Traumatic retroperitoneal hematoma

Traumatic

Retroperitoneal

Hematoma

SHELRY M. BAYLIS, M.D., EUGENE H. LANSING, M.D. AND WAYNE W. GLAS, M.D., Eloise, Michigan

From tbe Department of Surgery, Wayne County General Hospital, Eloise, Michigan.

tom (thirty patients). Back pain (thirteen patients), weakness (four patients), syncope (four patients) and nausea (three patients) followed in that sequence. Symptoms of blood loss were often present and in severa instances occurred without evidence of obvious hemorrhage. Extensive retroperitoneal hemorrhage is a condition which, when encountered at operation or necropsy, has according to Cushman [I] (1953) “usuaIIy been reported as an uncommon and puzzIing condition in which Ioss of blood had Most patients in this not been suspected.” report were admitted immediateIy after injury. Many were unabIe to give an adequate history because of the severity of the injury. AbdominaI pain was usually vague and generalized, but occasionaIIy was Iocalized over the hematoma. Gomcyekow has reported that the injection of 150 cc. to 250 cc. of .25 per cent procaine soIution into the retroperitoneal space may cause the symptom of pseudoperitonea irritation to subside [2]. He recommended this procedure as a means of diagnosing retroperitonea1 hematoma. We have not used this diagnostic technic. Physical signs depended upon the source and extent of bleeding. LocaI or generalized tenderness was present in two thirds, or thirty-five, of the patients. Shock occurred in twenty-eight. Absence of bowe1 sounds was noted in eighteen patients. Ecchymoses or abrasions occurred in eighteen patients; however, this did not aid in differentiating between intra- and retroperitoneal hemorrhage. OccasionaIIy a discrete tender mass (hematoma) was paIpabIe. Rectal examination in some cases reveaIed a boggy mass anterior to the rectum. In severa patients the retroperitoneal hematomas exceeded 2,000 m1. and no visibIe source of hemorrhage was evident. This is compatible with experimenta data which have shown that

RA~~MATICretroperitonear hematoma is an infrequently described and poorIy understood clinical entity. This Iesion may present the signs and symptoms of acute surgica1 abdomen or it may present such minima1 signs and symptoms as to go unrecognized or negIected. W’e have recentIy become more aware of this Iesion because of our reIuctance to deIay abdominal operation in any situation in which intra-abdomina1 injury or disease is suspected. OccasionaIIy retroperitoneal hematoma has been the onIy finding at operation. The purpose of the present study was to determine whether traumatic retroperitonea1 hematoma couId be defined as a separate cIinica1 entity. If such a cIass&cation or definition could be made, unnecessary operations and deaths might be avoided. The cause of retroperitonea1 hematoma varies, but in our experience it has been commonly associated with high speed automobiIe accidents. Forty-eight of the fifty patients studied in this report experienced bIunt trauma to the abdomen or flank. Two patients had penetrating injuries to the same areas. The sources of the retroperitonea1 hemorrhage were any organs, bones, blood vesseIs or muscIes adjacent to the retroperitonea1 areas. PeIvic fracture was by far the most common source of retroperitonea1 hemorrhage, occurring in thirty-three patients. BIeeding originated from the bone ends or from soft tissue which \vas Iacerated by sharp fragments. Lacerations of the kidnev, bIadder and urethra were frequently responsibIe (nine and five patients, respectivelyj. OccasionaIIy no definite origin of hemorrhage was identified (five patients). The spleen and liver were the source in two and one patient, respectively. Abdominal pain was the most frequent symp-

