Spontane retroperitoneale und Rektusscheidenhämatome und ihre interventionelle Therapie: ein Review

Zussamenfassung

Hintergrund Retroperitoneale und Rektusscheidenhämatome (RH/RSH) stellen ein Krankheitsbild dar, das unter anderem wegen unspezifischer klinischer Symptomatik und des drohenden Risikos einer Exsanguination bzw. Folgen des Blutverlustes, Mortalitätsraten bis zu 30 % aufweist. Ätiologisch werden traumatische, iatrogene und spontane Subtypen unterschieden. Mit in der Literatur beschriebenen Risikofaktoren eines Lebensalters > 65 Jahre und der Einnahme antikoagulativer Medikation werden steigende Inzidenzen insbesondere des spontanen Subtyps der RH/SRH in der alternden Gesellschaft prognostiziert.

Material und Methodik Analyse, Resümee und Diskussion publizierter Grundlagenarbeiten und Expertenempfehlungen.

Ergebnisse Am häufigsten wird das Vorliegen abdomineller Schmerzen im Rahmen der klinischen Untersuchung beschrieben; in Abhängigkeit vom Ausmaß des Volumenverlustes können die Symptome eines abdominellen Kompartments und eines hämorrhagischen Schocks auftreten. Die Computertomographie-Angiographie (CTA), mit hoher Sensitivität und Spezifizität für das Vorliegen aktiver Blutungen, spielt die entscheidende Rolle in der Detektion von RH und RSH. Das Therapiemanagement basiert auf verschiedenen Säulen, welche neben konservativen Maßnahmen (Volumenersatz, Optimierung der Gerinnungsparameter), chirurgische und interventionelle Maßnahmen umfassen, die eng aufeinander abgestimmt werden. Aufgrund ihrer geringeren Invasivität bei simultan hohen technischen und klinischen Erfolgsraten hat insbesondere die Säule der interventionellen Therapie zunehmend an Bedeutung gewonnen.

Schlussfolgerung Das Therapiemanagement von Patienten/innen mit RH/SRH erfordert eine niedrige klinische Verdachtsschwelle und die Zusammenarbeit in einem interdisziplinären Team zur bestmöglichen Therapiefindung. Die transarterielle Embolisation erfordert eine systematische, standardisierte Abfolge der Blutungsdetektion und bietet Vorteile hinsichtlich technischer und klinischer Erfolgsraten.

Kernaussagen: 

• Retroperitoneale und Rektusscheidenhämatome können sich klinisch sehr heterogen und unspezifisch präsentieren. Rasche Diagnosen sind aufgrund einer relativ hohen Mortalität (ca. 12–30 %) essenziell.

• Haupt-Risikofaktoren sind ein Alter > 65 Jahre und die Einnahme von Antikoagulantien, deren Verordnung in den vergangenen 10 Jahren um das 2,5-fache gestiegen ist. Seltener sind Koagulopathien, retroperitoneale Raumforderungen und Hämodialyse als ursächlich beschrieben

• Die Computertomographie-Angiographie (CTA) besitzt eine hohe Sensitivität und Spezifizität für das Vorliegen aktiver Blutungen und hat die Diagnostische Subtraktionsangiographie (DSA) ersetzt.

• Die Therapie sollte in einem multidisziplinären Setting, unter Einbezug der Inneren Medizin, der Radiologie und der Chirurgie erfolgen. Hauptindikationen für die Durchführung einer Embolisation sind der Nachweis eines aktiven Kontrastmittelaustritts in der CTA und das Vorliegen abdomineller Schmerzen. In Fällen ohne Nachweis einer aktiven Blutung und stabiler Vitalparameter können konservative Therapiemaßnahmen ausreichen. Die chirurgische Therapie bleibt oftmals therapierefraktären Blutungen mit Symptomen eines abdominellen Kompartments vorbehalten.

• Eine systematische, standardisierte Abfolge der Blutungsdetektion in der DSA scheint Vorteile hinsichtlich technischer und klinischer Erfolgsraten zu bieten.

Abstract

Background Retroperitoneal and rectus sheath hemorrhage (RRSH) has been described as a potentially fatal condition with mortality rates of up to 30 % due to the risk of exsanguination in combination with often nonspecific clinical symptoms. Patients at risk are > 65 years of age as well as those receiving anticoagulation/antiplatelet medicine. Classifications based on etiology consist of trauma, surgery, and/or underlying vascular pathologies, though spontaneous occurrences without precipitating factors have been reported and are expected to increase with the high number of patients undergoing anticoagulant therapy.

Method Analysis, summary, and discussion of published review articles and expert recommendations.

Results The most commonly described symptom during clinical examination is abdominal pain. However, depending on the volume loss, clinical symptoms may include signs of abdominal compartment and hemorrhagic shock. Computed tomography angiography (CTA) with high sensitivity and specificity for the presence of active bleeding plays an important role in the detection of RH and RSH. Therapy management is based on different pillars, which include surgical and interventional measures in addition to conservative measures (volume replacement, optimization of coagulation parameters). Due to its lower invasiveness with simultaneously high technical and clinical success rates, interventional therapy in particular has gained increasing importance.

Conclusion Diagnostic and therapeutic workup of the patients by an interdisciplinary team is essential for optimal patient care. In case of transcatheter arterial embolization, a standardized approach to the detection of bleeding sites within the vascular territory of the core hematoma appears to favorably influence success and patient outcome.

Key points: 

• The clinical presentation of retroperitoneal and rectus sheath hematomas can be very heterogeneous and nonspecific. Quick diagnosis is essential due to the relatively high mortality rate (approx. 12–30 %).

• The main risk factors are age > 65 years and the intake of anticoagulants, the use of which has increased 2.5 times in the last 10 years. Coagulopathies, retroperitoneal masses, and hemodialysis are less common causes.

• Computed tomography angiography (CTA) has a high sensitivity and specificity for the presence of active bleeding and has replaced diagnostic subtraction angiography (DSA).

• Treatment should be performed in a multidisciplinary setting with the inclusion of internal medicine, radiology, and surgery. The main indications for embolization are the detection of active contrast extravasation on CTA and the presence of abdominal pain. In cases without active bleeding and with stable vital parameters, conservative treatment measures can be sufficient. Surgical treatment is often reserved for treatment-refractory bleeding with symptoms of abdominal compartment.

• A systematic standardized approach to the detection of bleeding on DSA seems to have advantages regarding technical and clinical success rates.

Citation Format

• Becker LS, Dewald CLA et al. Spontaneous retroperitoneal and rectus sheath hematomas and their interventional therapy: a review. Fortschr Röntgenstr 2024; 196: 163 – 175

Key words

abdominal wall - retroperitoneum - angiography - embolization

Publication History

Received: 13 April 2023

Accepted: 01 July 2023

Article published online:
15 August 2023

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