Spontaneous intraperitoneal hemorrhage: imaging features

Omental venous malformation: a rare cause of spontaneous haemoperitoneum

Spontaneous haemoperitoneum is a rare condition with a variety of aetiologies. Regardless of the cause, it is invariably a life-threatening condition that requires urgent diagnosis and management. The most common causes of spontaneous haemoperitoneum include gynaecological, hepatic, splenic and vascular causes. However, here, we present a rare case of spontaneous haemoperitoneum secondary to idiopathic omental venous malformation.Our patient presented with acute onset of right iliac fossa pain, and a CT scan revealed a massive haemoperitoneum. A laparoscopic converted to open laparotomy was performed to diagnose and treat the patient. We discuss the management approach for such patients with spontaneous haemoperitoneum.

Massive intraperitoneal hemorrhage in patients with COVID-19: a case series

Coronavirus disease (COVID-19) initiates several life-threatening complications including coagulopathies with a unique characteristic that made this problem challenging. Here we presented 4 cases of RT-PCR positive patients that have experienced deadly intraperitoneal hemorrhage with fourth WHO Bleeding Grade after overcoming their respiratory phase. COVID-19 could induce several coagulopathies with different features that besides iatrogenic interventions increases its mortality and morbidity due to lack of clinical evidence based on well-designed randomized clinical trials on anticoagulation therapies (AT) and administration of varieties of newly approved and non-approved medicines. This report showed the urgent need for investigation on the pathophysiology of COVID-19-associated coagulopathy esp. in hemorrhagic events which are needed to make the best therapeutic decision.

Contrast-Enhanced Ultrasound (CEUS) in Non-Traumatic Abdominal Emergencies

Conventional ultrasound imaging (US) is the first-line investigation in acute non-traumatic abdominal emergencies, but sometimes it needs further examinations, such as computed tomography (CT), to reach a certain diagnosis. Contrast-enhanced ultrasound (CEUS), through injection of contrast medium, may provide the radiologist with additional information that could not be investigated with baseline US. It could help reach a diagnosis and rapidly determine the proper therapy in an emergency setting. The purpose of this review is to explain and illustrate the various possibilities and limitations of CEUS in acute non-traumatic abdominal diseases, in particular acute inflammation, parenchymal infarcts, and hemorrhages.

Idiopathic Spontaneous Intraperitoneal Hemorrhage due to Rupture of Short Gastric Artery Presenting as Massive Gastrointestinal Bleeding: A Rare Case Presentation and Literature Review

Idiopathic spontaneous intraperitoneal hemorrhage (ISIH) or abdominal apoplexy is due to the tear of an intra-abdominal visceral vessel spontaneously where no cause can be identified. It is an uncommon but potentially life-threatening condition that generally shows up as a diagnostic dilemma as well as is related to formidable mortality. Among all the reported cases, the extemporaneous tear of short gastric arteries is extremely rare, but it has never been reported to present with massive gastrointestinal bleeding. We report a rare instance of idiopathic spontaneous intraperitoneal hematoma eroding the stomach wall, causing massive gastrointestinal bleeding.

Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management

OBJECTIVE. The purposes of this article are to discuss a variety of liver masses that can present with hemorrhage, including their characteristic imaging features, and to propose a diagnostic approach. CONCLUSION. A broad spectrum of pathologic conditions can present as spontaneous hemorrhage within or surrounding the liver and may present acutely or as a chronic or incidental finding. Imaging characteristics and clinical history can often narrow the differential diagnosis and guide management.

Laparoscopic Management of Abdominal Apoplexy

Abdominal apoplexy, otherwise known as intraperitoneal idiopathic spontaneous haemorrhage, is a rare condition that presents as a diagnostic dilemma and is associated with high mortality. Symptoms and signs typically are similar to other conditions presenting with upper abdominal peritonitis. Intraabdominal haemorrhage can occur from many different causes, including trauma, iatrogenic, ruptured aneurysm, gynaecological conditions, malignancy, and inflammatory or autoimmune processes. Spontaneous or idiopathic causes are much rarer. Prompt diagnosis and ligation of the bleeding vessel usually result in a good outcome. Most cases described involve males in the fifth and sixth decade of life who present in the setting of hypertension and known atherosclerotic disease and are managed with laparotomy or are diagnosed at autopsy. We present a case of abdominal apoplexy managed laparoscopically in a healthy 20-year-old male with no pre-existing medical conditions. This case highlights the importance to consider abdominal apoplexy in any demographic.

