Abstract
A 73-year-old man presented with features of acute abdomen 2 days following evacuation of a subdural haematoma. CT scan demonstrated significant free fluid in the peritoneal cavity as well as an extensive abnormal area in the upper retroperitoneum. There was no obvious free gas or leak of contrast. As there was persistent metabolic acidosis and significant peritonism, the patient proceeded to an exploratory laparotomy. This revealed a large non-expanding retroperitoneal haematoma and free blood in the peritoneal cavity. There was no evidence of active bleeding and the bowel was found to be viable. As the patient was haemodynamically stable, a laparostomy was fashioned and the patient subsequently underwent angiography. This revealed a 1.5 cm pseudoaneurysm arising from the superior mesenteric artery which was treated with coil embolisation. The patient made an uneventful recovery and the laparostomy was closed.
BACKGROUND
Acute abdomen continues to pose a diagnostic challenge despite the developments in imaging modalities. Precise diagnosis can be elusive and the decision to operate on patients who have significant co-morbidities is difficult. Additionally, imaging may not clearly exclude conditions such as ischaemic bowel, localised perforations, etc. The decision to operate then is based on the clinical findings and progression of symptoms and signs.
Identification of a retroperitoneal haematoma at the time of exploratory laparotomy is rare and treatment decisions might not be straightforward. Provided conditions such as a leaking aortic aneurysm are excluded, exploration of a non-expanding retroperitoneal haematoma in a stable patient may be detrimental as this can result in significant haemorrhage. In such a situation formation of a laparostomy and subsequent interventional procedures under radiological guidance is a safe option.
CASE PRESENTATION
A 73-year-old man presented to the neurosurgeons with a chronic subdural haematoma, secondary to trauma. He had been injured against a garage door 3 weeks earlier. He underwent burr-hole drainage of the haematoma. On the second post-operative day he developed acute abdominal pain, abdominal distension and a brief period of hypotension. Abdominal examination revealed signs of peritonism. The hypotension was corrected with crystalloids.
INVESTIGATIONS
Change in haemoglobin prior to and following the onset of abdominal pain: 13.9 g/dl to 12.1 g/dl.
White cell count (WCC) change from 8.66×109/l to 11.73×109/l.
Amylase: 43 IU/l
Base excess in arterial blood gas (ABG) change from −2.2 to −15.0.
INR 1.2, PT (prothrombin time) 14 s, APTT (activated prothrombin time) 32 s.
Liver function test, renal function test and electrolytes were within normal limits (sodium 137 mEq/l, potassium 4.7 mEq/l).
The CT scan demonstrated significant free fluid in the peritoneal cavity. It also identified an abnormal area in the upper retroperitoneum posterior to the stomach and pancreas (fig 1). There was no obvious leak of contrast in the arterial phase of the contrast CT. There was no evidence of free intraperitoneal air and the abdominal aorta appeared normal.
Figure 1.
False aneurysm from a branch of the superior mesenteric artery with a large volume of retroperitoneal and intraperitoneal haematoma.
DIFFERENTIAL DIAGNOSIS
Severe haemorrhagic pancreatitis
Posterior gastric/duodenal perforation
TREATMENT
The patient underwent exploratory laparotomy which revealed a large non-expanding retroperitoneal haematoma (fig 2) and approximately 700 ml of free blood in the peritoneal cavity. There was no evidence of active bleeding and the bowel was found to be viable. As the patient was haemodynamically stable, a laparostomy was fashioned and the patient subsequently underwent angiography. This revealed a 1.5 cm pseudoaneurysm arising from the superior mesenteric artery. This was treated with coil embolisation (fig 3).
Figure 2.
Operative finding of a large retroperitoneal haematoma.
Figure 3.
CT image following embolisation of the pseudoaneurysm.
OUTCOME AND FOLLOW-UP
The patient made an uneventful recovery and was subsequently discharged home.
DISCUSSION
An aneurysm is the dilatation of a localised segment of the arterial system. It is broadly classified into true and false aneurysms based on the layers of the wall. Superior mesenteric artery aneurysm accounts for 5% of all splanchnic artery aneurysms.1 Based on the site, visceral abdominal artery aneurysm rupture could be either retroperitoneal or intraperitoneal. Posterior rupture of a visceral aneurysm leads to a retroperitoneal haematoma. Mortality due to intraperitoneal rupture is usually 50%.2 Occasionally, after an initial rupture into the retroperitoneum, there could be a secondary rupture into the peritoneal cavity (“double rupture”) causing vascular collapse.
The clinical features are due to the intrinsic (based on the blood supply) or the extrinsic (based on the compression of adjoining structures) elements of the aneurysm. Patients may present with gastrointestinal bleeding which is primarily due to bleeding from areas of intestinal infarction.
Both CT and MRI are suitable for the diagnosis of retroperitoneal haematoma, although MRI has its advantages3 in being superior to differentiate between abscesses, haematomas and tumours.4 Spontaneous retroperitoneal haematoma can occur as a complication of an aneurysm rupture. Although there is evidence of spontaneous resolution of retroperitoneal haematomas, these are mainly treated by surgery5 or increasingly through radiological intervention.6 Repair of asymptomatic aneurysms/pseudoaneurysms has been advocated due to their high risk of rupture and death.7 Traditional management has been open surgical ligation, resection of the aneurysm and interposition of a graft. Resection or partial resection of the involved end organ may be required.7 Recent studies have shown that angiography and transcatheter embolisation is a safe method for treating aneurysms, with coil embolisation being the preferred option.8 Other endovascular procedures include thrombin injection, stent graft exclusion or a combination of all the above. Complications of endovascular procedures depend on the site of the aneurysm and the procedure. Acute complications are limited infarction, duodenal and bile duct stenosis, fistula formation, pulmonary embolism, haemorrhagic shock and multi-organ failure. Long term complications are recanalisation and recurrence of the aneurysm and recurrent haemorrhage.9
LEARNING POINTS
Retroperitoneal abnormalities on imaging may be due to a haematoma from visceral artery aneurysm leak.
Angiography and intervention under radiological guidance is an attractive treatment option and can avoid surgery.
The patient should be closely observed following any radiological intervention for potential complications (ie, gut ischaemia).
If a non-expanding haematoma is identified intraoperatively and aortic aneurysm is excluded, then a laparostomy followed by vascular radiological intervention is a reasonable treatment strategy.
The laparostomy can be closed 24–48 h after the intervention.
Acknowledgments
Department of Radiology, Leeds General Infirmary, Leeds LS1 3EX, UK.
Footnotes
Competing interests: none.
Patient consent: Patient/guardian consent was obtained for publication.
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