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Spontaneous Retroperitoneal Hematoma
EJVES Extra 4, 69±71 (2002) doi:10.1053/ejvx 2002.0177, available online at http://www.sciencedirect.com on
SHORT REPORT
Spontaneous Retroperitoneal Hematoma M. Tamura, M. Shinagawa and Y. Funaki Department of Surgery, Wajima Municipal Hospital, Ishikawa, Japan Key Words: Retroperitoneal hematoma; Iliac vein rupture.
Introduction Spontaneous rupture of the iliac vein is such an uncommon occurrence that most general and vascular surgeons may not consider it in the differential diagnosis of the patient presenting with acute hypotension.1 This report describes the preoperative CT findings of spontaneous iliac vein rupture, and emphasizes that emergency surgery is not always essential.
colloid. CT finding, 4 days after the onset, revealed a hematoma connecting to thrombus in the external iliac vein (Fig. 1b, c, d). Venography showed deep vein thrombosis in the popliteal and femoral vein (Fig. 2b). The common iliac vein was completely occluded and collateral flow was evident (Fig. 2a). Two weeks after onset, the left leg swelling had resolved, and the patient is now mobile and active. Discussion
Case Report A 74-year-old man was admitted to hospital, having collapsed at home. Numbness and swelling of the left leg a week prior to this episode were noted. There was no history of trauma and he was not taking any medication. On admission, he was pale and sweaty, his blood pressure was 68/42 mmHg and the pulse was regular at 120 minÿ1. Abdominal examination revealed a large non-pulsatile mass in the left iliac fossa. Femoral pulses were both present and there were no bruits. Abdominal computerized tomography (CT) scanning confirmed the diagnosis of a left retroperitoneal hematoma (Fig. 1a). Emergency operation was not performed because arterial haemorhage could not be definitively diagnosed, and the patient's hemodynamic status was improved after the infusion of Please address all correspondence to: M. Tamura, Department of Surgery, Wajima Municipal Hospital, 1-1 Yamagishimachi, Wajima, Ishikawa 928-8585, Japan.
Hematomas presenting in the absence of anticoagulation therapy or trauma are uncommon.2 Occasionally, differential diagnosis from soft-tissue neoplasm is needed. A diagnosis could have been made in this case because of the radiological density of the clot on CT imaging, which also excluded a diagnosis of arterial aneurysm, which would be much more likely. A spontaneous rupture of the iliac or femoral vein was more likely in this case, because the left leg of the patient revealed swelling and pain which are typical symptoms of deep vein thrombosis prior to hypovolemic shock. The spontaneous rupture of an iliac vein is a rare phenomenon.3 Since 1961 only 18 cases have been described in the literature. The likely cause in this case is a sudden rise in venous pressure, which is induced by coughing, defecation, and bending. In addition, venous obstruction and damage to the intima by thrombosis may predispose to rupture of the vein.4 All the reported cases except one underwent emergency laparotomy, and revealed a 15±40 mm
1533±3167/03/040069 03 $35.00/0 # 2003 Published by Elsevier Science Ltd
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M. Tamura et al.
Fig. 1. (a) CT scan showing an extensive retroperitoneal hematoma (white arrow). (b±d) CT scan 4 days after onset of symptoms. Deep vein thrombosis was demonstrated on CT(b), which also revealed a hematoma which communicates with the thrombus in the external iliac vein (b, c) (black arrow).
Fig. 2. Venography. (a) Common iliac vein was completely occluded (white arrow) and the collateral flows were distinct (black arrow). (b) Deep vein thrombosis in the popliteal and femoral vein. EJVES Extra, 2002
Spontaneous Retroperitoneal Hematoma
(mean 20 mm) tear in the iliac vein. Five cases involved swelling of the leg soon after direct suture or ligation of the vein was performed. Two cases died despite intensive treatment. Two points should be made about this case; the first is that the diagnosis cannot be made on the clinical findings alone and the second is that conservative treatment can be successful because of the development of collateral flow.
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References 1 McDonald RT, Vorpahl TE, Caskey J. Spontaneous rupture of the iliac vein. Vasc Surg 1980; 14: 330±333. 2 Chia SH, Torosian MH. Spontaneous pelvic hematoma simulating neoplasm: Case report and literature review. Oncol Rep 1999; 6: 189±191. 3 Damme HV, Haststein G, Limet R. Spontaneous rupture of the iliac vein. J Vasc Surg 1993; 17: 757±758. 4 Stock SE, Gunn A. Spontaneous rupture of the iliac vein. Br J Surg 1986; 73: 565.