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American

Journal

of Surgery,

Volume zoj. April 1962

BayIis, Lansing

and GIas

and fractured vertebra. In one patient peIvic phIeboIiths were dispIaced by the expanding retroperitonea1 hematoma. Intravenous pyeIograms and retrograde cystograms were routineIy obtained in a11 patients with suspected retroperitoneal. hematoma. This was probabIy the most vaIuabIe singIe too1 in the diagnosis of retroperitonea1 hematoma. The pyeIocystographic signs of retroperitonea1 hematoma were as foIIows: poor or nonvisuaIization of one kidney, dispIaced ureter or asymmetry of the urinary bIadder. Of a tota of forty intravenous pyeIograms, seventeen showed abnormahties. Cystograms reveaIed abnormaIities in thirty patients. RetroperitoneaI hematoma was not often considered a primary diagnosis at the time of admission because of the high incidence of other severe injuries. These incIuded head injuries, chest injuries and fractures of the Iong bones. The most frequent compIication was rupture of the hematoma into the peritonea1 cavity. This occurred in thirteen patients and caused signs of peritonea1 irritation. ThrombophIebitis, acute renaI faiIure and intestina1 obstruction were other compIications. Some of these CompIications appeared to be enhanced by increased venous pressure caused by the hematoma. For exampIe, thrombophIebitis and acute renaI faiIure may be aggravated by venous hypertension. Rupture of the peritoneum over the hematoma is probabIy secondary to mechanica and ischemic causes. To determine if increased venous pressure could be caused by retroperitonea1 hematomas, eleven mongreI dogs ranging in weight from 15 to 40 pounds were subjected to artificiaIIy induced retroperitonea1 hematoma. These dogs were anesthetized with intravenous NembutaI.@ After the abdomen and flank were surgicalIy prepared a midIine verticaI incision measuring 3 cm. was made above the symphysis pubis. A No. 18 spina needIe was inserted in the ffank, and the tip guided to a pIace just beneath the peritoneum at the sacra1 promontory. The abdominaI incision was then cIosed with interrupted sutures. The right femoraI artery and vein were exposed in the inguina1 region. InitiaI venous pressure was taken. ApproximateIy 200 to 400 mI. of venous bIood was removed and coIIected in transfusion bottIes. Venous pressures were again obtained. The bIood was then introduced into the retroperitonea1 space with the needle. Venous pressures were again taken.

4,000 m1. of fluid can extravasate into the retroperitonea1 space under pressures equa1 to that in the pelvic vessels [z]. DuIIness to percussion over the ffank or abdomen which did not vary with a change in position was recorded in a few instances, and was a distinct aid in suggesting retroperitonea1 hematoma. UsuaIIy hemogIobin and hematocrit determinations on admission were within normaI Iimits because hemodiIution had not yet occurred. Cushman [I] has reported that progressive anemia is a constant finding. Hematuria was present in thirty-nine of the fifty patients. Complete urinaIysis was done on admission for a11 injured patients. Hematuria may represent the first cIue to a deveIoping retroperitonea1 hematoma. PeritoneaI taps are done in our emergency room when intra-abdomina1 injury is suspected. The technic consists of inserting a No. 18 spina needle into the peritoneal cavity. The presence of noncIotting (defrbrinated) bIood indicates hemorrhage. Free noncIotting bIood was aspirated in eighteen of these patients. In fourteen, no bIood was aspirated. OccasionaIIy a so-caIIed “faIse-positive” peritonea1 tap was obtained because blood was aspirated from the retroperitonea1 hematoma. This has Ied us to the erroneous concIusion of intraperitonea1 hemorrhage in a number of instances. AbdominaI roentgenograms were obtained in every patient. Fracture of the peIvis was the most constant finding (thirty-four patients). Other roentgenographic findings incIuded obliteration of the psoas shadows (sixteen patients), abdomina1 mass (eight patients), paraIytic ileus (four patients), scoliosis, displaced bowe1 478

Traumatic

RetroperitoneaI

peritoneal. These hematomas are exposed and evacuated to determine if the bowel has been injured. Nine of the fifty patients died. Seven deaths occurred in the patients who underwent operation. Five of these deaths were in patients who had multiple severe injuries in addition to the retroperitoneal hematoma. Acute renal failure occurred in two patients, one of Tvhom died. Pneumonia and congestive failure were responsible for the remaining two deaths. In the patients not operated on, one patient died of multiple severe injuries.

