Spontaneous retroperitoneal and rectus muscle hemorrhage as a potentially lethal complication of cirrhosis

Aims/background: Cirrhosis may be complicated by bleeding from varices at sites of porto-systemic anastomosis and may be exacerbated by coagulopathy. Methods: We describe two cases with decompensated cirrhosis who developed spontaneous retroperitoneal hemorrhage, with rectus sheath hematoma additionally in one case. Results: The diagnosis was readily made by physical examination as both patients had Grey Turner's sign - ecchymosis of the flank. In addition, non-contrast computed tomography was very useful in confirming the diagnosis. The hemorrhage in both patients was associated with the coagulopathy typical of liver disease. However, one patient had features of disseminated intravascular coagulation initially while the other developed this complication during the course of the illness. Both patients died despite vigorous efforts to correct the coagulopathy together with surgical exploration in one case and angiography in the other. Conclusions: We speculate that the hemorrhage may have originated from varices within the retroperitoneum and abdominal wall, as both patients had significant hypertension. This suggests that variceal decompression may be useful in the management of such cases in the future.