Case Reports in Medicine

Case Reports in Medicine / 2011 / Article

Case Report | Open Access

Volume 2011 |Article ID 373047 | 5 pages | https://doi.org/10.1155/2011/373047

Fatal Retroperitoneal Bleeding Caused by Metastasis of a Sigmoid Carcinoma

Academic Editor: G. Pineo
Received19 Jan 2011
Revised10 Jun 2011
Accepted29 Jun 2011
Published16 Aug 2011

Abstract

Retroperitoneal bleeding is relatively rare and a potentially life-threatening condition with significant mortality. Early recognition requires a high index of suspicion. Increased life expectancy, the widespread use of anticoagulants, and the rise of endovascular interventions have caused an increase in the incidence of retroperitoneal bleeding. We present a case of a 74-year-old woman who died because of retroperitoneal bleeding caused by retroperitoneal metastasis of a sigmoid carcinoma with angioinvasive growth into a lumbar artery. In addition we discuss etiology, diagnostic management, and treatment strategy.

1. Introduction

Retroperitoneal bleeding is relatively rare, and recognition requires a high index of suspicion [1]. It is a potentially life-threatening condition with a mortality rate of up to 20% [2].

The widespread use of anticoagulants and the increased life expectancy cause an increase in the incidence of retroperitoneal bleeding [3, 4]. In addition, the rise of endovascular interventions causes an increase in the incidence of (iatrogenic) retroperitoneal bleeding as well. The cause of a retroperitoneal bleeding is sometimes readily identified, especially in the case of iatrogenic bleeding or retroperitoneal bleeding due to trauma. However, in other cases the underlying cause is difficult to find.

We report a unique case of a fatal retroperitoneal bleeding caused by a metastasis of a sigmoid carcinoma. Additionally, an overview of all causes of retroperitoneal bleeding, published in Medline between 1950 and 2010, is given and contemporary management is discussed.

2. Case Presentation

A 74-year-old female was presented to our emergency department with fever, malaise, and intermittent left abdominal pain. The medical history included resection of a T3N2M0 sigmoid carcinoma, 4 months before admission. Medical examination showed a pale female with a breathing frequency of 32 breaths/minute, a blood pressure of 90/40 mmHg, and a pulse rate of 140 beats/minute. The temperature was 38.9 degrees Celsius. She had no signs of peritonitis. Laboratory testing showed the following (normal range between parentheses): hemoglobin 4.7 mmol/L (7.5–10.0 mmol/L), CRP 362 mg/mL (<10 mg mg/mL), leucocytes 4 1 . 3 × 1 0 9 /L (4.0–10.0 × 109/L), creatinine 629 mmol/L (55–90 mmol/L), and urea 47.6 mmol/L (2.5–7.5 mmol/L). A chest X-ray showed no abnormalities. Urinalysis was positive for nitrites and leukocytes, and microscopy demonstrated bacteria. Abdominal ultrasound demonstrated hydronephrosis of the left kidney, and nephrostomy tube drainage was performed.

She was admitted to the intensive care unit with the diagnosis of urosepsis. Vital functions were stabilized, antibiotic treatment was started, and she was treated with central veno-venous hemofiltration (CVVH) because of renal failure. During CVVH, intravenous heparin was routinely administered. Initially the patient recovered, but on day 6 she developed shock with swelling of the abdomen and a sudden fall in hemoglobin count from 5.6 to 2.5 mmol/L (7.5–10.0 mmol/L) without signs of gastrointestinal bleeding. Because of severe hemodynamic instability, urgent laparotomy was performed, but no source of bleeding was identified. In the next 12 hours, the patient remained hemodynamically unstable and the laparotomy wound started to leak serosanguineous fluid. At relaparotomy this time a large retroperitoneal hematoma was found. Because there was no intraperitoneal bleeding and the hematoma was confined to the retroperitoneal space, the hematoma was left untouched and the abdomen was closed again. Urgent CT-scanning demonstrated a large retroperitoneal hematoma with a paralumbar blush (Figure 1). Catheterization of the femoral artery, and subsequent selective coil embolisation of a bleeding right lumbar artery was performed (Figure 2). However, despite intensive therapy, the patient remained hemodynamically unstable and died 6 hours later.

On autopsy a metastasis of the previously removed sigmoid carcinoma was identified. On microscopy the metastasis demonstrated angioinvasive growth in the right lumbar artery that had been coiled. A second, para-aortic metastasis was found which compressed the left ureter causing the hydronephrosis leading to the patient’s presenting problem of urosepsis.

