Background:
End-stage renal disease (ESRD) and anticoagulation are risk factors for spontaneous bleeding (SB). Retroperitoneal bleeding (RB) is a rare but described manifestation of SB1. Sometimes the differential diagnosis of ACS postoperatively may not be easy, like in this case.  

Case report:
A 69 year-old man with atrial fibrillation, mechanical mitral valve prosthesis, and ESRD underwent renal transplantation. Subcutaneous anticoagulation treatment with LMW heparin was restarted on day 3. Two days later, he became anaemic and an angiography showed a retroperitoneal bleeding (RB) from two lumbar arteries that were successfully embolized. Due to hemodynamic instability he was transferred to the ICU and transfused. After transfusion, haemoglobin and coagulation values were normal but one thrombopathy (maybe uremic) was observed. Nevertheless, he required an increasing IV epinephrine perfusion with the presence of severe shock markers. A cardiogenic cause was discarded by echocardiography. After 12 hours he suffered a cardiorespiratory arrest in electromechanical dissociation reverting after 15 minutes resuscitation manoeuvres. A massive retroperitoneal hematoma displacing abdominal organs was removed through emergency laparotomy, improving clinical status and lab values. Finally, one abdominal compartment syndrome (ACS) was responsible for the shock’s cause. 

Discussion:
While ACS is easily related to abdominal disorders, triggering shock and organ failure, retroperitoneal pathologies may also be the origin. However, only a few cases associated ACS to a RB2. In this case, the lack of active bleeding forced to conservative treatment. If an ACS had been suspected, early surgery could have avoided the cardiorespiratory arrest. 

References:
1Yamamura, H., Morioka, T., Yamamoto, T., Kaneda, K., Mizobata, Y. Spontaneous retroperitoneal bleeding: a case series. BMC Res Notes. 2014: 7; 659. 
2 Won, D.Y., Kim, S.D., Park, S.C., Moon, I.S., Kim, J. Abdominal compartment síndrome due to Spontaneous retroperitoneal hemorrhage in a patient undergoing anticoagulation. Yonsei Med J. 2011: 52(2):358-361.

Learning points:
RB is a rare condition and an exceptional trigger for ACS. ACS is associated with shock and organ failure and must be taken into consideration also when dealing with retroperitoneal abnormalities.



04 / Postoperative shock due to abdominal compartment syndrome after massive retroperitoneal bleeding post-renal transplantation and anticoagulation