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,

MD, MPH

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.

RETROPERITONEAL HEMATOMAS

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.

72

Kasotakis

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)

Penetrating

Exploration

Exploration

Exploration/angiography

Blunt

Exploration

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.

73

74

Kasotakis

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

1. Sunga KL, Bellolio MF, Gilmore RM, et al. Spontaneous retroperitoneal hematoma: etiology, characteristics, management, and outcome. J Emerg Med 2012;43(2):e157–61. 2. Ernits M, Mohan PS, Fares LG 2nd, et al. A retroperitoneal bleed induced by enoxaparin therapy. Am Surg 2005;71(5):430–3. 3. Besir FH, Gul M, Ornek T, et al. Enoxaparin-associated giant retroperitoneal hematoma in pulmonary embolism treatment. N Am J Med Sci 2011;3(11):524–6. 4. Kim YH, Kim CK, Park CB, et al. Spontaneous rupture of internal iliac artery secondary to anticoagulant therapy. Ann Thorac Cardiovasc Surg 2013;19(3): 228–30. 5. Britt LD, Maxwell RA. Chapter 12. Management of abdominal trauma. In: Zinner MJ, Ashley SW, editors. Maingot’s abdominal operations. 12th edition. New York: McGraw-Hill; 2013. Available at: http://www.accesssurgery.com. ezproxy.bu.edu/content.aspx?aID557008151. Accessed July 8, 2013. 6. Chan YC, Morales JP, Reidy JF, et al. Management of spontaneous and iatrogenic retroperitoneal haemorrhage: conservative management, endovascular intervention or open surgery? Int J Clin Pract 2008;62(10):1604–13. 7. Ali J. Chapter 95. Torso trauma. In: Hall JB, Schmidt GA, Wood LD, editors. Principles of critical care. 3rd edition. New York: McGraw-Hill; 2005. Available at: http://www.accesssurgery.com.ezproxy.bu.edu/content.aspx?aID52298290. Accessed July 8, 2013. 8. Feliciano DV. Management of traumatic retroperitoneal hematoma. Ann Surg 1990;211(2):109–23. 9. Burlew CC, Moore EE, Smith WR, et al. Preperitoneal pelvic packing/external fixation with secondary angioembolization: optimal care for life-threatening

Retroperitoneal and Rectus Sheath Hematomas

10.

11. 12. 13. 14. 15.

16.

17.

18.

19.

20.

21. 22.

23. 24.

25. 26. 27.

28.

hemorrhage from unstable pelvic fractures. J Am Coll Surg 2011;212(4):628–35 [discussion: 635–7]. Cothren CC, Moore EE, Smith WR, et al. Preperitoneal pelvic packing in the child with an unstable pelvis: a novel approach. J Pediatr Surg 2006;41(4): e17–9. Cherry WB, Mueller PS. Rectus sheath hematoma: review of 126 cases at a single institution. Medicine 2006;85(2):105–10. Smithson A, Ruiz J, Perello R, et al. Diagnostic and management of spontaneous rectus sheath hematoma. Eur J Intern Med 2013;24(6):579–82. Edlow JA, Burstein J. Rectus sheath hematoma. Ann Emerg Med 2000;36(1):79. Gabel A, Muller S. Fatal hematoma during treatment with adjusted-dose subcutaneous heparin therapy. N Engl J Med 1999;340(1):61–2. Lambroza A, Tighe MK, DeCosse JJ, et al. Disorders of the rectus abdominis muscle and sheath: a 22-year experience. Am J Gastroenterol 1995;90(8): 1313–7. Girolami A, Allemand E, Tezza F, et al. Rectus muscle sheath haematoma in a patient with congenital FX deficiency and in another with congenital FVII deficiency. Haemophilia 2010;16(1):182–5. Fitzgerald JE, Fitzgerald LA, Anderson FE, et al. The changing nature of rectus sheath haematoma: case series and literature review. Int J Surg 2009;7(2): 150–4. Fujikawa T, Kawato M, Tanaka A. Spontaneous rectus sheath haematoma caused by warfarin-induced overanticoagulation. BMJ Case Rep 2011;2011. pii: bcr0720114533. Tolcher MC, Nitsche JF, Arendt KW, et al. Spontaneous rectus sheath hematoma pregnancy: case report and review of the literature. Obstet Gynecol Surv 2010; 65(8):517–22. Salemis NS. Spontaneous rectus sheath hematoma presenting as acute surgical abdomen: an important differential in elderly coagulopathic patients. Geriatr Gerontol Int 2009;9(2):200–2. Denard PJ, Fetter JC, Zacharski LR. Rectus sheath hematoma complicating lowmolecular weight heparin therapy. Int J Lab Hematol 2007;29(3):190–4. Donaldson J, Knowles CH, Clark SK, et al. Rectus sheath haematoma associated with low molecular weight heparin: a case series. Ann R Coll Surg Engl 2007; 89(3):309–12. Dubinsky IL. Hematoma of the rectus abdominis muscle: case report and review of the literature. J Emerg Med 1997;15(2):165–7. Parkinson F, Khalid U, Woolgar J. Rectus sheath haematoma: a serious complication of a commonly administered drug. BMJ Case Rep 2013;2013. pii: bcr2012008183. Laohapensang K, Sirivanichai C. An unusual complication of EVAR, spontaneous rectus sheath hematoma: a case report. Ann Vasc Dis 2009;2(2):122–5. Sahin M, Coskun S, Cobanoglu M, et al. Rapidly onset rectus sheath hematoma mimicking cholecystitis. Am J Emerg Med 2011;29(6):698.e5–8. Shokoohi H, Boniface K, Reza Taheri M, et al. Spontaneous rectus sheath hematoma diagnosed by point-of-care ultrasonography. CJEM 2013;15(2): 119–22. McBeth PB, Dunham M, Ball CG, et al. Correct the coagulopathy and scoop it out: complete reversal of anuric renal failure through the operative decompression of extraperitoneal hematoma-induced abdominal compartment syndrome. Case Rep Med 2012;2012:946103.

75

76

Kasotakis

29. Rimola J, Perendreu J, Falco J, et al. Percutaneous arterial embolization in the management of rectus sheath hematoma. AJR Am J Roentgenol 2007;188(6): W497–502. 30. Jafferbhoy SF, Rustum Q, Shiwani MH. Abdominal compartment syndrome–a fatal complication from a rectus sheath haematoma. BMJ Case Rep 2012;2012. pii:bcr1220115332.

Retroperitoneal and rectus sheath hematomas.

The retroperitoneum is rich in vascular structures and can harbor large hematomas, traumatic or spontaneous. The management of retroperitoneal hematom...
393KB Sizes 0 Downloads 0 Views