3. Discussion

Retroperitoneal bleeding caused by a metastasis of a sigmoid carcinoma has not been previously described. In this case the patient presented with urosepsis and subsequent renal failure, which was caused by a second metastasis, which compressed the left ureter and caused hydronephrosis. The heparin, administered during CVVH, might have intensified or prolonged the retroperitoneal bleeding caused by the metastasis in the right lumbar artery.

In the current literature (Medline 1960–2010, no restrictions on language), only 12 cases of retroperitoneal bleeding due to metastases are described. These were retroperitoneal metastases of the following primary tumors: non-small-cell lung carcinoma ( 𝑛 = 7 ), small cell lung carcinoma ( 𝑛 = 1 ), choriocarcinoma ( 𝑛 = 1 ), hepatocellular carcinoma ( 𝑛 = 1 ), chondrosarcoma of the rib ( 𝑛 = 1 ), and gastric sarcoma ( 𝑛 = 1 ) [516].

A wide range of causes of retroperitoneal bleeding have been described. It includes trauma, iatrogenic causes, malignancies of the kidneys or adrenal glands, vascular pathology (i.e., aneurysms or dissection), and coagulation disorders (see Table 1). When the cause of spontaneous retroperitoneal bleeding is identified, it concerns mostly renal tumors (57%–63%), vascular pathology (18%–26%), and inflammatory diseases (11%) [17]. Furthermore, the increase in the number of endovascular interventions leads to more iatrogenic retroperitoneal bleedings, especially when access is gained through the femoral artery [2]. However, frequently a specific cause is never found. These retroperitoneal hematomas are mostly found in patients who use anticoagulant therapy or have coagulation disorders. The incidence of retroperitoneal bleeding is 0.6–6.6% in patients using anticoagulants. However, in patients without any anticoagulant usage, retroperitoneal bleeding is rare [2].


Trauma

Iatrogenic
 Femoral catheterization
 Central line insertion
 Perforation v. cava + aorta by v. cava filter
 Erosion aorta by spine fixation material

Vascular

Aneurysms
 Aorta
 Renal artery
 Adrenal artery
 Uterine artery
 Pancreaticoduodenal artery
 Ovarian artery
Dissection
 Ovarian artery
 Inferior mesenteric artery
Spontaneous rupture
 Portal vein
 Splenic vein
 Superior mesenteric artery
 Uterine artery (at labor)
 Iliac vein
Other vascular causes
 Fibromuscular dysplasia of common iliac artery
 Arteriovenous malformation

Miscellaneous

 Idiopathic
 Pancreatic pseudocyst
 Varicosis due to liver cirrhosis
 Iliopsoas muscle bleeding
 Acute cholestatic viral hepatitis
 Dilatation v. cava due to right heart failure.
 Neurofibromatosis type I

(Ad)renal

Tumors
 Angiomyolipoma
 Phaeochromocytoma
 Renal cel carcinoma
Infections
 Abces
 Pyelonefritis
 Tuberculosis
Miscellaneous
 (ad)renal cysts
 Renal infarction
 Nephritis/nephrosclerosis
 Lymfangioma
 Transplant rejection
 Transplant rupture
 Kidney stones

Malignancies

Tumors
 Thymoma
 Gastric carcinoma
Metastasis
 NCSLC
 Choriocarcinoma
 HCC
 Small cell lung carcinoma
 Chondrosarcoma
 Gastric sarcoma

Systemic

Anticoagulants
Vasculitis
Hematologic disorders
 Leukemia
 Polycythemia
 Hemophilia
 ITP
Alcohol and NSAID use
Amyloidosis

The exact pathophysiology and pathogenesis of spontaneous retroperitoneal bleeding remain unclear. It has been hypothesized that occult vasculopathy and arteriosclerosis can make arteries vulnerable. A subsequent microtrauma, for example, occurring during coughing or sports, might cause a rupture of these vulnerable arteries. However, histopathologic evidence for this theory has not been found so far [2].

Retroperitoneal bleeding should be suspected in high-risk patients (high age, use of anticoagulants) who present with anemia or signs of shock without an evident source of bleeding, such as gastrointestinal blood loss. In the management of retroperitoneal bleeding, it is important to differentiate between hemodynamically stable and hemodynamically unstable patients. Stable patients can be managed conservatively by withdrawal of anticoagulant therapy, correction of coagulopathy, fluid resuscitation, and blood transfusion, if necessary [1, 2].