Spontaneous rupture of right gastroepiploic artery aneurysm: a rare cause of hemorrhagic shock. case report

CONTEXT

Aneurysms of the gastroepiploic arteries are seen only rarely. They are usually diagnosed during autopsy or laparotomy in patients with hemodynamic instability. Although the operation to treat this condition is relatively easy, delay in making the diagnosis affects the course of the disease.

CASE REPORT

A 57-year-old woman was admitted to the emergency department with abdominal pain and unconsciousness. A computed tomography scan showed extravasation of contrast agent at the headcorpus junction of the pancreas, and the patient underwent exploratory laparotomy under general anesthesia. During laparotomy, aneurysmatic rupture of the right gastroepiploic artery was detected. Control over bleeding was achieved by ligating the right gastroepiploic artery at its origin. The aneurysm was also resected and sent for pathological examination.

CONCLUSION

Especially in cases of unidentified shock, splanchnic artery aneurysms should be kept in mind. Moreover, in the light of the data in the literature, the possibility of death should be taken into account seriously and, if feasible, prophylactic aneurysmectomy should be performed.

Spontaneous idiopathic omental haemorrhage: a rare cause of right iliac fossa pain

Background

Isolated omental haemorrhage is a rare entity of which only case reports exist. This is usually in the setting of trauma, neoplasms or anticoagulation.

Case presentation

We report a case of spontaneous idiopathic omental haemorrhage with no evidence of trauma, neoplasm or presence of anticoagulation. This was identified on the imaging studies performed for the purpose of diagnosis of the cause of the patient’s right iliac fossa pain. The patient required urgent laparotomy and omentectomy to achieve haemostasis.

Discussion

Spontaneous omental haemorrhage is a rare entity that is usually preceeded by trauma or occurs in the context of adhesions, neoplasms or anticoagulation. If there are delays in diagnosis, it could lead to significant morbidity for the patient. Therefore, it requires prompt recognition and definitive management.

Conclusion

Spontaneous omental haemorrhage is a rare entity characterised only in case reports. It is usually a secondary event and requires prompt management.

The use of contrast-enhanced ultrasonography for the detection of active renal hemorrhage in a dog with spontaneous kidney rupture resulting in hemoperitoneum

OBJECTIVE

To describe the use of contrast-enhanced ultrasonography (CEUS) for the detection of active renal hemorrhage in a dog with spontaneous kidney rupture resulting in hemoperitoneum.

CASE SUMMARY

A 9-month-old, sexually intact male Boxer dog presented for acute collapse, abdominal pain, and tachycardia. Physical examination findings were consistent with hypovolemia and acute abdomen. B-mode ultrasonography revealed peritoneal effusion and a right kidney mass. Subsequently, a CEUS study was performed on the right kidney, which demonstrated active hemorrhage from that kidney resulting in both hemoretroperitoneum and hemoperitoneum. At exploratory surgery, ultrasonographic findings were confirmed and a right nephrectomy was performed. Histopathology demonstrated severe parenchymal alterations along with the presence of nematode larvae. Fecal and urine testing for the presence of parasitic ova were negative. Identification of the larvae was inconclusive. At 30 days postoperatively, repeat B-mode ultrasound and clinicopathologic testing was unremarkable. The dog was alive at 1 year postsurgery with no ill effects.

NEW OR UNIQUE INFORMATION PROVIDED

To the authors' knowledge, this is the first report of CEUS for the detection of active hemorrhage from a kidney resulting in hemoretroperitoneum and hemoperitoneum in a dog. Although rare, the finding of nematode larvae within the renal parenchyma may have been the cause of kidney rupture. Importantly, surgical removal of the kidney was curative. Benign processes causing kidney rupture such as parasitic infestation should be considered in the working diagnosis as related to geographical location.

