exact location of blood accumulation or related injuries and show if bleeding is still happening.
It’s important to note that CT scans do have their drawbacks. They use ionizing radiation, which can increase the risk of developing cancer later. The injected dye can also cause kidney damage in some patients. So, when evaluating children or pregnant women, doctors generally prefer techniques that don’t use radiation, such as ultrasound and MRI (magnetic resonance imaging).
Treatment Options for Retroperitoneal Bleeding
Retroperitoneal bleeding, which is bleeding in the area behind the abdominal cavity, can be quite serious and is treated in several steps. These steps range from non-surgical treatment to procedures that block the blood flow (angiography) and in severe cases, surgery. Doctors decide the specific treatment based on several things like where exactly the bleeding is coming from, how stable the patient is, and what caused the bleeding in the first place. In all cases, regardless of how the bleeding was caused, the first step is usually to ensure that the patient’s basic life functions (breathing, heart function, mental state, etc.) are stable.
The retroperitoneum (the area behind the abdomen) can be divided into three regions. Region 1 is in the upper part and includes major organs and blood vessels such as the aorta, pancreas, and duodenum. Region 2 is located beside region 1 and includes the kidneys, adrenal glands and parts of the colon. Region 3 is the lower part that contains the estuary vessels and the rectum.
When a trauma causes retroperitoneal bleeding, the treatment depends on what caused the injury. In cases of penetrating injury (like a knife or gunshot wound), areas 1 and 3 should be surgically checked immediately. If there is active bleeding in region 2, it might also need surgical exploration. For blunt injuries, like a car accident or a hard fall, always explore region 1 and region 2 if there’s active bleeding. However, if bleeding is coming from region 3, surgery should not be attempted because this is usually due to a pelvic fracture and operating could make the bleeding worse.
The primary survey of injured patients using the “ABCDE” method is another way to quickly assess the patient’s condition. It starts with checking the “Airway” to see if it’s clear, then the patient’s “Breathing.“ If there are issues with either the airway or breathing, the patient may need to be intubated to ensure adequate oxygen supply. “C” stands for Circulation, meaning that the medical team needs to establish sturdy vein access to maintain blood flow. If there’s severe bleeding, it’s important that the transfusion of blood and other fluids begins immediately. The team then checks for “Disability”, including a quick check of the patient’s conscious level, spine and pupils. Lastly, they “Expose” the patient, so they can do a full physical exam. In retroperitoneal bleeding, they pay attention to the abdominal exam.
If the patient is stable but still bleeding, an angiography might be used. Here, a catheter (a thin tube) is gently inserted into one of the arteries, usually one in the thigh, and then guided to the bleeding area. A special dye is then injected which allows the doctor to pinpoint the area of bleeding with the help of an imaging technique. Once the injury has been identified, it can be addressed immediately by blocking the blood vessel either with a tiny coil or particle, which stops the bleeding.
No matter the treatment approach, constant reassessment is crucial for all patients with retroperitoneal bleeding. Nonoperative care includes reversing any blood thinning medication, replacing the lost fluids and blood, regular abdominal exams, and trying to identify and address the cause of the bleeding. Doctors pay careful attention to the patient’s heartbeat and blood pressure because patients can get worse quickly despite attempts to stabilize them.
What else can Retroperitoneal Bleeding be?
If an injury occurs to the retroperitoneal area – the part of your body near the back that houses several important organs – it can harm various parts, like the adrenal glands, aorta, inferior vena cava, certain parts of the duodenum, different sections of the pancreas, the ureters, colon, kidneys, esophagus, and rectum. These injuries might happen alone or they could occur together, often if there’s been a traumatic event, and they may appear with other injuries in the retroperitoneal space, other areas of the abdomen, the spine, or the pelvis.
