VA Caribbean Healthcare System San Juan, PR, United States
Gian Rodriguez-Franco, MD, Pedro Rosa-Cortes, MD, Nicole Sosa-Castellanos, MD, Hendrick Pagan-Torres, MD, Doris H. Toro, MD, Alvin A. Almodovar, MD VA Caribbean Healthcare System, San Juan, Puerto Rico
Introduction: Spontaneous retroperitoneal hematoma (SRH) is a rare but potentially lethal clinical entity. It is defined as bleeding into the retroperitoneal space without prior trauma or manipulation. Data surrounding SRH suggests this diagnosis is more common in the elderly and those receiving anticoagulation therapy. Herein, we report a unique case of SRH in a young female hospitalized due to acute alcoholic hepatitis.
Case Description/Methods: A 34-year-old woman with history of alcohol abuse and recent acute pancreatitis presents with a three-day history of jaundice and abdominal pain. Two weeks prior, she binge drank for 10 consecutive days. On examination she was tachycardic and jaundiced. The abdomen was tender, moderately distended, and with caput medusa. There was hepatomegaly. Abdominal sonogram revealed an enlarged, echogenic liver with fatty infiltration and a spleen measuring 11.3 cm with splenic varices. CT of abdomen showed similar findings. She was diagnosed with acute alcoholic hepatitis and was managed with IV steroids due to a 49-point Maddrey score. On day four of hospitalization, she developed worsening abdominal pain. Abdominopelvic CT was repeated and revealed what was thought to be a splenic subcapsular hematoma with hyperdense fluid in the right lower quadrant concerning for hemoperitoneum. An arteriogram demonstrated active hemorrhage from a pancreatic branch arising from the splenic artery but embolization was unsuccessful due to its small size. Hemoglobin levels continued to drop, reaching 5g/dL. Repeated visceral angiography demonstrated persistent active bleeding. Despite bland embolization she continued bleeding requiring multiple transfusions, developed abdominal compartment syndrome, multi-organ failure and died.
Discussion: The available literature on SRH points out a key concept: SRH mimics several acute intra-abdominal pathologies and should be suspected in patients complaining of abdominal pain regardless of their age or coagulation status. Underlying causes of SRH include rupture of parenchymal lesions, malignancies, cysts or vascular malformations. Some suggest an unrecognized trauma in the microcirculation may lead to hemorrhage in the setting of abnormal coagulation. An explanation to this patient’s fatal bleeding is a vascular complication associated to the prior acute pancreatitis. Alcoholic hepatitis and the associated coagulopathy likely contributed to the fatal outcome. Early recognition of SRH is crucial to ensue prompt, appropriate therapy when warranted.
Figure: A: CT demonstrating a liver measuring 32.6cm at midclavicular line with diffuse fatty infiltration B: Repeat CT with interval development of a retroperitoneal hematoma measuring 9.2 x 8.9 x 21.5 cm in AP (red arrow) C: Visceral angiogram demonstrating a small, active hemorrhage by a tiny branch of a pancreatic artery that originates from the splenic artery (white arrow)
Gian Rodriguez-Franco indicated no relevant financial relationships.
Pedro Rosa-Cortes indicated no relevant financial relationships.
Nicole Sosa-Castellanos indicated no relevant financial relationships.
Hendrick Pagan-Torres indicated no relevant financial relationships.
Doris Toro indicated no relevant financial relationships.
Alvin Almodovar indicated no relevant financial relationships.
Gian Rodriguez-Franco, MD, Pedro Rosa-Cortes, MD, Nicole Sosa-Castellanos, MD, Hendrick Pagan-Torres, MD, Doris H. Toro, MD, Alvin A. Almodovar, MD. P2866 - The Obstreperous Spontaneous Retroperitoneal Hematoma, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.