Emergency radiology

US has a relevant role in the initial assessment of non-traumatic emergencies of the abdomen, sometimes being conclusive and some other times for selecting the patients for further imaging with CT. Injection of a contrast medium may give to the radiologist additional information to that obtained at baseline US and Doppler examination, since real-time, contrast-enhanced US (CEUS) may allow observing findings in the abdomen not recognizable at baseline US or even at color Doppler imaging. Extravascular use of microbubbles may also be useful in clinical practice to rapidly solve a number of unclear aspects. CEUS has a number of distinct advantages in acute patients, including its quickness, low invasiveness, and its possible bedside use. The information based on contrast enhancement is useful for initial diagnosis, therapeutic decision making, and follow-up of the critically ill patients. The purpose of this review is to illustrate the possibilities and limitations of abdominal CEUS in the acute setting, with special emphasis on the detection and characterization of acute inflammatory processes, infarcts, and hemorrhages.

A Case Report of Spontaneous Lesser Omental Haemorrhage

Spontaneous rupture of the lesser omental artery in the absence of identifiable causes is rare. We describe a case of abdominal apoplexy secondary to a spontaneous lesser omental artery rupture. A 73-year-old woman presented to our emergency department for acute abdominal pain with persistent nausea and vomiting. Abdominal examination revealed mild epigastric tenderness but no signs of peritonitis. Computed tomography of the abdomen suggested a massive volume of blood in the peritoneal and pelvic cavity. The diagnosis was made by exploratory laparotomy revealing haemoperitoneum, a haematoma in the lesser omentum near the antrum with an active bleeder. Choices of investigation modality for diagnosis and treatment are discussed. (Hong Kong j.emerg.med. 2015;22:53-56)

Acute abdominal pain due to spontaneous rupture of the right gastric artery

Abdominal apoplexy was reported by Barber in 1909, and the occurrence rate of the apoplexy is known to be quite rare, but the mortality is high if untreated. We report an unusual case of abdominal apoplexy due to spontaneous rupture of gastric artery. A male patient in his fifth decade with recently diagnosed liver cirrhosis history arrived to the emergency department with severe abdominal pain, which led to abdominal computer tomography indicating spontaneous rupture of gastric artery. Celiac angiogram and embolization were conducted, and exploratory laparotomy was followed. The outcome of the patient was poor, and he died on the second day of admission. As in our case, the mortality can be high, so prompt restoration of circulation volume and early diagnosis should be made in similar cases.

Spontaneous hemoperitoneum

Spontaneous hemoperitoneum is a rare, but life-threatening condition usually caused by nontraumatic rupture of the liver, spleen, or abdominal vasculature with underlying pathology. Management revolves around angioembolization or surgical intervention. This article provides a brief overview of the diagnosis and treatment of this disorder.

Idiopathic omental bleeding

Omental bleeding without any evidence of trauma, aneurysms, or other pathology has been rarely described in the literature. We report a case of a 24 year-old female on aspirin/acetaminophen/caffeine for migraines who presented with abdominal pain and tachycardia. Computed tomography angiography revealed active extravasation in the right lower quadrant. During exploratory laparotomy, a small bleeding artery within the greater omentum was suture ligated, and two liters of fresh and clotted blood were evacuated. The patient recovered successfully. We review the diagnosis and management of this rare condition.

Spontaneous hemoperitoneum from hepatic metastatic trophoblastic tumor

Spontaneous hemoperitoneum (SP) is defined as the presence of blood within the peritoneal cavity that is unrelated to trauma. Although there is a vast array of etiologies for SP, primary hepatocellular carcinoma and hepatic adenoma are considered to be the most common causes. Hepatic metastatic tumor associated with spontaneous rupture is rare. SP from hepatic metastatic trophoblastic tumor may initially present with a sudden onset of abdominal pain. Abdominal computed tomography (CT) plays an important role in establishing the diagnosis of SP, indicating its origin and etiology, and determining subsequent management. Herein, we report an uncommon case of hemoperitoneum from spontaneous rupture of a hepatic metastatic trophoblastic tumor in a young female patient. Interestingly, the contrast-enhanced CT findings demonstrated hypervascular hepatic masses with persistent enhancement at all phases, which were completely different from the common appearances of hepatic metastases. For SP resulting from hepatic metastatic tumors, surgical intervention is still the predominant therapeutic method, but the prognosis is very poor.