Hemodynamically unstable patients need further investigation and intervention to stop the bleeding. Ultrasonography is unreliable for demonstrating a retroperitoneal hematoma. A CT scan is the golden standard for detecting and locating a retroperitoneal hematoma. In case of profound bleeding, such as in this case, contrast extravasation can even be visualized. When the bleeding site is located, endovascular treatment by selective coil embolisation can be performed. Alternatively, a covered stent can be placed in the bleeding artery, under the condition that the diameter of the vessel permits this approach. For example, in the case of a bleeding puncture hole in the distal external iliac artery, caused by a percutaneous endovascular procedure through the groin. When no contrast extravasation is demonstrated by CT, there is low probability that the bleeding focus will be visualized during angiography. However, when the site of bleeding is surmised based on clinical information (e.g., trauma mechanism, prior surgery, endovascular procedure, or presence of tumor), selective arterial catheterization might allow visualization and subsequent treatment of the bleeding vessel.

When endovascular intervention is not possible or available and the patient remains hemodynamically unstable despite aggressive conservative treatment (as described above), surgery can be indicated. A disadvantage of surgical therapy is the fact that the retroperitoneal space is opened, and a possible tamponade effect will be disturbed. However, any visible active bleeding can be controlled, and the hematoma can be evacuated during surgery. In case of diffuse bleeding, the retroperitoneum can be packed and re-explored after 24 to 48 hours [18]. Another indication for open surgery is the development of an abdominal compartment syndrome due to a large retroperitoneal hematoma [19, 20]. Percutaneous drainage of such hematomas has been described and might be useful in case of femoral nerve compression or abdominal compartment syndrome. However, the pressure reduction after drainage might cause rebleeding in the hematoma. This procedure is therefore not indicated in the acute phase of bleeding [1].

4. Conclusion

Retroperitoneal bleeding has a wide range of possible causes. A high index of suspicion is required to identify this potentially lethal condition. This is the first case describing a retroperitoneal bleeding caused by a metastasis of a sigmoid carcinoma that invaded a lumbar artery. In patients with a sudden fall in hemoglobin count and who belong to a high-risk group (high age, anticoagulant therapy, recent endovascular intervention), retroperitoneal bleeding should be considered, when no other cause of bleeding can be identified. CT angiography is the golden standard for the identification of the hematoma and possible bleeding focus. It also allows evaluation of endovascular treatment options. Therapy may consist of conservative, endovascular, or surgical treatment, depending on the cause of bleeding and the hemodynamic state of the patient.

Conflict of Interests

The authors declare no conflict of interests.

