|Year : 2015 | Volume
| Issue : 2 | Page : 116-119
Spontaneous retroperitoneal hematoma with deep venous thrombosis of left lower limb managed conservatively
Vishwanath M Pattanshetti1, Sheetal V Pattanshetti2, Mahadev Abhishek1
1 Department of Surgery, J. N. Medical College and KLES Dr. Prabhakar Kore Hospital and MRC, Belgaum, Karnataka, India
2 Department of Anatomy, J. N. Medical College, Belgaum, Karnataka, India
|Date of Web Publication||14-May-2015|
Vishwanath M Pattanshetti
Department of General Surgery, J. N. Medical College and KLES Dr. Prabhakar Kore Hospital and MRC, Belgaum - 590 010, Karnataka State
Source of Support: None, Conflict of Interest: None
Deep vein thrombosis (DVT) of iliac and femoral veins is a common condition in our clinical practice. Spontaneous retroperitoneal hematoma (SRH) is a relatively rare condition. The occurrence of both DVT and SRH concomitantly is very rare. Many of the times the exact pathology leading to SRH with DVT is unknown. Both conditions being fatal in nature, the management remains very challenging. Here we report a similar case with review of the literature.
Keywords: Deep vein thrombosis, May-Thurner syndrome, retroperitoneal hematoma
|How to cite this article:|
Pattanshetti VM, Pattanshetti SV, Abhishek M. Spontaneous retroperitoneal hematoma with deep venous thrombosis of left lower limb managed conservatively. J Sci Soc 2015;42:116-9
|How to cite this URL:|
Pattanshetti VM, Pattanshetti SV, Abhishek M. Spontaneous retroperitoneal hematoma with deep venous thrombosis of left lower limb managed conservatively. J Sci Soc [serial online] 2015 [cited 2020 Jan 24];42:116-9. Available from: http://www.jscisociety.com/text.asp?2015/42/2/116/157050
| Introduction|| |
Spontaneous retroperitoneal hematoma (SRH) is a relatively uncommon condition, but concomitant presence of deep vein thrombosis (DVT) of iliac and femoral vein of the same side of hematoma is very rare. The SRH are not related to trauma, surgery or puncture of vessels. There are many causes for SRH, such as renal tumor rupture,  spontaneous iliac vein rupture  underlying some vascular lesions/anomalies, acquired and congenital coagulopathies, anti-coagulation treatments and small undetectable occult tumors. ,, The patients who are not on anti-coagulation or not having bleeding disorders may be due to iliac vein rupture secondary to May-Thurner's syndrome (MTS) or a rupture of a pelvic varix.  Long back in 1851, Virchow observed that DVT of left iliac and femoral vein was 5 times more common compared with the right. In 1957, May and Thurner explained this phenomenon by determining an anatomical variation of left common iliac vein, where the left common iliac vein had a vascular thickening at the point where it was crossed and compressed against the fifth lumbar vertebrae by overlying right common iliac artery. They called this lesion, "a venous spur," which leads to a venous obstruction. This anatomic variant is now recognized as the MTS.  SRH can be fatal, requiring immediate recognition and intervention.
In this case report, we have described an interesting case of middle-aged female patient who presented with left-sided SRH with concomitant DVT of left lower limb. The management of such potentially fatal case is challenging when the exact pathology leading to SRH and DVT is unknown.
| Case report|| |
A 51-year-old woman with no significant medical history presented to her local hospital with a history of the fall at home in the bathroom following sudden onset dizziness and loss of consciousness. Once she regained consciousness, she had acute left leg pain and swelling and also pain in left lumbar and iliac region. She was in hypotension with severe pallor. Patient was initially resuscitated with intravenous (IV) fluids, and then two units of blood as her hemoglobin (Hb) was 6 g%. Once the patient was stable on the next day computed tomography (CT) scan of abdomen was done, which showed a large left-sided retroperitoneal hematoma of size 14.6 cm × 8.3 cm × 7.0 cm mainly infrarenal in position. Then the patient was transported to our hospital for further management. On arrival, the patient's blood pressure was 90/60 mm Hg, with a pulse rate of 118 bpm. Patient was managed conservatively with close monitoring of vitals for a day, with IV fluids and one unit of blood, as her repeat Hb was 7.9 g%. CT scan [Figure 1] [Figure 2] [Figure 3] was repeated on next day, which showed a left-sided retroperitoneal hematoma of size 21 cm × 8 cm × 8.2 cm with no obvious extravasation of contrast in hematoma. There was DVT involving left superficial femoral and common femoral veins, left iliac veins and extending to the inferior vena cava, which was unreported in previous CT abdomen report.