Hemoperitoneum in cirrhotic patients without abdominal trauma or tumor

BACKGROUND

Hemoperitoneum is associated with several emergency conditions and is especially evident when it occurs in patients with liver cirrhosis. This study aimed to assess the clinical characteristics of cirrhotic patients who did not have abdominal trauma or tumor but who developed hemoperitoneum.

METHODS

We reviewed the clinical records of 1276 consecutive cirrhotic patients with hemoperitoneum at our center between January 2007 and December 2009. Hemoperitoneum was confirmed by abdominal paracentesis.

RESULTS

Of the 1276 cirrhotic patients, 19 were found to have hemoperitoneum, but only 6 did not have abdominal trauma or tumor. The occurrence of spontaneous hemoperitoneum in the cirrhotic patients was therefore 0.5%. Hemoperitoneum can occur spontaneously in severely decompensated cirrhotic patients with intra-abdominal collateral vessels and high scores on the model for end-stage liver disease and Child-Pugh-Turcotte test. Most patients presented with abdominal distension, abdominal pain, increased abdominal girth and hemodynamic instability with a significant drop in the hemoglobin level. Three patients died of hemorrhagic shock within 24 hours, and the other 3 died of hepatic encephalopathy or spontaneous bacterial peritonitis after 5 to 10 days because of further decompensation of the liver.

CONCLUSIONS

Hemoperitoneum can occur in cirrhotic patients who do not have abdominal trauma or tumor. It mainly occurs in severely decompensated end-stage cirrhotic patients. Cirrhotic patients with hemoperitoneum have a poor prognosis.

Delayed enhancement of ascites after i.v. contrast material administration at CT: time course and clinical correlation

OBJECTIVE

The objective of our study was to determine the prevalence and clinical predictors of delayed contrast enhancement of ascites.

MATERIALS AND METHODS

In this retrospective study, 132 consecutive patients with ascites who underwent repeated abdominopelvic CT examinations performed within 7 days of each other were identified. These patients included 112 patients who received and 20 who did not receive i.v. contrast material at the initial CT examination. For each examination, we recorded the CT attenuation of the ascites. For the follow-up scan, the presence of delayed enhancement of ascites was defined as an increase in CT attenuation > 10 HU over baseline. The Fisher's exact test, unpaired Student's t test, and logistic regression were used to determine predictors of delayed enhancement of ascites.

RESULTS

A threshold increase in the attenuation of ascites by > 10 HU or more between the initial and follow-up CT examinations occurred only when i.v. contrast material was given with the initial examination. The increased attenuation was due to delayed contrast enhancement of ascites and occurred in 15 of the 112 patients (13%). Of the 16 patients scanned less than 1 day apart, 10 (63%) showed delayed enhancement of ascites. Delayed enhancement was not observed 3 or more days after i.v. contrast material administration. For each 1 mg/dL increase in serum creatinine level, the likelihood of delayed enhancement of ascites increased (odds ratio, 2.02; 95% CI, 1.11-3.69). Multivariate logistic regression showed that a short time interval between examinations (p < 0.001), increased serum creatinine level (p < 0.001), and presence of loculated ascites (p = < 0.01) were independent predictors of the magnitude of delayed enhancement of ascites.

CONCLUSION

Delayed contrast enhancement of ascites occurs commonly after recent prior i.v. contrast material administration and should not be mistaken for hemoperitoneum or proteinaceous fluid such as pus.

Spontaneous hemoperitoneum from a ruptured mesenteric branch arterial aneurysm: report of a case

We report a case of spontaneous intraperitoneal hemorrhage from a ruptured mesenteric branch artery aneurysm in a patient presenting with syncope. A 54-year-old woman was brought to our emergency department as a medical code, following two syncopal episodes. Computed tomography, carried out to rule out aortic aneurysmal disease, revealed hemoperitoneum without evidence of solid organ injury. Emergency exploratory laparotomy revealed a large jejunal mesenteric hematoma accompanying a ruptured mesenteric branch artery aneurysm with active extravasation. We ligated and excised the lesion and diagnosis was confirmed on final pathologic examination. We report this case because general surgeons should be aware of these vascular lesions and the basic guidelines for treatment.