References

  1. C. González, S. Penado, L. Llata, C. Valero, and J. A. Riancho, “The clinical spectrum of retroperitoneal hematoma in anticoagulated patients,” Medicine, vol. 82, no. 4, pp. 257–262, 2003. View at: Publisher Site | Google Scholar
  2. Y. C. Chan, J. P. Morales, J. F. Reidy, and P. R. Taylor, “Management of spontaneous and iatrogenic retroperitoneal haemorrhage: conservative management, endovascular intervention or open surgery?” International Journal of Clinical Practice, vol. 62, no. 10, pp. 1604–1613, 2008. View at: Publisher Site | Google Scholar
  3. “Stroke Prevention in Atrial Fibrillation Investigators. Bleeding during antithrombotic therapy in patients with atrial fibrillation,” Archives of Internal Medicine, vol. 154, no. 4, pp. 409–416, 1996. View at: Google Scholar
  4. M. Szyper Kravitz, R. A. Mishaal, and Y. Shoenfeld, “Renal failure and low molecular weight heparins. A dangerous liaison? The case of retroperitoneal hematoma,” Israel Medical Association Journal, vol. 7, no. 9, pp. 600–601, 2005. View at: Google Scholar
  5. M. Guivarc'h, R. Pérol, J. E. Rohan, and P. Loirat, “2 retroperitoneal hematomas revealing an angiomyolipoma of the kidney and an adrenal metastasis from a lung cancer,” Chirurgie, vol. 97, no. 7, pp. 431–437, 1971. View at: Google Scholar
  6. N. Hiroi, R. Yanagisawa, M. Yoshida-Hiroi et al., “Retroperitoneal hemorrhage due to bilateral adrenal metastases from lung adenocarcinoma,” Journal of Endocrinological Investigation, vol. 29, no. 6, pp. 551–554, 2006. View at: Google Scholar
  7. C. R. Berney, A. D. Roth, A. Allal, and A. Rohner, “Spontaneous retroperitoneal hemorrhage due to adrenal metastasis for non-small cell lung cancer treated by radiation therapy,” Acta Oncologica, vol. 36, no. 1, pp. 91–93, 1997. View at: Google Scholar
  8. A. H. Yamada, A. E. Sherrod, W. Boswell, and D. G. Skinner, “Massive retroperitoneal hemorrhage from adrenal gland metastasis,” Urology, vol. 40, no. 1, pp. 59–62, 1992. View at: Publisher Site | Google Scholar
  9. U. Tappe, F. Kristen, A. Löffler, and H. W. Keller, “Spontaneous retroperitoneal hematoma in adrenal metastasis,” Deutsche Medizinische Wochenschrift, vol. 122, pp. 471–474, 1997. View at: Google Scholar
  10. G. Suárez, Z. Valera, M. A. Gómez, F. Docobo, and J. M. Alamo, “Etiology and diagnosis of severe retroperitoneal hematoma: therapeutic options and surgical indication,” Cirugía Española, vol. 78, no. 5, pp. 328–330, 2005. View at: Publisher Site | Google Scholar
  11. F. Hoshiyama, Y. Hosokawa, H. Kumamoto, Y. Hayashi, K. Fujimoto, and Y. Hirao, “Choriocarcinoma presenting as a spontaneous rupture of an adrenal metastasis: a case report,” Acta Urologica Japonica, vol. 54, no. 4, pp. 281–284, 2008. View at: Google Scholar
  12. P. W. Yang, W. Y. Wang, C. H. Yang, C. C. Chou, D. H. T. Yen, and J. Chou, “Treatment of massive retroperitoneal hemorrhage from adrenal metastasis of hepatoma,” Journal of the Chinese Medical Association, vol. 70, no. 3, pp. 126–131, 2007. View at: Google Scholar
  13. J. J. Rodríguez Martínez, M. Herreros Villaraiz, F. J. Pérez García et al., “Suprarenal hemorrhage as the first manifestation of a small cell pulmonary carcinoma. Presentation of a case,” Archivos Españoles de Urología, vol. 53, pp. 726–730, 2000. View at: Google Scholar
  14. G. Liguori, S. Bucci, L. Buttazzi, C. Trombetta, M. Cortale, and E. Belgrano, “A renal metastasis from primary peripheral chondrosarcoma presenting as spontaneous retroperitoneal hematoma,” Archivio Italiano di Urologia, Andrologia, vol. 72, no. 4, pp. 292–294, 2000. View at: Google Scholar
  15. A. Alonso, F. Domínguez, M. Verez et al., “Wünderlich syndrome caused by metastatic gastric sarcoma in the kidney. Report of a case,” Actas Urologicas Españolas, vol. 20, no. 4, pp. 395–398, 1996. View at: Google Scholar
  16. H. H. Wang, “Spontaneous rupture of a metastatic epidermoid carcinoma of the kidney,” International Surgery, vol. 58, no. 11, pp. 797–798, 1973. View at: Google Scholar
  17. V. Gimeno Argente, M. Bosquest Sanz, M. Ramírez Backhaus, M. Trassierra Villa, S. Arlandis Guzmán, and J. F. Jiménez Cruz, “Spontaneous retroperitoneal hemorrhage: our experience at last 10 years,” Actas Urologicas Espanolas, vol. 31, no. 5, pp. 521–527, 2007. View at: Google Scholar
  18. I. G. Finlay, T. J. Edwards, and A. W. Lambert, “Damage control laparotomy,” British Journal of Surgery, vol. 91, no. 1, pp. 83–85, 2004. View at: Publisher Site | Google Scholar
  19. T. R. Howdieshell, C. D. Proctor, E. Sternberg, J. I. Cué, J. S. Mondy, and M. L. Hawkins, “Temporary abdominal closure followed by definitive abdominal wall reconstruction of the open abdomen,” American Journal of Surgery, vol. 188, no. 3, pp. 301–306, 2004. View at: Publisher Site | Google Scholar
  20. A. Dabney and B. Bastani, “Enoxaparin-associated severe retroperitoneal bleeding and abdominal compartment syndrome: a report of two cases,” Intensive Care Medicine, vol. 27, no. 12, pp. 1954–1957, 2001. View at: Publisher Site | Google Scholar

Copyright © 2011 Cornelis G. Vos and Arjan W. J. Hoksbergen. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

3344 Views | 389 Downloads | 4 Citations
 PDF  Download Citation  Citation
 Download other formatsMore
 Order printed copiesOrder