EJVES Extra, 2002
SHORT REPORT
Spontaneous Retroperitoneal Hematoma M. Tamura, M. Shinagawa and Y. Funaki Department of Surgery, Wajima Municipal Hospital, Ishikawa, Japan Key Words: Retroperitoneal hematoma; Iliac vein rupture.
Introduction Spontaneous rupture of the iliac vein is such an uncommon occurrence that most general and vascular surgeons may not consider it in the differential diagnosis of the patient presenting with acute hypotension.1 This report describes the preoperative CT findings of spontaneous iliac vein rupture, and emphasizes that emergency surgery is not always essential.
colloid. CT finding, 4 days after the onset, revealed a hematoma connecting to thrombus in the external iliac vein (Fig. 1b, c, d). Venography showed deep vein thrombosis in the popliteal and femoral vein (Fig. 2b). The common iliac vein was completely occluded and collateral flow was evident (Fig. 2a). Two weeks after onset, the left leg swelling had resolved, and the patient is now mobile and active. Discussion
Case Report A 74-year-old man was admitted to hospital, having collapsed at home. Numbness and swelling of the left leg a week prior to this episode were noted. There was no history of trauma and he was not taking any medication. On admission, he was pale and sweaty, his blood pressure was 68/42 mmHg and the pulse was regular at 120 minÿ1. Abdominal examination revealed a large non-pulsatile mass in the left iliac fossa. Femoral pulses were both present and there were no bruits. Abdominal computerized tomography (CT) scanning confirmed the diagnosis of a left retroperitoneal hematoma (Fig. 1a). Emergency operation was not performed because arterial haemorhage could not be definitively diagnosed, and the patient's hemodynamic status was improved after the infusion of Please address all correspondence to: M. Tamura, Department of Surgery, Wajima Municipal Hospital, 1-1 Yamagishimachi, Wajima, Ishikawa 928-8585, Japan.
Hematomas presenting in the absence of anticoagulation therapy or trauma are uncommon.2 Occasionally, differential diagnosis from soft-tissue neoplasm is needed. A diagnosis could have been made in this case because of the radiological density of the clot on CT imaging, which also excluded a diagnosis of arterial aneurysm, which would be much more likely. A spontaneous rupture of the iliac or femoral vein was more likely in this case, because the left leg of the patient revealed swelling and pain which are typical symptoms of deep vein thrombosis prior to hypovolemic shock. The spontaneous rupture of an iliac vein is a rare phenomenon.3 Since 1961 only 18 cases have been described in the literature. The likely cause in this case is a sudden rise in venous pressure, which is induced by coughing, defecation, and bending. In addition, venous obstruction and damage to the intima by thrombosis may predispose to rupture of the vein.4 All the reported cases except one underwent emergency laparotomy, and revealed a 15±40 mm
1533±3167/03/040069 03 $35.00/0 # 2003 Published by Elsevier Science Ltd
70
M. Tamura et al.
Fig. 1. (a) CT scan showing an extensive retroperitoneal hematoma (white arrow). (b±d) CT scan 4 days after onset of symptoms. Deep vein thrombosis was demonstrated on CT(b), which also revealed a hematoma which communicates with the thrombus in the external iliac vein (b, c) (black arrow).
Fig. 2. Venography. (a) Common iliac vein was completely occluded (white arrow) and the collateral flows were distinct (black arrow). (b) Deep vein thrombosis in the popliteal and femoral vein. EJVES Extra, 2002
Spontaneous Retroperitoneal Hematoma
(mean 20 mm) tear in the iliac vein. Five cases involved swelling of the leg soon after direct suture or ligation of the vein was performed. Two cases died despite intensive treatment. Two points should be made about this case; the first is that the diagnosis cannot be made on the clinical findings alone and the second is that conservative treatment can be successful because of the development of collateral flow.
71
References 1 McDonald RT, Vorpahl TE, Caskey J. Spontaneous rupture of the iliac vein. Vasc Surg 1980; 14: 330±333. 2 Chia SH, Torosian MH. Spontaneous pelvic hematoma simulating neoplasm: Case report and literature review. Oncol Rep 1999; 6: 189±191. 3 Damme HV, Haststein G, Limet R. Spontaneous rupture of the iliac vein. J Vasc Surg 1993; 17: 757±758. 4 Stock SE, Gunn A. Spontaneous rupture of the iliac vein. Br J Surg 1986; 73: 565.
EJVES Extra, 2002