Spontaneous rupture of the right gastroepiploic artery: unusual cause of acute abdomen and shock

Introduction

Spontaneous rupture of the right gastroepiploic artery is an extremely rare case which can be a cause of abdominal apoplexy.

Case report

We present a case of a 64-year old woman with a Spontaneous rupture of the right gastroepiploic artery with hemorrhagic shock that was successfully treated by emergency surgery.

Conclusion

Simultaneous restoration of circulating volume and rapid diagnosis are keys in determining the patient outcome in this situation. Though the mortality is high if untreated, the operation is relatively simple and carries a low risk.

Abdominal apoplexy: a case report and review

Abdominal apoplexy, or the newer term, idiopathic spontaneous intraperitoneal hemorrhage (ISIH), represents a rare cause of non-traumatic intra-abdominal bleeding. As with any acute blood loss, this problem often presents to the Emergency Department (ED) for initial evaluation and resuscitation. The case of a 52-year-old man with abdominal pain and distention due to spontaneous intraperitoneal hemorrhage is presented. This patient developed impending cardiovascular compromise in the ED and was subsequently diagnosed by computed tomography scan as having an intra-abdominal hematoma. Emergent exploratory laparotomy was performed and the patient was found to have spontaneous bleeding from a branch of the middle colic artery that was ligated without complication. The patient recovered well with no recurrent bleeding. The pathophysiology, diagnostic approach, and treatment of ISIH are reviewed.

Blood in the belly: CT findings of hemoperitoneum

Hemoperitoneum may occur in various emergent conditions. In the trauma setting, evidence of intraperitoneal blood depicted at computed tomography (CT) should lead the radiologist to conduct a careful search of images for the injured visceral organ (the liver or spleen). Specific CT signs, such as a sentinel clot or extravasation of intravascular contrast material, may indicate the source of bleeding and help direct management. In addition, the configuration of accumulated blood may help identify the injured organ; for example, triangular fluid collections are observed in the mesentery most often in the setting of bowel or mesenteric injury. Less commonly, hemoperitoneum may have a nontraumatic origin. Iatrogenic hemoperitoneum may occur as a complication of surgery or other interventional procedures in the abdominal cavity or as a result of anticoagulation therapy. Hemoperitoneum also may be seen in the setting of blood dyscrasias such as hemophilia and polycythemia vera. Tumor-associated hemorrhage, which most often occurs in hepatocellular carcinoma, hepatic adenoma, or vascular metastatic disease, also may produce hemoperitoneum. Other potential causes of nontraumatic hemoperitoneum are gynecologic conditions such as hemorrhage or rupture of an ovarian cyst and rupture of the gestational sac in ectopic pregnancy, and hepatic hematoma in syndromic hemolysis with elevated liver enzymes and low platelet count (HELLP syndrome). Vascular lesions (visceral artery aneurysms and pseudoaneurysms) that occur in systemic vascular diseases such as Ehlers-Danlos syndrome or in pancreatitis are another less common source of hemoperitoneum.

Active abdominal bleeding: contrast-enhanced sonography

Active contrast medium extravasation is a recognized and important angiographic and computed tomographic (CT) sign of bleeding. It is an indicator of active, ongoing, and potentially life-threatening hemorrhage and, hence, of the need for an immediate surgical or interventional treatment. Sonography (US) is frequently used as the first imaging option for screening patients with traumatic and nontraumatic abdominal emergencies. Owing to the current possibilities of low-mechanical index, real-time, contrast-specific systems, it is now possible to detect a contrast leakage by using US. This finding opens new possibilities in the assessment and management of several abdominal emergencies, including trauma (initial workup and monitoring), spontaneous hematomas, and rupture of aneurysms or masses. This article describes the technique, findings, possibilities, and limitations of contrast-enhanced US in the evaluation of active abdominal bleeding.

Computed tomography manifestations of peritoneal diseases

The peritoneal cavity is a potential space that is divided by the peritoneal reflections into various complex subspaces. It can be involved in many disease processes including developmental, inflammatory, neoplastic and traumatic conditions. Computed tomography is highly sensitive and consistent in detecting peritoneal pathology. This pictorial essay aims to emphasize and illustrate the CT features of the spectrum of peritoneal diseases.

