The American Journal of Surgery 189 (2005) 345–347
Scientific paper
Spontaneous retroperitoneal hemorrhage Felicia A. Ivascu, M.D., Randy J. Janczyk, M.D.*, Holly A. Bair, N.P., Phillip J. Bendick, Ph.D., Greg A. Howells, M.D. Division of Trauma, Department of General Surgery, William Beaumont Hospital, 3601 W. Thirteen Mile, Royal Oak, MI 48073, USA Manuscript received September 14, 2004; revised manuscript November 23, 2004 Presented at the 47th Annual Meeting of the Midwest Surgical Association, Mackinac Island, Michigan, August 15–18, 2004
Abstract Background: We evaluated patients with spontaneous retroperitoneal hemorrhage for reliable predictors of early diagnosis and improved outcomes. Methods: A retrospective chart review was done to determine patient demographic and laboratory findings, presenting symptoms, time to diagnosis, anticoagulant and/or antiplatelet agent use, transfusions, and patient outcome. Results: One hundred nineteen patients were identified; 14 (12%) died (mean age 77 ⫾ 9 years vs. 74 ⫾ 10 years for survivors [P ⫽ 0.235]). All nonsurvivors were on anticoagulants: 8 of 89 (9%) were on heparin or warfarin alone, and 6 of 23 (26% [P ⫽ 0.028]) were on a combined anticoagulant–antiplatelet regimen. Symptom onset to computed axial tomography (CAT) scan averaged 1.3 ⫾ 1.3 days for nonsurvivors versus 1.5 ⫾ 1.9 days for survivors (P ⫽ 0.778). Hemoglobin was 9.07 ⫾ 3.35 for nonsurvivors versus 9.60 ⫾ 2.07 for survivors (P ⫽ 0.435). Eighty-eight patients were transfused, and 10 died; 31 patients had no transfusion, and 4 of these died (P ⫽ 0.821). Conclusions: A high index of clinical suspicion is necessary for diagnosis of spontaneous retroperitoneal hemorrhage because these patients present with a variety of symptoms. Prospective studies are necessary to determine whether earlier diagnosis combined with aggressive resuscitation can impact the high mortality rate seen in these patients. © 2005 Excerpta Medica Inc. All rights reserved. Keywords: Anticoagulant complications; Antiplatelet agents; Coumadin; Heparin; Retroperitoneal hemorrhage
The use of anticoagulants, including oral warfarin and intravenous unfractionated or low molecular–weight heparin sulfate, is now commonplace for the treatment of several disease entities. Although generally considered safe, hemorrhagic complications are not uncommon. Among these complications is hemorrhage isolated to the retroperitoneum. The literature concerning spontaneous retroperitoneal hemorrhage is limited and primarily consists of single case reports or very small series [1–5]. Unlike hemorrhage in other locations, retroperitoneal bleeding can be difficult to diagnose, and a significant delay in the diagnosis and management of spontaneous retroperitoneal hemorrhage may lead to significant morbidity or death. We reviewed our recent experience with these patients to determine whether
* Corresponding author. Tel.: ⫹1-248 898-5925; fax: ⫹1-248 8981667. E-mail address:
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reliable predictors exist for early diagnosis and improved outcomes.
Materials and Methods The records of all patients found to have spontaneous bleeding as identified by International Classification of Diseases–9 code 459.0 and admitted to the hospital between January 1995 and December 2003 were reviewed. Abdominal computerized axial tomography (CAT) scan and/or autopsy reports were reviewed to identify those patients with spontaneous retroperitoneal hemorrhage. Patients were excluded if they had undergone any interventional procedure at or before the time of diagnosis, such as cardiac catheterization, that may have contributed to the retroperitoneal hemorrhage. Data were abstracted from the records of those patients meeting the criteria for patient demographic and laboratory findings, comorbidi-
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F.A. Ivascu et al. / The American Journal of Surgery 189 (2005) 345–347
Table 1 Characteristics of survivors versus nonsurvivors Characteristic
Survivors
Nonsurvivors
P value
Age (y) Sex ACT PT INR Hemoglobin Platelet count
74 ⫾ 10 60F:45M 210 ⫾ 37 20.9 ⫾ 16.6 2.42 ⫾ 2.35 9.07 ⫾ 3.35 217.2 ⫾ 110.3
77 ⫾ 9 8F:6M 211 ⫾ 32 21.5 ⫾ 10.3 2.97 ⫾ 3.16 9.6 ⫾ 2.07 224.7 ⫾ 94.5
0.235 0.335 0.927 0.875 0.570 0.435 0.784
ACT ⫽ activated clotting time; PT ⫽ prothrombin time; INR ⫽ international normalized ratio.
ties, symptoms preceding CAT scan or autopsy, time from symptom onset to CAT scan, type of and indication for anticoagulation, use of antiplatelet agents, any transfusions, and patient outcome. Data were analyzed statistically using Student t or Chi-square testing.