Findings

lindings ............ of the spleen ........... Rupture of the bladder. .......... Rupture of the kidney. ........ Rupture of the urethra. ....... Rupture of the ileum. .......... L.xcration of liver and gallbladder No associated findings .......

Hematoma

Associated Rupture

3

COMMENTS

The experimental retroperitoneal hematomas were similar to those observed in the operating room. They frequently extended to the diaphragm bilaterally, into the leaves of the mesentery, into the pelvis and around the kidneys. Often, a smaI1 amount of blood was present in the peritoneal cavity which seemecl to ooze through the peritoneum.

One hour later the abdominal cavity was reexamined. Figure I is a graph of the results and demonstrates that nine of the eleven dogs showed a considerable increase in the periphera1 venous pressure. TREATMENT

Twenty-five of these fifty patients were subjected to operation. (Table I.) In eighteen of the twenty-five, peritoneal taps were positive for abnormalities. Fifteen of the twenty-five had visceral injury in addition to retroperitoneal hematoma. In the remaining ten patients retroperitoneal hematoma was the onIy operative finding. Rupture of the hematoma into the peritoneal cavity occurred in thirteen patients. Supportive treatment aTone was utilized in the other twenty-five patients. This consisted of close observation, bedrest, eIastic dressing for the Iegs and whole blood transfusions as indicated. In the patients who underwent operation, laceration of the aorta or major arteries was not found. A specific bleeding point was seIdom discovered. Bleeding was controlled by ligation of a specific artery in only one instance. In this patient the internal iliac artery was ligated to stop bleeding from pubic bone fragments. Retroperitoneal drains were used in a11 patients with urethral or bladder perforations. In one patient drainage of the retroperitoneal space was necessary because of respiratory distress following increased intra-abdominal pressure. In tweIve patients no operation for hematoma was performed. In general, we do not recommend exploration and drainage of retroperitoneal hematomas except in portions of the gastrointestinal tract which are partially extra-

RESULTS

From a review of the clinical data we believe that isoIated retroperitoneal hematomas of moderate size may be recognized and the patient treated conservatively. Approximately 50 per cent of those admitted to our hospital fell into this classification. These patients usually were not severely injured and did not have multiple injuries. They demonstrated minimal or absent peritonea1 signs and responded readily to genera1 supportive measures. It was cIinicaIIy impossible for us consistently to separate Iarge or expanding retroperitoneal hematomas from intraperitoneal hemorrhage. This was particularly evident with the severely injured patient or the patient with multiple injuries. In addition, in these patients both intra- and retroperitoneal hemorrhage were often present. PeritoneaI signs were usually positive and vital signs were generally unstable. Patients in this category should be operated upon earIy, as soon as the patient’s condition permits. SUMMARY

Retroperitoneal hemorrhage is a lesion which is commonly associated v+ith abdomina1 trauma. It should be recognized as a possible site of massive blood 10s~. The differential diagnosis 479

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Lansing

between intra- and extraperitonea1 hemorrhage was impossibIe in many patients, particuIarIy in the severeIy injured patient or the patient with muItipIe injuries. In these patients we recommend operation as soon as their condition permits. In generaI, patients with uncompIicated retroperitonea1 hematomas diagnosed at operation were best managed conservativeIy. Drains were avoided when possibIe. When the diagno-

and GIas sis is estabIished, either operativeIy or nonoperativeIy, we recommend the use of eIastic support for the Iegs to aid in avoiding the compIications of venous stasis. REFERENCES

1. 2.

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CUSHMAN, G. F. SubperitoneaI hemorrhage. California Med., 78: I I, 1953. GOMCYEKOW, G. E. CIosed fractures of the pelvis compIicated by retroperitonea1 hematomas. Vestnik kbir., 75: 67, 1955.