Becker Lena Sophie, Dewald Cornelia Lieselotte Angelika, Wacker Frank K, Hinrichs Jan B
Diagnostic and Interventional Radiology, MHH, Hannover, Germany.
Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany.
Rofo. 2024 Feb;196(2):163-175. doi: 10.1055/a-2124-2098. Epub 2023 Aug 15.
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.
Analysis, summary, and discussion of published review articles and expert recommendations.
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.
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.
· 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..
· Becker LS, Dewald CLA et al. Spontaneous retroperitoneal and rectus sheath hematomas and their interventional therapy: a review. Fortschr Röntgenstr 2024; 196: 163 - 175.
腹膜后和腹直肌鞘出血（RRSH）被认为是一种潜在的致命疾病，由于存在失血风险且临床症状往往不具有特异性，其死亡率高达30%。高危患者为年龄大于65岁者以及正在接受抗凝/抗血小板药物治疗的患者。基于病因的分类包括创伤、手术和/或潜在的血管病变，不过也有报道称存在无诱发因素的自发性出血情况，并且随着接受抗凝治疗的患者数量增多，预计此类情况会增加。
对已发表的综述文章和专家建议进行分析、总结和讨论。
临床检查中最常描述的症状是腹痛。然而，根据失血量不同，临床症状可能包括腹腔间隔室综合征和失血性休克的体征。计算机断层扫描血管造影（CTA）对活动性出血具有高敏感性和特异性，在腹膜后出血（RH）和腹直肌鞘出血（RSH）的检测中起着重要作用。治疗管理基于不同的支柱，除了保守措施（容量补充、凝血参数优化）外，还包括手术和介入措施。由于其侵入性较低，同时技术成功率和临床成功率较高，介入治疗尤其变得越来越重要。
由多学科团队对患者进行诊断和治疗评估对于实现最佳患者护理至关重要。在进行经导管动脉栓塞术时，采用标准化方法检测核心血肿血管区域内的出血部位似乎有利于提高成功率和改善患者预后。
· 腹膜后和腹直肌鞘血肿的临床表现可能非常多样化且不具有特异性。鉴于相对较高的死亡率（约12 - 30%），快速诊断至关重要。· 主要危险因素是年龄大于65岁以及服用抗凝剂，在过去10年中抗凝剂的使用增加了2.5倍。凝血障碍、腹膜后肿块和血液透析是较不常见的病因。· 计算机断层扫描血管造影（CTA）对活动性出血具有高敏感性和特异性，已取代诊断性减影血管造影（DSA）。· 治疗应在多学科环境中进行，包括内科、放射科和外科。栓塞的主要指征是CTA上检测到活动性造影剂外渗以及存在腹痛。在无活动性出血且生命体征稳定的情况下，保守治疗措施可能就足够了。手术治疗通常保留用于治疗难治性出血且伴有腹腔间隔室综合征症状的情况。· 在DSA上采用系统的标准化方法检测出血似乎在技术成功率和临床成功率方面具有优势。
· Becker LS, Dewald CLA等。自发性腹膜后和腹直肌鞘血肿及其介入治疗：综述。Fortschr Röntgenstr 2024; 196: 163 - 175。