Results One hundred nineteen patients were identified with documented spontaneous retroperitoneal hemorrhage: 68 women and 51 men (mean age of 74 ⫾ 10 years). Eightynine patients were on anticoagulants alone; 7 patients were taking antiplatelet agents alone; and 23 patients were on a combined anticoagulant-plus-antiplatelet regimen. Patients were on anticoagulation for several reasons including atrial fibrillation (n ⫽ 33), myocardial infarction/angina (n ⫽ 20), cerebral vascular accident (n ⫽ 18), deep vein thrombosis (n ⫽ 18), pulmonary embolus (n ⫽ 11), prosthetic valve (n ⫽ 5), and other (n ⫽ 7). Patients presented with a variety of symptoms including (in order of decreasing frequency) abdominal pain, hip and upper thigh pain, hypotension, anemia, and back pain. One hundred seventeen patients underwent CAT scan documentation of a retroperitoneal hemorrhage; only 2 patients had their bleed identified at autopsy. Mean time from symptom onset to CAT scan was 1.5 ⫾ 1.7 days (range 1.1 days for symptoms of hypotension to 2.2 days for anemia [P ⫽ 0.265]). Fourteen patients died (12%; 8 women and 6 men; mean age 77 ⫾ 9 years), and 105 survived (mean age 74 ⫾ 10 years [P ⫽ 0.235]; Table 1). All patients who died were on anticoagulants: 8 of the 89 (9%) were on heparin or warfarin alone, and 6 of the 23 (26%; P ⫽ 0.028) were on a combined anticoagulantand-antiplatelet regimen. Time from symptom onset to CAT scan was 1.3 ⫾ 1.3 days for nonsurvivors versus 1.5 ⫾ 1.9 days for survivors (P ⫽ 0.778). In patients acutely started on anticoagulants, time from initiation of anticoagulant therapy to onset of symptoms was 4.9 ⫾ 5.6 days in survivors and 3.9 ⫾ 3.8 days in nonsurvivors (P ⫽ 0.592). No differences were seen in presenting symptoms for nonsurvivors versus survivors. Hemoglobin at the
time of CAT scan was 9.07 ⫾ 3.35 for nonsurvivors versus 9.60 ⫾ 2.07 for survivors (P ⫽ 0.435), and platelet count was 217.2 ⫾ 110.3 for nonsurvivors versus 224.7 ⫾ 94.5 for survivors (P ⫽ 0.784). There were no significant differences in activated clotting time (ACT), prothrombin time (PT), or international normalized ratio (INR) between survivors and nonsurvivors. Eighty-eight patients received packed red blood cells, and 10 of these died; 31 patients had no transfusion, and 4 of these died (P ⫽ 0.821). Transfused survivors received an average of 4.0 ⫾ 2.5 versus 5.1 ⫾ 3.4 units for patients who died (P ⫽ 0.226).
