R e t ro p e r i t o n e a l a n d R e c t u s Sheath Hematomas George Kasotakis,
KEYWORDS Retroperitoneal Rectus sheath Hematomas Retroperitoneum KEY POINTS The retroperitoneum is rich in vascular structures and can harbor large hematomas, traumatic or spontaneous. The management of retroperitoneal hematomas depends on mechanism of injury and whether they are pulsatile/expanding. Rectus sheath hematomas are uncommon abdominal wall hematomas usually secondary to trauma to the epigastric arteries of the rectus muscle. Common risk factors include anticoagulation, strenuous exercise, coughing, coagulation disorders, and invasive procedures on/through the abdominal wall. The management is largely supportive, with reversal of anticoagulation and transfusions; angioembolization may be necessary.
The retroperitoneum is an organ-rich region with several vital structures. It can be a site of major bleeding and harbor sizable hematomas caused by its highly vascular nature after trauma, surgical or endovascular interventions in the area, or spontaneously in patients on anticoagulation therapy or with vascular lesions.1–4 The retroperitoneum is divided in 3 anatomically distinct zones (Fig. 1): Zone I, or central retroperitoneal (RP), is defined as the area medial to the renal hila and contains the abdominal aorta and inferior vena cava, the celiac axis, superior mesenteric artery, and proximal renal vasculature. It also contains the pancreas and RP portion of the duodenum. Zone II, or lateral RP, includes the adrenals, the kidneys, and proximal genitourinary tract. Zone III, or pelvic RP, contains the rectum, the iliac vessels, and their branches/tributaries.5 Although in patients with multiple injuries a significant RP hemorrhage can manifest with hemodynamic instability and less commonly with ecchymoses in the affected areas, its clinical presentation in postprocedural or anticoagulated patients can be protean and include signs and symptoms such as malaise, unexplained tachycardia,
Section of Trauma & Acute Care Surgery, Boston Medical Center, Boston University School of Medicine, 840 Harrison Avenue, Dowling 2 South, #2414, Boston, MA 02118, USA E-mail address: [email protected]
Surg Clin N Am 94 (2014) 71–76 http://dx.doi.org/10.1016/j.suc.2013.10.007 surgical.theclinics.com 0039-6109/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
Fig. 1. The zones of the retroperitoneum.
a slowly dwindling hematocrit, hematuria, flank or back pain, ecchymoses, or even hypotension and abdominal compartment syndrome. Although the diagnosis can easily be established with computed tomography, ideally with intravenous contrast that may detect active extravasation, the acute care surgeon should consider RP bleeding in hypotensive injured patients with normal chest and pelvic radiographs and a negative FAST (focused abdominal sonography for trauma).2 The management of RP hematomas, in addition to resuscitation and transfusions as needed, almost always revolves around surgical exploration in cases of spontaneous or postprocedural hemorrhage, with reversal of anticoagulation and angioembolization being useful adjuncts. Traumatic RP hematomas identified at laparotomy are explored depending on the mechanism of injury (blunt vs penetrating) and whether they are pulsatile or expanding.6,7 All zone I RP hematomas mandate exploration, ideally after proximal (and when applicable, distal) control is established, to ensure no major vascular injuries are missed. Similarly, all RP hematomas after penetrating injuries should be explored, especially when major vessels are within the bullet/sharp object trajectory. Zone II and III RP bleeds after blunt injury should be explored only if pulsatile or expanding.8 Should patients with hypotensive blunt trauma with severe pelvic fractures and a zone III hematoma require laparotomy, preperitoneal packing (usually with 3 laparotomy pads on either side of the bladder) can be undertaken through a separate low transverse incision, until angiography and embolization can be performed.5,9,10 Table 1 summarizes the management principles of RP hematomas. RECTUS SHEATH HEMATOMAS
Rectus sheath hematoma (RSH) is a relatively uncommon condition, which arises from bleeding into the sheath of the rectus muscle, typically from trauma to the epigastric
Retroperitoneal and Rectus Sheath Hematomas
Table 1 Management of RP hematomas identified at laparotomy Zone I (Central RP)
Zone II (Lateral RP)
Zone III (Pelvic RP)
Exploration if expanding
Angiography/exploration if expanding
arteries or less commonly of the rectus muscle itself.11,12 Most commonly it is localized below the arcuate line, where the posterior rectus sheath is absent and the epigastric vessels are relatively fixed and vulnerable to shearing forces.13 Although injury to the anterior abdominal wall is the most common triggering factor for RSH, spontaneous RSH is being encountered with increasing frequency.12 Anticoagulation is the risk factor most commonly associated with spontaneous RSH, although other factors, such as antiplatelet therapy, advanced age, pregnancy, hypertension, recent abdominal surgery, and coagulation disorders, have also been described.14–22 Acute paroxysmal coughing seems to be the most common triggering factor, usually in patients with any of the aforementioned predisposing factors.11 In addition to coughing, any condition that leads to a transient, sudden increase in intra-abdominal pressure, such as vomiting, straining during defecation or labor, and strenuous abdominal exercises, can cause RSH.11,22 Women seem to be twice as prone to developing RSH as men because of the differences in muscle mass and stretching of their anterior abdominal wall associated with pregnancy.23 RSH can also be iatrogenic after abdominal wall injections, paracenteses, or other invasive procedures through the lower anterior abdominal wall (Fig. 2).24,25 RSH typically presents with abdominal pain, usually progressively worsening as the hematoma enlarges, and a mass that does not cross the midline. Abdominal wall
Fig. 2. Spontaneous RSH in an anticoagulated patient.
ecchymoses can often be appreciated on clinical examination.11,26 Signs of acute blood loss (tachycardia, dizziness, orthostasis) are frequently present. The pain associated with RSH can worsen while lifting the shoulders from a supine position (Carnett sign), suggestive of abdominal wall pathology.22 Smaller hematomas can become more evident on physical examination if patients contract the abdominal wall musculature by elevating their lower extremities while supine (Fothergill sign).12 One or more of the previously discussed risk factors can usually be elicited in the history. Less commonly, a large RSH can present with hypotension, anemia, and even abdominal compartment syndrome.27,28 Diagnosis is established through consistent history and clinical examination findings and can be confirmed with ultrasonography or computed tomography. The latter can demonstrate active extravasation from the bleeding vessel if intravenous contrast is administered. Even though most RSH are self-limiting with observation alone, they may lead to hemorrhagic shock in up to 37.5% of cases; mortality can be as high as 25%, particularly if associated with anticoagulation therapy.12 In such severe cases, repeated transfusions and/or angioembolization of the bleeding vessel may be required.29 Imaging-guided drainage can be considered in carefully selected cases; however, the risk of superinfection of the residual hematoma and rebleeding caused by the loss of the tamponade effect must be taken into consideration. Surgical evacuation is rarely appropriate because it may release the tamponade effect and is associated with significant morbidity.22 It should be considered in cases when conservative management has failed and hemorrhage is ongoing or in the presence of compartment syndrome.30 REFERENCES
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