In contrast, spontaneous retroperitoneal hemorrhage has an unclear pathogenesis. Some authors have suggested unrecognized minor trauma such as coughing as a possible cause.8 The patient in this case was asked on hospital day 2 if she had experienced a history of cough the week prior to presentation to the ED, to which she stated she had not.
Risk Factors
More recent case reports focus on renal or adrenal tumors as a potential source of spontaneous retroperitoneal bleeding. Although this patient did have a renal cyst in left kidney, its contribution to the retroperitoneal bleed is unknown and thought to be only incidental.
A retrospective chart review of 119 identified patients with spontaneous retroperitoneal bleeds sought to identify reliable predictors of early diagnosis. Ivascu et al2 found that elderly patients on both anticoagulation and antiplatelet therapy were at the highest risk. Shah et al9 echoed the sentiment of severity in their retrospective review which showed that those on combined anticoagulant and antiplatelet therapy were more likely to require intensive care unit (ICU) admission and had longer ICU stays.
Conclusion
Unlike hemorrhages in other locations in the body, retroperitoneal bleeding can be difficult to diagnose since patients often present with nonspecific symptoms such as lower abdominal pain. Clinicians should therefore maintain a high index of suspicion, especially in patients who are on anticoagulation therapy, who have a coagulopathy, or who are on hemodialysis. Delay or failure to diagnose this condition may lead to significant morbidity and mortality.
Dr Lui is a resident, department of emergency medicine, Henry Ford Wyandotte Hospital, Wyandotte, Michigan. Dr Boehm is the emergency medicine residency program director in the graduate medical education department, Saint Mary Mercy Hospital, livonia, Michigan; and is an emergency physician at the Emergency physicians Medical Group, ann arbor, Michigan.