284 Wunderlich Syndrome - Case Report of a Surgical Emergency Due to Spontaneous Non-Traumatic Retroperitoneal Haemorrhage

A 42-year-old female with no other significant co-morbidities presented with complaints of sudden onset abdominal pain, she was in state of shock- her haemoglobin dropped drastically to 6.8g/dl from 11.8g/dl. She was resuscitated and was given blood transfusion. CT Scan was suggestive of retroperitoneal haemorrhage due to rupture of Renal angiomyolipoma (RAML). Patient underwent selective embolization of renal artery the next day and was discharged after 3 days of post-operative stay. Wunderlich Syndrome-is a rare condition in which spontaneous nontraumatic renal haemorrhage occurs into the subcapsular and perirenal spaces is most commonly caused due to spontaneous rupture of RAML.It is characterized by Lenk’s triad – Acute flank pain, flank mass, hypovolemic shock. Size of AML (>4 cm), prothrombotic states such as pregnancy are main causes of AML rupture. Patients are managed conservatively or with help of selective arterial embolization. Nephrectomy is last resort in a hemodynamically unstable patient or in cases of embolization failure. When dealing with acute abdomen with haemodynamic instability in non-traumatic cases it is essential to consider possibility of Wunderlich Syndrome. Early diagnosis, availability of Interventional radiology is key to successful management and potentially avoiding a Nephrectomy.

Spontaneous retroperitoneal haemorrhage secondary to anticoagulation polypharmacy

Retroperitoneal haemorrhage (RH) is not uncommon in patients with provoking events like trauma. However, spontaneous RH (SRH) is a rare and life-threatening complication described as the development of bleeding into the retroperitoneal cavity, appearing spontaneously and without a preceding history of trauma or other predisposing illness. We are reporting a case of an elderly patient with recurrent deep vein thrombosis who had developed SRH secondary to concurrent use of multiple anticoagulation agents, resulting from poor healthcare follow-up and lack of sufficient medication reconciliation. This article highlights the significance of recognising risk factors for SRH, as well as management strategies through literature review.

Double-edged sword effect of anticoagulant in COVID-19 infection

Coagulation predominant-type coagulopathy such as microthrombosis and macrothrombosis is a well-known recognised complication found in COVID-19 infected critically ill patients. In the context of high incidence of thrombotic events in patients with COVID-19, supplementation with anticoagulant therapy has been routinely recommended and shown to reduce mortality. However, the recommended type, dose, duration and timing of anticoagulant has not been determined yet. Spontaneous retroperitoneal haematoma secondary to anticoagulant therapy is one of the well-known but self-limiting conditions. We report a 51-year-old COVID-19 positive woman, who was taking intermediate-intensity heparin therapy for venous thromboembolism prophylaxis and died from complication of retroperitoneal bleeding. Further studies are needed to verify the risk–benefit ratio of anticoagulant therapy in patients with COVID-19. Although anticoagulant deems appropriate to use in patients with COVID-19, clinicians should be cautious about major bleeding complication such as retroperitoneal haemorrhage even when full therapeutic dosage is not used.

Spontaneous retroperitoneal haemorrhage post-coronary angioplasty: a case report

Background Spontaneous retroperitoneal haemorrhage (SRH) is a rare cause of retroperitoneal haemorrhage in patients who are on anticoagulants or antiplatelet agents or both. Case summary We report here a rare and catastrophic complication of use of anticoagulants and antiplatelet drugs in a case undergoing coronary angioplasty. The patient had multiple coronary risk factors and developed acute myocardial infarction with pulmonary oedema and hypotension during hospitalization for treatment of lower respiratory tract infection and diabetic ketoacidosis. He underwent successful angioplasty of the culprit vessel but later developed hypotension attributable to retroperitoneal haemorrhage. No bleeding site was identified despite extensive evaluation of the aorta and iliac vessels. Discussion A diagnosis of SRH is considered when a patient on anticoagulants or antiplatelet drugs develops retroperitoneal haemorrhage without any specific identifiable site of bleeding in the retroperitoneum. Diffuse vasculopathy and atherosclerosis or vasculitis of the small vessels in the retroperitoneum may result in rupture of the most friable vessels and result in bleeding. Intense cough, forceful vomiting or sneezing may also be responsible for traumatizing the vessels and resulting in bleeding. Most cases recover with conservative management but some may benefit from interventional occlusion of the leak or surgical decompression in cases of abdominal compartment syndrome.

Endovascular management of an unsual case of spontaneous Retroperitoneal Haemorrhage due to Fibromuscular Dysplasia

Background Fibromuscular dysplasia (FMD) is an uncommon vascular disease that results in stenosis, dissection or aneurysmal degeneration. However, it can sometimes manifest atypically, as we show in this case. Case presentation A 24-year old patient with no relevant medical history with severe left hypochondrium pain. The physical examination showed blood pressure levels of 160/90 mmHg. An abdominopelvic CT evidenced left retroperitoneal haematoma associated with active bleeding and left renal artery stenosis. Given these findings, it was decided to perform an endovascular treatment. Significant stenosis was seen during the arteriography in both renal arteries, suggesting fibromuscular dysplasia and development of a collateral neovascular network responsible for the retroperitoneal haematoma. It was embolised in association with angioplasty of the left renal artery. The patient had a favourable outcome; however, high blood pressure levels persisted. A new bilateral renal angioplasty was performed, which returned blood pressure values to normal. The patient was discharged without needing antihypertensives. Conclusions FMD is a rare disease that can show multiple clinical presentations and need individualized treatment options. Endovascular techniques are in the first therapeutic line regarding fibromuscular dysplasia.