|Figure 2: Computed tomography abdomen with oral and intravenous contrast showing le spontaneous retroperitoneal hematoma with deep vein thrombosis. Coronal section view|
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|Figure 3: Computed tomography abdomen with oral and intravenous contrast showing le spontaneous retroperitoneal hematoma with deep vein thrombosis. Sagi al section view|
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In view of hemodynamic stability, no extravasation of contrast in hematoma on CT, no rapid fall in Hb level and no other symptoms of jeopardized blood supply to descending colon, the surgical treatment of hematoma was not considered and Conservative management was continued with a close watch over the vitals, Hb%, packed cell volume and abdominal girth monitoring. The only dilemma was whether to start anti-coagulation therapy actively for extensive DVT, if so; in turn, which may increase bleeding in retroperitoneal hematoma and cause hypovolemic shock, which could be fatal. If anti-coagulation is not started, the thrombus can extend into vena cava or prone to have pulmonary embolism. However, still the cause for SAH and DVT was not known. Just we thought there is a possibility of MTS with left iliac vein rupture.
Considering all the factors, it was then decided to start the patient on low molecular weight heparin with monitoring of PT/INR with target INR being 1.5-2.0. The conservative management was continued with the patient showing clinical improvement with reduced left leg and lumbar pain and also reduced swelling of left lower limb. Repeat CT scans after 8 days showed no increase in size of the hematoma with no extension of the thrombus. After 3 day's patient was discharged with tablet acenocoumarol, the dose was adjusted to maintain INR between 2.0 and 2.5. Patient was asked to follow-up every week for a month; then every fortnight. The recent follow-up after 3 months showed the size of hematoma reduced to 7 cm × 6 cm × 6 cm on ultrasonography and partial compression of iliac and femoral vein with no extension of thrombus on color Doppler examination.
| Discussion|| |
Retroperitoneal space is a potential space due to loose attachments of peritoneum to the extra peritoneal structures in the posterior abdominal wall below the diaphragm.  SRH associated with iliac vein rupture is a rare but life-threatening emergency that usually occurs in middle-aged or elderly women.  The iliac vein rupture primarily results from major trauma or injury during pelvic surgery or activities, which increase pelvic venous pressure, such as sudden bending, defecation, and climbing. Spontaneous rupture of the iliac vein is even rarer. There are only a small number of reported cases of spontaneous rupture of the iliac vein; most of them are middle-aged or elderly women, with rupture predominately on the left-side. Sudden onset of hypotension, lower abdominal pain and distension with a nonpulsatile mass in the iliac fossa, and edema of the lower extremity of the affected side, without a history of recent trauma, are the characteristic symptoms found in cases of spontaneous rupture of the iliac vein.
In our case, the cause of spontaneous rupture of the left common iliac vein is believed to be related to MTS as there was concomitant DVT of iliac veins on left-side. Many case series have reported that patients with spontaneous iliac vein rupture, almost 79% had concomitant DVT or thrombophlebitis and approximately 28.6% had MTS. ,,, It is difficult to distinguish which phenomenon occurred first; SRH or DVT?
There are two speculations: (1) DVT may be a cause of iliac vein rupture. , Venous obstruction alone is unlikely to cause rupture, as veins are being used as an arterial substitute without problems. The associated thrombophlebitis can result in weakening of the intima and plays an important role in venous rupture. Considering that most reported cases were middle-aged or elderly women and the rupture occurred on the left-side in most cases, loss of estrogenic effect or thrombophlebitis combined with a sudden rise in intraluminal pressure in a segment of the vein between the inguinal ligament and the right common iliac artery may be one of the possible explanations for the spontaneous rupture of the iliac veins.  (2) DVT may be a complication of iliac vein rupture.  DVT may result from a combination of hypovolemia, local trauma with loss of endothelial integrity, compression by the hematoma, and MTS.
In our case, the exact pathology leading to SRH with DVT is unknown. However, the presentation in a middle-aged female with sudden onset hypotension with anemia with severe abdominal pain (left iliac and lumbar region) following defecation (increased abdominal pressure) with a preexisting thrombus in the left iliac vein as seen on the CT scan done at the time of presentation goes in favor of spontaneous iliac vein rupture in an undiagnosed preexisting case of MTS or DVT.
Several treatment methods have been reported, such as conservative therapy, open surgical procedures, endovascular interventions, and combined surgical and endovascular treatment. ,, Hemodynamic status is the key factor to choose the type of treatment. The observing indexes include patient's symptoms, vital signs, Hb concentration, hematocrit, and urine volume. If vital signs were not stable and the level of Hb was decreasing continuously even after resuscitation, a surgical procedure would be compelled. Active hemorrhage is the main indication for surgical intervention. However, surgical intervention is associated with high mortality and morbidity in these patients. Endovascular stent graft placement may be performed when the bleeding site is identified by venography.  In a case series authors have reported that in their experience, conservative treatment was safer than open surgical procedures. 
In our case, we have successfully treated the patient by conservative method, initially with resuscitation followed by low molecular weight anti-coagulation therapy and then later by oral acenocoumarol tablet.
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[Figure 1], [Figure 2], [Figure 3]