Retroperitoneal hematoma

　　The action of external force leads to injury and bleeding of retroperitoneal organs and blood vessels, and the spread of blood in the retroperitoneal space forms a hematoma, known as retroperitoneal hematoma. The most common cause is pelvic and vertebral fractures, accounting for 50% to 60%. In addition to the symptoms of primary injuries such as pelvic fractures, the hematoma itself has few typical symptoms, and may have mild abdominal pain, back pain, bloating, reduced bowel sounds, and blurred shadows of the psoas muscle on X-ray films. If the hematoma is large enough, it can cause hypovolemic shock. Retroperitoneal hematoma without associated organ injury should be treated conservatively, and the hematoma can usually be absorbed spontaneously. If there is injury to retroperitoneal organs and major blood vessels, laparotomy should be performed.

　　The common complications of retroperitoneal hemorrhage are mainly secondary peritonitis and hemorrhagic shock. Patients assume an强迫position (prefer to stay still and not move, and prefer to bend the lower limbs), and the specific manifestations are as follows:

　　1. Abdominal pain: It starts suddenly, is severe, and persistent; the onset site and the primary site of the disease are consistent, spreading rapidly, but the pain is most severe at the primary site of the disease. Coughing and turning over can exacerbate the pain, and deep breathing or activity can worsen the pain, so patients dare not breathe deeply or turn over.

　　2. Nausea and vomiting: Initially, it is reflexive and relatively mild, but it tends to become more frequent due to infection and poisoning reactions or secondary paralytic ileus.

　　3. Body temperature and pulse: Their changes are related to the severity of inflammation. Initially, they may be normal, but the body temperature gradually increases and the pulse gradually accelerates. In elderly or weak patients, the body temperature may not increase, but the pulse often accelerates. If the pulse is fast but the body temperature drops, this is one of the signs of deterioration of the condition.

　　4. Symptoms of infection and poisoning: Patients may experience high fever, rapid pulse, shallow breathing, profuse sweating, dry mouth, and further development of the condition may lead to pale complexion, weakness, sunken eye sockets, dry skin, cold extremities, rapid breathing, cyanosis of the lips, dry tongue with thick fur, weak pulse, sudden rise or drop in body temperature, decreased blood pressure, confusion or loss of consciousness, indicating severe dehydration, metabolic acidosis, and shock.

　　5. Mental and spiritual state: apathy, few words, or restlessness, followed by confusion and even coma.

　　Abdominal pain is the most common symptom of retroperitoneal hematoma. Some patients have abdominal distension and lumbar and back pain, and 1/3 of patients have hemorrhagic shock. Large hematoma or those with渗入peritoneal cavity may have abdominal muscle tension and rebound pain, decreased or absent bowel sounds. However, retroperitoneal hematoma lacks characteristic clinical manifestations and varies greatly with the degree of hemorrhage and the extent of the hematoma.

　　Abdominal pain, abdominal distension, lumbar and back pain, hemorrhagic shock, abdominal muscle tension and rebound pain, abdominal, spinal and pelvic trauma with decreased or absent bowel sounds should be considered as possible retroperitoneal hematoma. Simple retroperitoneal hematoma without injury to large blood vessels or important organs usually presents with late and mild peritoneal irritation signs, and is often effective after anti-shock treatment. Retroperitoneal hematoma lacks characteristic clinical manifestations and varies greatly with the degree of hemorrhage and the extent of the hematoma. Abdominal pain is the most common symptom, with some patients experiencing abdominal distension and lumbar and back pain, and 1/3 of patients with hemorrhagic shock. Large hematoma or those with渗入peritoneal cavity may have abdominal muscle tension and rebound pain, decreased or absent bowel sounds. Retroperitoneal hematoma caused by injury to major abdominal blood vessels (abdominal aorta and inferior vena cava) is more than 90% due to penetrating injury. Due to rapid and massive bleeding, most patients die at the scene, and the mortality rate after rescue at the hospital also reaches 70%. Progressive abdominal distension and shock suggest this diagnosis. Immediate laparotomy should be performed to control bleeding while actively treating shock.

