A case report on spontaneous retroperitoneal hemorrhage

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A case report on spontaneous retroperitoneal hemorrhage

Spontaneous retroperitoneal hemorrhage (SRH)—a rare condition where blood vessels in the space behind the abdominal organs rupture without trauma, surgery, or tumor involvement—is notoriously hard to diagnose and carries a high risk of death. For patients with chronic health conditions, SRH can strike unexpectedly, progressing rapidly from vague symptoms to life-threatening shock. A 2021 case report from the Chinese Medical Journal details the story of a 49-year-old woman whose long-term diabetes and hypertension set the stage for this devastating event, offering critical lessons for doctors and patients alike.

The Patient’s Story

Ruo-Dong Han and Xiu-Xia Yan, critical care physicians at the People’s Hospital of Bozhou (affiliated with Anhui Medical University), treated a 49-year-old postmenopausal woman admitted in February 2019 for leg swelling, reduced urine output (oliguria), and worsening health over two weeks. She had a 19-year history of type 2 diabetes (complicated by kidney damage, nerve problems, and peripheral vascular disease) and 2 years of hypertension. Her initial tests showed high blood sugar (15.47 mmol/L), elevated blood pressure (143/102 mmHg), and normal hemoglobin (Hb, a marker of red blood cells: 119 g/L).

Doctors prescribed diuretics (for swelling), insulin (for diabetes), blood thinners (low-molecular-weight heparin and aspirin), and kidney support. But on February 14, she developed acute left heart failure—unable to lie down due to shortness of breath—and was moved to the ICU. There, she received oxygen, sedation, blood pressure management, and continuous renal replacement therapy (CRRT), a dialysis-like treatment for acute kidney failure.

Over the next five days, her Hb dropped to 93 g/L (a sign of anemia), so doctors stopped her blood thinners. On February 20, she reported left lower abdominal pain—and her Hb plummeted to 71 g/L. An ultrasound showed fluid in her pelvic area, and a belly tap (peritoneal puncture) revealed clear yellow fluid (not blood). She received urgent fluids and a blood transfusion, but her Hb continued to fall—to 60 g/L—even after 2 units of red blood cells. Her heart rate spiked to 120 beats per minute, and doctors suspected a ruptured lumbar artery (a blood vessel in the lower back) causing active bleeding.

Emergent artery embolization (a procedure to block the bleeding vessel) was planned, but during transport to the catheterization lab, her blood pressure crashed from 117/84 mmHg to 50/30 mmHg. She lost consciousness, and despite urgent fluids and medications to raise blood pressure, her heart stopped. Cardiopulmonary resuscitation (CPR) failed, and she died from hemorrhagic shock (severe blood loss) and organ failure.

What Is Spontaneous Retroperitoneal Hemorrhage?

Retroperitoneal hemorrhage usually stems from trauma, surgery, or organ/tumor rupture. SRH, however, has no clear trigger—it’s defined as spontaneous rupture of blood vessels in the retroperitoneal space (behind the stomach, intestines, and other abdominal organs). It’s rare: studies show SRH affects 0.6–6.6% of people on blood thinners, 0.9% of dialysis patients, and 0.3–1.4% of those with kidney cancer. For people without these risks, it’s even more uncommon, as noted in a 2011 study in Emerg Radiol.

Why Does SRH Happen?

While SRH’s exact cause isn’t always clear, most patients have underlying vascular damage from conditions like hypertension or atherosclerosis (hardened arteries). In this case, the woman’s long-term diabetes and hypertension likely weakened her artery walls: diabetes and hypertension together accelerate atherosclerosis, making vessels more prone to rupture. CRRT dehydration may have suddenly changed pressure around her retroperitoneal vessels, triggering the weakened wall to break. She also had nephrotic syndrome—a kidney condition that increases blood vessel permeability—leading to fluid buildup behind her abdomen. This pressure may have “peeled” the vessel wall, causing bleeding.

Symptoms to Watch For

SRH often presents with the “Lenk triad”: abdominal pain, shock (low blood pressure, rapid heart rate), and a non-pulsating belly mass. But symptoms vary based on where and how much bleeding occurs. Key warning signs include:

  • Sudden or worsening abdominal/back pain
  • Rapid drop in Hb (unexplained anemia)
  • Abdominal swelling or distension
  • Trouble breathing or lying down

In this case, the woman’s falling Hb was a critical red flag—even after a blood transfusion, her Hb didn’t rise, signaling ongoing internal bleeding.

Diagnosis and Treatment Challenges

Ultrasound is a quick first test for SRH, but abdominal CT scans are more reliable for locating bleeding and hematomas (blood clots). Enhanced CT (with contrast dye) can show active bleeding but wasn’t used here: moving the patient could worsen bleeding, and contrast dye might harm her already failing kidneys.

Treatment depends on the bleed’s severity:

  • Conservative care: Rest, fluids, and monitoring for small, stable hematomas.
  • Interventional therapy: Artery embolization (blocking the bleeding vessel) for active bleeding.
  • Surgery: For uncontrollable hemorrhage.

For this patient, doctors acted fast to plan embolization, but the bleed progressed too quickly. SRH’s high mortality—especially when combined with kidney failure—highlights the need for rapid, coordinated care.

Key Takeaways

This case underscores three critical lessons:

  1. Awareness saves lives: For doctors, an unexplained Hb drop in a patient with diabetes or hypertension should trigger SRH suspicion.
  2. Multidisciplinary teams matter: SRH treatment requires collaboration between critical care, radiology, and interventional teams to balance diagnosis and intervention.
  3. Chronic condition management is key: Controlling blood sugar and pressure may reduce SRH risk for people with diabetes or hypertension—though SRH can still strike unexpectedly.

While SRH remains poorly understood, sharing cases like this helps doctors recognize warning signs earlier. More research is needed to unravel its causes and improve treatments—but for now, vigilance is the best defense.

The authors obtained consent from the patient’s family to share her story (her name and identifying details were withheld). The original study was published in the Chinese Medical Journal (2021;134(14):1750–1752).

References

  1. Diaz JR, Agriantonis DJ, Aguila J, Calleros JE, Ayyappan AP. Spontaneous perirenal hemorrhage: what radiologists need to know. Emerg Radiol 2011;18:329–334. doi: doi.org/10.1007/s10140-011-0944-9
  2. Torp-Pedersen C, Jeppesen J. Diabetes and hypertension and atherosclerotic cardiovascular disease: related or separate entities often found together. Hypertension 2011;57:887–888. doi: doi.org/10.1161/HYPERTENSIONAHA.110.168583
  3. Gonzalez C, Penado S, Llata L, Valero C, Riancho JA. The clinical spectrum of retroperitoneal hematoma in anticoagulated patients. Medicine 2003;82:257–262.
  4. Lu HY, Wei W, Chen QW, Meng QG, Hu GH, Yi XL, et al. A rare life-threatening disease: unilateral kidney compressed by huge chronic spontaneous retroperitoneal hemorrhage. Ther Clin Risk Manag 2018;14:489–492. doi: doi.org/10.2147/TCRM.S152460
  5. Peng CH, Hsu CH, Wang NL, Lee HC, Lin SP, Chan WT, et al. Spontaneous retroperitoneal hemorrhage in Menkes disease: a rare case report. Medicine 2018;97:e9869. doi: doi.org/10.1097/MD.0000000000009869

Original study DOI: doi.org/10.1097/CM9.0000000000001278

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