Suspected Retroperitoneal Bleed

Variant: 1 Clinically suspected retroperitoneal bleed. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Appropriate	☢☢☢☢
CTA abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢☢
Aortography abdomen and pelvis	May Be Appropriate (Disagreement)	☢☢☢☢
CT abdomen and pelvis without IV contrast	May Be Appropriate	☢☢☢
US abdomen and pelvis	Usually Not Appropriate	O
Radiography abdomen and pelvis	Usually Not Appropriate	☢☢☢
MRA abdomen and pelvis with IV contrast	Usually Not Appropriate	O
MRA abdomen and pelvis without and with IV contrast	Usually Not Appropriate	O
MRA abdomen and pelvis without IV contrast	Usually Not Appropriate	O
MRI abdomen and pelvis without and with IV contrast	Usually Not Appropriate	O
MRI abdomen and pelvis without IV contrast	Usually Not Appropriate	O
RBC scan abdomen and pelvis	Usually Not Appropriate	☢☢☢

Panel Members

Nupur Verma, MD^a; Michael L. Steigner, MD^b; Ayaz Aghayev, MD^c; Ezana M. Azene, MD, PhD^d; Suzanne Chong, ^e; Benoit Desjardins, MD, PhD^f; Riham H. El Khouli, MD, PhD^g; Nicholas E. Harrison, MD^h; Sandeep S. Hedgire, MDⁱ; Sanjeeva P. Kalva, ^j; Yoo Jin Lee, MD^k; David M. Mauro, MD^l; Hiren J. Mehta, MD^m; Mark Meissner, MDⁿ; Anil K. Pillai, MD^o; Nimarta Singh, MD, MPH^p; Pal S. Suranyi, MD, PhD^q; Eric E. Williamson, MD^r; Karin E. Dill, MD^s.

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).

Discussion of Procedures by Variant

Variant 1: Clinically suspected retroperitoneal bleed. Initial imaging.

Variant 1: Clinically suspected retroperitoneal bleed. Initial imaging.
A. Aortography abdomen and pelvis

Variant 1: Clinically suspected retroperitoneal bleed. Initial imaging.
B. CT Abdomen and Pelvis

Variant 1: Clinically suspected retroperitoneal bleed. Initial imaging.
C. CTA Abdomen and Pelvis

Variant 1: Clinically suspected retroperitoneal bleed. Initial imaging.
D. MRA Abdomen and Pelvis

Variant 1: Clinically suspected retroperitoneal bleed. Initial imaging.
E. MRI Abdomen and Pelvis

Variant 1: Clinically suspected retroperitoneal bleed. Initial imaging.
F. Radiography Abdomen and Pelvis

Variant 1: Clinically suspected retroperitoneal bleed. Initial imaging.
G. RBC Scan Abdomen and Pelvis

Variant 1: Clinically suspected retroperitoneal bleed. Initial imaging.
H. US Abdomen and Pelvis

Summary of Highlights

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

References

1.	Kasotakis G.. Retroperitoneal and rectus sheath hematomas. [Review]. Surg Clin North Am. 94(1):71-6, 2014 Feb.
2.	Simsek A, Ozgor F, Yuksel B, et al. Spontaneous retroperitoneal hematoma associated with anticoagulation therapy and antiplatet therapy: two centers experiences. Arch Ital Urol Androl. 86(4):266-9, 2014 Dec 30.
3.	Uludag N, Totterman A, Beckman MO, Sundin A. Anatomic distribution of hematoma following pelvic fracture. Br J Radiol. 91(1085):20170840, 2018 May.
4.	Fitzpatrick J, Bhat R, Young JA. Angiographic embolization is an effective treatment of severe hemorrhage in pancreatitis. Pancreas. 43(3):436-9, 2014 Apr.Pancreas. 43(3):436-9, 2014 Apr.
5.	Patell R, Gutierrez A, Rybicki L, Khorana AA. Identifying predictors for bleeding in hospitalized cancer patients: A cohort study. Thromb Res. 158:38-43, 2017 Oct.
6.	Wang ZW, Xue HD, Li XG, Pan J, Zhang XB, Jin ZY. Life-threatening Spontaneous Retroperitoneal Haemorrhage: Role of Multidetector CT-angiography for the Emergency Management. Chin Med Sci J. 31(1):43-48, 2016 Mar 20.
7.	Caleo O, Bocchini G, Paoletta S, et al. Spontaneous non-aortic retroperitoneal hemorrhage: etiology, imaging characterization and impact of MDCT on management. A multicentric study. Radiol Med (Torino). 120(1):133-48, 2015 Jan.
8.	American College of Radiology. ACR–NASCI–SIR–SPR Practice Parameter for the Performance and Interpretation of Body Computed Tomography Angiography (CTA). Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=164+&releaseId=2.
9.	Tani R, Sofue K, Sugimoto K, et al. The utility of transarterial embolization and computed tomography for life-threatening spontaneous retroperitoneal hemorrhage. Jpn J Radiol. 37(4):328-335, 2019 Apr.
10.	Baekgaard JS, Eskesen TG, Lee JM, et al. Spontaneous Retroperitoneal and Rectus Sheath Hemorrhage-Management, Risk Factors and Outcomes. World Journal of Surgery. 43(8):1890-1897, 2019 08.
11.	Fujimura N, Takahara M, Isogai N, et al. Retroperitoneal hematoma volume is a good predictor of perioperative mortality after endovascular aneurysm repair for ruptured abdominal aortic aneurysm. Journal of Vascular Surgery. 68(4):998-1006.e2, 2018 10.
12.	Goenka AH, Shah SN, Remer EM. Imaging of the retroperitoneum. Radiol Clin North Am 2012;50:333-55, vii.
13.	Yumoto T, Kosaki Y, Yamakawa Y, et al. Occult Sources of Bleeding in Blunt Trauma : A Narrative Review. [Review]. Acta Med Okayama. 71(5):363-368, 2017 Oct.
14.	Thorne DA, Datz FL, Remley K, Christian PE. Bleeding rates necessary for detecting acute gastrointestinal bleeding with technetium-99m-labeled red blood cells in an experimental model. J Nucl Med. 28(4):514-20, 1987 Apr.
15.	Sunga KL, Bellolio MF, Gilmore RM, Cabrera D. Spontaneous retroperitoneal hematoma: etiology, characteristics, management, and outcome. J Emerg Med 2012;43:e157-61.
16.	Georgieva M, Beyer L, Goecze I, Stroszczynski C, Wiggermann P, Jung EM. Contrast-enhanced ultrasound (CEUS) in an interdisciplinary intensive care unit (ICU): Diagnostic efficacy in the assessment of post-operative complications compared to contrast-enhanced computed tomography (CECT): First results. Clin Hemorheol Microcirc. 66(4):277-282, 2017.
17.	Rubano E, Mehta N, Caputo W, Paladino L, Sinert R. Systematic review: emergency department bedside ultrasonography for diagnosing suspected abdominal aortic aneurysm. Acad Emerg Med 2013;20:128-38.
18.	American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.

Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.