Clinical History
A 77-year-old male admitted to emergency department after a car accident. The patient underwent plain X-ray, ultrasound and CT examination.
Imaging Findings
The patient was admitted to our hospital after a car accident. Bone X-ray showed multiple fractures of right acetabulum and ipsilateral pubis. Abdominal X-ray showed increased attenuation of the
lower abdomen with pressure signs upon intestinal loops of illeus (Figure 1). Ultrasound examination revealed deformation of normal urinary bladder shape, indirect sign of external compression
(Figure 2). CT examination visualized multiple fractures of the right side pelvis. Fractures of the anterior and posterior right acetabular column and pubic bone with associated hematoma visualized.
Enlargement of the right obturator internus muscle .Heamatoma was limited to retroperitoneal space, Douglass pouch was free (Figure 3). At precontrast CT scan examination, a deformed urinary bladder
was observed surrounded by fluid collection with densities greater than that of water. At post contrast scan the lesion remained unenhanced, and the retroperitoneal blood vessels were normally filled
with contrast medium. The urinary bladder was filled with contrast medium inserted by the urinary bladder catheter no contrast medium extraversion was observed. The diagnosis was that of
retroperitoneal hemorrhage due to traumatic bone lesions.
Discussion
Retroperitoneal hematomas can result from vertebral or pelvic fracture, injuries of the pancreas, urogenital tract orvascular injuries. Among these causes, trauma of the kidneys is the most frequent.
Spontaneous retroperitoneal or pelvic haemorrhage in adult requires exclusion of an aortic rupture. It may also be due to neoplastic disease, hemorrhagic diathesis, or antiquagulant therapy, which is
the most frequent cause of spontaneous psoas hematoma. Retroperitoneal hematoma may be localized (e.g. to the perirenal space) or may involve the entire retroperitoneum depending on the primary
lesion and the extent of the collection. Clinical suspicion of retroperitoneal hematoma, or intraperitoneal fluid recognized seen at ultrasound requires further evaluation by CT. CT will influence
the treatment planning and is useful for evaluating response to therapy. Contrast enhanced CT in the arterial or portal phase can be used to demostrare active bleeding, which in many cases may
mandate immediate therapy, such as surgery orinterventional treatment by embolization therapy. Hematomas appear as masses of varying size whose attenuation depends largerly on the age and size of the
collection. Sedimentation causes layering of the blood components with gradient toward the dependent portions of the hemorrhagic material. Fluid levels may occur. Clot formation leads to typical
hyperattenuating regions within the hemorrhage (up to 70 HU) which are often ill defined and rounded in appearance. Hematomas do not enhance after intravenous contrast administration. With increasing
resorption of the hemorrhage there will be a contrast enhancing rim that should not be mistaken with superinfection. The only secure sign of superinfection is the presence of gas bubble in the
patient who have not had any type of percutaneus puncture. A primary retroperitoneal hematoma may become an intraperitoneal hemorrhage if it ruptures the posterior parietal peritoneum, Hematoma of
sufficient size can displace and compress adjacent organs. A chronic hematoma may be confused with abscess or necrotic mass and percutaneus needle aspiration may be necessary for definitive
diagnosis.
Differential Diagnosis List
Retroperitoneal hemorrhage due to multiple pelvic fractures
Final Diagnosis
Retroperitoneal hemorrhage due to multiple pelvic fractures
