Retroperitoneal hemorrhage with hematoma formation is a significant complication for patients receiving anticoagulation. This may occur in patients receiving either heparin or oral anticoagulants. Most cases are spontaneous but some may occur after injury or associated with a demonstrable lesion (tumor, aneurysm, other).


Patients: mean age ranges from 60 to 74 (usually in older adults)


About half of the patients will be over-anticoagulated while the rest will be in the therapeutic range.


Usual clinical features (Lenk or Wunderlich triad):

(1) abdominal, pelvic, hip or groin pain

(2) palpable abdominal mass

(3) hemorrhagic hypotension or shock with anemia


Additional findings:

(1) Cullen sign (ecchymoses around the umbilicus)

(2) Grey-Turner sign (ecchymoses in the flanks)

(3) decreased strength in psoas and/or quadriceps muscles

(4) hematoma within the iliopsoas muscle

(5) hemorrhage into the adrenal glands


Additional complications due to compartment syndrome in the retroperitoneal space:

(1) symptoms due to compression of the femoral nerve (pain, paresis, hypoesthesia)

(2) pressure on kidney with declining function

(3) pressure on the ureters reducing urine flow

(4) pressure on the pancreas


Imaging studies (CT, ultrasound) is able to demonstrate the lesion.


Once a hematoma is identified then:

(1) anticoagulation is stopped

(2) an attempt is made to reverse the anticoagulation if possible (vitamin K, FFP, factor VII concentrate, protamine sulfate)

(3) blood transfusion and medical support for hemorrhage

(4) hormone support if there is hemorrhagic destruction of the adrenal glands

Management Problem


when is surgical intervention indicated

usually surgery is not performed; surgery is indicated if there is a demonstrable lesion such as an aneurysm or tumor; embolization is usually tried first if medical management fails and a leak can be found on arteriography

when to drain the hematoma with a catheter

indications include femoral nerve compression or decreasing renal function, but the hematoma may reform once the tamponanding pressure is removed

when to re-initiate anticoagulation therapy

if there is a clear indication for anticoagulation then it can usually be restarted in a few (> 4) days after bleeding is controlled and patient is stable


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