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15 yr male with hx of hemophilia presenting with 1 day hx of progressively worsening RLQ pain, decreased PO, nausea, and vomiting. Described RLQ as a “small swelling’ that continued to span across the R abdomen as the day progressed. Denies dysuria, hematuria, hematemesis, hematochezia, constipation, diarrhea, abd trauma, or testicular pain. No previous abdominal surgeries. Physical exam is significant for RUQ and RLQ tenderness, no obvious swelling, no ecchymosis seen. He definitely appeared ill and uncomfortable. A&Ox4.
So already…what are we considering? Appendicitis …. Peritoneal bleed … bowel obstruction …maybe a few others (UTI, Kidney Stones, STI).
While waiting on CT Abd/Pelvis imaging to be completed, patient is found to be anemic with a Hgb of 8. Normal WBCs. Platelets: 300. Elevated PTT: 83. Normal PT/INR. Urinalysis…. negative. IV Fluids have already been started. Zofran for his continued nausea.
Here’s a significant snapshot of the CT
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It spanned from the R kidney down to the bladder. Actively extravasating. Hydronephrosis due to the hematoma compressing the R ureter. It compressed the R renal vasculature as well, and anteriorly displaced the R kidney.
Contacted Hematology, where we decided to administer FEIBA. (He usually takes Alphanate MWF, but had not taken any medicine on day of presentation. Plus, the hospital did not have his particular medication, so we needed to find an alternative.) He was admitted to the Hematology service. They have plans of contacting Surgery for any possible interventions once his Hgb stabilized.
Repeat CBC (after patient had been admitted) showed that the Hgb had fallen to 6.0.
Diagnosis: 15 year old male with non-traumatic R retro peritoneal hematoma. Source currently unknown.
Pretty impressive bleed; Assuming the pt was stable, slapping on the USN would have narrowed your ddx by half. Sometimes CT gets backed up and this could help expedite the evaluation.
Just an FYI, this is almost always treated medically. The retroperitoneum should tamponade itself, especially in non traumatic, spontaneous bleeds (had my self on coumadin). So sure you call the surgeon, but they will have nothing to offer. From what I was told, entering that portion of the abdomen would make things significantly worse. REVERSAL
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