　　Retroperitoneal hematoma is a common complication of abdominal and lumbar injuries, accounting for about 10-40%, which can be caused by direct or indirect violence. The most common cause is pelvic and spinal fractures, accounting for about 2/3. The second is the rupture of retroperitoneal organs (kidneys, bladders, duodenum, and pancreas, etc.) and injuries to large blood vessels and soft tissues. Because they often occur with severe multiple injuries and hemorrhagic shock, the mortality rate can reach 35-42%. General measures for preventing retroperitoneal hematoma are as follows:

　　1. In addition to the pelvic or vertebral body fracture, retroperitoneal hematoma is generally difficult to diagnose and is mostly found during exploratory surgery. Retroperitoneal hematoma caused by pelvic fracture can usually stop bleeding spontaneously and rarely requires laparotomy exploration. If the hematoma does not expand during surgery, it does not need to be incised, otherwise, it should be incised to stop bleeding. If it is impossible to find the bleeding point or the bleeding cannot be controlled, it is advisable to ligate both internal iliac arteries. If retroperitoneal hematoma is found adjacent to the upper abdomen or ascending and descending colon during surgery, it must be explored to exclude organ injury in the corresponding area.

　　2. Avoiding injury factors. In case of hematoma rupture, it should be handled promptly to prevent the occurrence of hemorrhagic shock.

　　Retroperitoneal hematoma is a common complication of abdominal and lumbar injuries, which can be caused by direct or indirect violence. Retroperitoneal hematoma lacks characteristic clinical manifestations and has significant differences in degree of hemorrhage and size of hematoma. The following is a general introduction to the symptoms of retroperitoneal hematoma, as follows:

　　1. There is a clear history of abdominal trauma, pelvic fracture, or spinal fracture.

　　2. The above clinical manifestations.

　　3. Abdominal X-ray film suggests blurred shadows of the psoas muscle.

　　4. Ultrasound shows a limited liquid shadow area behind the peritoneum.

　　On the second day after the retroperitoneal hematoma surgery, some easily digestible foods such as congee, soft egg custard, milk, noodles, and noodles can be eaten. Foods rich in full nutrients, such as foods for special medical purposes and enteral nutrition agents, can also be added for one or two meals. This is beneficial for the absorption of nutrients in the body without increasing the burden on the gastrointestinal tract. However, the body's digestive ability decreases when starting to eat, so it is not advisable to eat too much at once. Eat in small amounts and frequently, about 5-6 meals a day. If the body's tolerance increases and appetite increases, it is necessary to restore normal dietary intake as soon as possible, eating more foods rich in high-quality protein and vitamins.

　　At the same time, it is forbidden to drink stimulants such as opium, garlic, ginger, cinnamon, and other spicy and刺激性 foods, smoking, drinking, greasy, fried, moldy, and preserved foods, and animals such as roosters and geese. For example, Chuanxiong sugar tea, 6 grams of Chuanxiong, 6 grams of tea, and appropriate amount of brown sugar. Boil Chuanxiong, pour the boiling medicine juice into tea, and add brown sugar, drink as tea. There are also Shanzhi, Maodongqing, and others in equal amounts, and appropriate decoction for internal use.

　　Retroperitoneal hematoma is generally difficult to diagnose except when blood clots can be predicted in cases of pelvic or vertebral fractures. The treatment of retroperitoneal hematoma should follow the general principles of abdominal trauma, but the treatment of various types and locations of hematoma should be different.

　　1. Principles of treatment for retroperitoneal hematoma

　　①Preventing and treating shock.

　　②Anti-infection.

　　③Correcting electrolyte and water imbalance.

　　④For patients without retroperitoneal organ injury and stable blood pressure, conservative treatment is recommended. Otherwise, laparotomy should be performed.

　　⑤Treating primary injuries such as pelvic fractures and vertebral fractures.

　　2. Principles of medication for retroperitoneal hematoma

　　For conservative treatment and patients with good general condition, mainly focus on fluid replacement, anti-infection, and correction of electrolyte and water imbalance. For patients with shock, active anti-shock treatment should be performed, and blood transfusion, human serum albumin, and other measures may be necessary to enhance the patient's recovery ability.

　　3. Surgical treatment

　　The treatment of retroperitoneal hematoma should follow the general principles of abdominal trauma, but the treatment of various types and locations of hematoma should be different.

　　Penetrating abdominal injury with retroperitoneal hematoma should further explore the hematoma after the injury to abdominal organs are treated, as such injuries often involve retroperitoneal organs and large blood vessels. For stable perirenal hematoma without shock and massive hematuria, non-surgical treatment can be considered. If necessary, intravenous pyelography can be used to clarify the diagnosis. If the diagnosis cannot still be confirmed or bleeding does not stop, renal angiography is an accurate method for diagnosing renal artery and renal injury, and can also be used for embolization therapy to control bleeding.