Discussion Spontaneous retroperitoneal hemorrhage can present a difficult diagnostic dilemma, which if delayed may lead to significant morbidity and mortality. In part because of this difficulty in diagnosis, retroperitoneal hemorrhage historically has not been well documented compared with other complications of anticoagulation. Russek [6] first reported 2 cases of retroperitoneal hemorrhage in 1953. The next 20 years of literature contained only short reports consisting of 1 or 2 cases [7,8]. In 1974, Curry and Bacon reported 9 cases of retroperitoneal hemorrhage in patients on anticoagulation; 1 patient died (11%) [9]. Five years later, Lowe et al [10] described 8 deaths in anticoagulated patients with retroperitoneal hemorrhage. Three of these patients had undergone surgery to investigate the cause of hemorrhage, and only 5 of the 8 patients died secondary to their hemorrhage. The more recent literature contains a few additional case reports, but many focus on retroperitoneal disease (e.g., renal or adrenal tumors) as the nidus for hemorrhage [11–13]. This report is the first large series to attempt to characterize this complication of anticoagulant use. The previously mentioned data did not demonstrate any significant characteristics for patients who develop a spontaneous retroperitoneal hemorrhage secondary to anticoagulation. The overall patient population had typical values for PT, INR, and ACT that would be seen in any population taking heparin or warfarin, and their indication for anticoagulation was typical of such patients. The patients in this study were elderly and predominantly female, but this is again typical of the population on anticoagulation. The results also show that it was not possible to demonstrate among patients who developed retroperitoneal bleeding any defining characteristics predictive of nonsurvivors compared with survivors. Demographics, including age and sex as well as initial symptoms, were not significantly different between survivors and nonsurvivors. Degree of anticoagulation, as defined by ACT or PT/INR, also was not significantly different between nonsurvivors and survivors, and the degree of
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anemia as shown by serum hemoglobin values and transfusion requirements was not predictive of mortality. The limitations secondary to the retrospective nature of this study should be noted. Although there was not a significant difference from time of symptom onset to CAT scan diagnosis between survivors and nonsurvivors, it is difficult to be certain using chart review that the signs and symptoms suggesting retroperitoneal hemorrhage were not present sooner but not appreciated and documented. Additionally, there is no evaluation of a matched control group on anticoagulation who did not bleed, so it is not possible to make definitive statements regarding the characteristics of those more likely to bleed. Finally, there may be patients who went undiagnosed and were therefore not included in the study. For example, unstable patients would not have undergone a CAT scan to confirm the diagnosis, and subsequent nonsurvivors may not have had an autopsy. Spontaneous retroperitoneal hemorrhage occurs in an elderly population receiving anticoagulant therapy and is significantly more likely to cause death in those patients also taking antiplatelet agents. A high index of clinical suspicion is necessary to make the diagnosis as these patients present with a variety of symptoms, laboratory findings, and varying degrees of anemia. Further prospective study is necessary to determine the true incidence of this complication and to determine whether early diagnosis by CAT scan, combined with aggressive resuscitation, can favorably impact the high mortality rate in this patient population.
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References [1] Vanichayakornkul S, Cioffi RF, Haper E, et al. Spontaneous retroperitoneal hematoma: a complication of dialysis. JAMA 1974;230: 1164 – 65. [2] Bhasin HK, Dana CL. Spontaneous retroperitoneal hemorrhage in chronically hemodialzyed patients. Nephron 1978;22:322–27. [3] Swift DL, Lingeman JE, Baum WC. Spontaneous retroperitoneal hemorrhage: a diagnostic challenge. J Urology 1980;123:577– 82. [4] Palleja XE, Domingo P, Fontucuberta J. Spontaneous retroperitoneal hemorrhage during oral anticoagulant therapy. Arch Intern Med 1985; 145:1531–34. [5] Ferrera PC, David SH, Bartfield JM. Spontaneous retroperitoneal hemorrhage presenting as asystolic arrest. Am J Emerg Med 1995; 13:107– 8. [6] Russek HI, Zohman BL. Anticoagulant therapy in acute myocardial infarction. Am J Med 1953;14:651–53. [7] Lange LS. Lower limb palsies with hypoprothrombinaemia. Br Med J 1966;5505:93–94. [8] Parkes JD, Kidner PH. Perieral nerve and root lesions developing as a result of haematoma formation during anticoagulant treatment. Postgrad Med J 1970;46:146 – 48. [9] Curry PV, Bacon PA. Retroperitoneal haemorrhage and neuropathy complicating anticoagulant therapy. Postgrad Med J 1974;50:37– 40. [10] Lowe GD, McKillop JH, Prentice AG. Fatal retroperitoneal haemorrhage complicating anticoagulant therapy. Postgrad Med J 1979;55: 18 –21. [11] Pode D, Caine M. Spontaneous retroperitoneal hemorrhage. J Urology 1992;147:311–18. [12] Swift DL, Lingeman JE, Baum WC. Spontaneous retroperitoneal hemorrhage: a diagnostic challenge. J Urology 1980;23:577– 82. [13] Block M, Davis TE, Wolberg W. Spontaneous retroperitoneal hemorrhage: a case report. J Surg Oncol 1982;21:27–29.