Spontaneous retroperitoneal hematoma originating at lumbar arteries in context of cirrhosis

A 56-year-old male presented to the emergency department with a 2-week history of increasing abdominal girth, nausea, vomiting, and lower extremity edema. His girlfriend had also noted a yellow tinge to his skin and eyes. His past medical history was significant for bipolar disorder, alcoholrelated seizures, and pneumonia. He had no allergies and denied medications prior to admission. Family history was negative for liver disease and social history was notable for ongoing tobacco use and alcohol dependence. He was afebrile with stable vital signs. Physical examination demonstrated an alert gentleman whose answers to questions required occasional factual correction by his partner. His abdomen was distended and nontender with prominent vasculature and shifting dullness. Lower extremity edema was symmetric and bilateral, rated as 2þ. Scattered spider angiomata and a fine bilateral hand tremor without asterixis were also noted. Initial laboratory data demonstrated a white blood cell count of 13,900/lL, hematocrit 37%, and platelet count 176,000/lL. His sodium was 130 mg/dL, blood urea nitrogen (BUN) 1 mg/dL, and creatinine 0.7 mg/ dL. International normalized ratio (INR) was 1.8, aspartate aminotransferase (AST) was 117 U/L, alanine aminotransferase (ALT) 33 U/L, alkaline phosphatase 191 U/L, total bilirubin 9.2 mg/dL, total protein 7.0 g/dL, and albumin 1.9 g/dL. Abdominal ultrasound revealed a diffusely hyperechoic liver with a large amount of ascites. The patient was admitted with the diagnoses of presumed alcoholic hepatitis and end-stage liver disease. Model for End-Stage Liver Disease (MELD) score was 21 and discriminant function 16.8. Paracentesis demonstrated a serum-ascites albumin gradient of >1.1 and no evidence of spontaneous bacterial peritonitis. Diuresis was initiated. He was placed on unfractionated heparin at a dose of 5000 units every 8 hours for deep venous thrombosis (DVT) prophylaxis. By hospital day 3, the patient’s laboratory values had improved, yet his stay was prolonged by alcohol withdrawal requiring benzodiazepines, altered mental status presumed secondary to hepatic encephalopathy, acute renal failure, aspiration pneumonia, and persistent unexplained leukocytosis. He required medical restraints during this time given confusion and propensity to ambulate without assistance, yet sustained no falls or other known trauma in care delivered during this time. Between days 14 and 17, the patient’s hematocrit fell from 36% to 30%; vital signs remained stable. He underwent an uncomplicated, ultrasound-guided therapeutic paracentesis, which yielded 1.4 L of straw-colored fluid on the afternoon of day 17; the procedure was attempted only on the right side. On the morning of day 18, the patient’s blood pressure dropped to 78/55 mmHg with a pulse of 123 beats per minute; he became pale and unresponsive. Physical examination was notable for somnolence and a tender, warm left flank mass, contralateral to his paracentesis site. No flank or periumbilical ecchymoses were identified. Complete blood count demonstrated a white blood count (WBC) of 22,970/lL, hematocrit 16%, and platelet count 104,000/lL. INR was 2.0, unchanged from the last check on day 10. Partial thromboplastin time was 41 seconds and fibrinogen was 293 mg/dL (normal 150-400 mg/dL). Peripheral blood smear was negative for red cell fragments. Blood chemistries revealed a sodium of 134 mg/dL, bicarbonate 20 mEq/L, anion gap 7, BUN 24 mg/dL, and creatinine 1.6 mg/dL (up from 1.0 mg/dL the previous day). His venous lactate level was 4.6 mmol/L and arterial blood gas sampling on room air demonstrated a pH of 7.35, partial pressure of carbon dioxide (pCO2) 29 mmHg, partial pressure of oxygen (pCO2) 54 mmHg, and bicarbonate 15 mEq/L. A femoral introducer was placed for volume resuscitation and the patient was urgently transfused with packed red blood cells (PRBCs) and fresh-frozen plasma (FFP) to correct his coagulopathy. Computed tomography of the abdomen revealed a large left retroperitoneal hematoma measuring 15 15 22 cm (Figure 1). Despite transfusion, his hematocrit continued to fall. Urgent angiography was performed, upon which he was found to have active bleeding from the left L3-L5 lumbar arteries. These were successfully embolized. He required PRBCs and FFP transfusion only once following this procedure. Given a transient decrease in his urine output, his bladder pressures were followed closely for evidence of abdominal compartment syndrome, which did not develop. He was transferred from the intensive care unit (ICU) to the floor on day 20, where his physical exam and hematocrit remained stable and his delirium slowly cleared. He was ultimately discharged to a skilled nursing facility on day 33.