Mimics of Renal Colic: Alternative Diagnoses at Unenhanced Helical CT

During the past decade, unenhanced computed tomography (CT) has become the standard of reference in the detection of urinary calculi owing to its high sensitivity (>95%) and specificity (>98%) in this setting. Numerous diseases may manifest as acute flank pain and mimic urolithiasis. Up to one-third of unenhanced CT examinations performed because of flank pain may reveal unsuspected findings unrelated to stone disease, many of which can help explain the patient's condition. Alternative diagnoses are most commonly related to gynecologic conditions (especially adnexal masses) and nonstone genitourinary disease (eg, pyelonephritis, renal neoplasm), closely followed by gastrointestinal disease (especially appendicitis and diverticulitis). Hepatobiliary, vascular, and musculoskeletal conditions may also be encountered. Vascular causes of acute flank pain must always be considered, since these constitute life-threatening emergencies that may require the intravenous administration of contrast material for diagnosis. Radiologists must be familiar with the typical findings of urinary stone disease at unenhanced CT, as well as the spectrum of alternative diagnoses that may be detected with this modality, to accurately diagnose the source of flank pain.

Gynecologic ultrasound in emergency medicine

The true value of ultrasound in acute abdominal pain lies in its ability to detect gynecologic disorders and effectively rule out other causes of acute abdominal pain that require surgical repair. Although the emergent gynecologic indications discussed in this article are few in number, this does not suggest that the nonpregnant patient presenting to the ED with abdominal pain should not receive an ultrasound examination. On the contrary, the author believes that in a "perfect world," ultrasound should be the initial imaging study in most of these patients. The reality is that it is difficult to convince radiology colleagues to call in a sonologist in the middle of the night for any indication other than ovarian torsion when CT scans can diagnose ovarian cysts and tubo-ovarian abscess. As was pointed out in the section on ovarian torsion, even adequate ovarian blood flow does not rule out this diagnosis.Ideally, an ultrasound of the pelvis could be undertaken at the time of the pelvic examination, adding as little as 5 to 10 minutes. If a gynecologic disorder could be confirmed, other imaging studies might be unnecessary,thereby reducing cost (potential savings on laboratory tests, cervical cultures, or CT scans), length of stay, and adverse complications of CT(contrast material reactions, and radiation exposure).Emergency medicine ultrasound continues to grow at a rapid pace. We are working toward a time when most EPs will be competent and comfortable performing bedside ultrasound examinations in a limited number of applications. The gynecologic application of ultrasound,however, requires skill beyond the level of the primary applications of emergency medicine ultrasound-specifically, mastering Doppler ultra-sound. Although ultrasound has proved to be a valuable imaging modality in the nonpregnant patient with acute abdominal pain when performed by a seasoned sonographer, the role of ED ultrasound has been limited to those EPs with significantly more training. The author believes that even limited expertise in gynecologic ultrasound is valuable in helping direct the management of these patients. Further research by skilled EP sonographers eventually will help define the role of EPs in this particular application of ultrasound. EPs should not be discouraged from developing expertise in this examination when a confirmatory study in radiology will be performed. Miles on the "ultrasound odometer" will not only sharpen sonographic skills but also will help the EP to better communicate with nonpregnant patients presenting with abdominal pain. There is a fairly specific barometer already in place to gauge one's gynecologic ultrasound skills: a seasoned EP sonographer never skips over the chart of a young woman with right lower quadrant pain.

Fulminant herpes hepatitis in an immunocompetent pregnant woman: CT imaging features

Fulminant hepatitis due to herpes simplex virus (HSV) is rare in immunocompetent adults. Most reported cases have clearly established pregnancy as a condition that can predispose to disseminated HSV infection. We report a case of a 25-year-old previously healthy pregnant woman who presented with fatigue, fever, and anicteric hepatitis. Triphasic contrast-enhanced computed tomography demonstrated a miliary pattern of multiple, hypovascular, subcentimeter lesions scattered throughout the liver. Familiarity with the clinical findings and computed tomographic appearance may prompt early recognition of fulminant HSV hepatitis and allow differentiation from other hepatic disease during pregnancy.