If a sudden, unexplained bleed in the retroperitoneal space is found, doctors need to find out what might have caused it. They would consider things like whether the patient has been using anticoagulation drugs, or has had recent fibrinolytic therapy. Additionally, they might check for things like kidney or adrenal growths, gynecological complications, inflammation of the pancreas, or aneurysms in the aorta and kidneys.
In cases where bleeding in the retroperitoneal area is caused by a medical procedure, it’s crucial to find out exactly where the bleeding is coming from. In such instances, the bleeding likely started along the path of the specific catheter that the doctor used during the procedure. A full check of the blood vessels is needed to see if there has been a rupture, a tearing, a pseudoaneurysm, a fistula, or a wall hematoma.
What to expect with Retroperitoneal Bleeding
Retroperitoneal hemorrhage, a type of internal bleeding that occurs behind the abdomen, often due to trauma, is linked to a high degree of death risk – around 18%. The situations that are most lethal involve blunt trauma, damage to 2 or more retroperitoneal zones (areas behind the abdomen), and those who had surgery more than 6 hours after the injury.
The causes of retroperitoneal bleeding that happens spontaneously (without injury or trauma) are many and varied, leading to different clinical outcomes. Most patients respond well to medical treatment alone. However, around 25% of patients with continuous bleeding and worsening symptoms require angiographic therapy, a type of treatment using images to guide small tubes through blood vessels. An additional 9% may need to go under the knife. The death rate due to all causes ranges from 6% to 22%. It’s common for spontaneous retroperitoneal bleeding to occur in Zone 3, an area behind the abdomen. Those who tragically die while experiencing a bleed are typically also dealing with another medical condition at the same time.
Possible Complications When Diagnosed with Retroperitoneal Bleeding
Various complications may occur due to retroperitoneal bleeding – that is, bleeding in the area behind your abdomen. If a blood clot forms and creates pressure, it could result in leg or pelvic nerve pain, blockage of the small intestine, urinary blockage, or blockage of the opening between the stomach and the small intestine.
Retroperitoneal bleeding can be severe enough to cause a drop in blood pressure, decrease in blood volume, or shock. This could lead to more serious complications such as a heart attack, sudden kidney damage, sudden liver damage, inadequate blood flow to the brain, inadequate oxygen levels in the body, and decay of the intestines.
Surgical intervention also has potential complications such as infection, damage to nearby structures in the surgical field, and increased bleeding. Other complications could arise from angioembolization, a procedure to stop bleeding, which could lead to infection, vascular damage, increased bleeding, kidney damage due to contrast dye, and lack of blood supply to arteries that have been embolized.
Complications due to bleeding behind the abdomen:
- Pain in leg or pelvic nerves
- Blockage of the small intestine
- Urinary obstruction
- Blockage between the stomach and the small intestine
- Heart attack
- Sudden kidney damage
- Sudden liver damage
- Inadequate blood flow to the brain
- Inadequate oxygen levels in the body
- Decay of the intestines
- Increased infection and damage with surgical intervention
- Increased infection, vascular damage, and kidney damage from angioembolization
- Lack of blood supply to embolized arteries
Preventing Retroperitoneal Bleeding
Retroperitoneal bleeding is a serious health condition where blood seeps into space located at the back of the belly – a condition often caused by a severe injury. Sometimes, it might be necessary to have surgery to stop this bleeding. This type of bleeding can also occur due to cancer, taking blood thinning medications, an abnormal swelling of blood vessels, or other stomach diseases. Additionally, unintentional bleeding might happen during medical procedures.
Certain surgeries, such as those involving the abdomen or the heart’s arteries can cause bleeding into this back-of-the-belly space. If this occurs, it may necessitate a hospital stay and potentially more procedures to resolve the issue. Regular check-ups with your primary care physician are crucial. It’s equally important that you take your blood pressure and blood-thinning medications exactly as prescribed.
For men aged over 65, especially those who have smoked, it’s recommended that you have one screening ultrasound of your aorta – the main blood vessel in your body. This is to check for any enlargement, which could increase the risk of this kind of bleeding.
