Hemoperitoneum

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Sunita Kumawat, M.B.B.S[2]

Synonyms and Keywords: peritonel hemorrhage, Hemorrhage into peritoneal cavity, Intraperitoneal hemorrhage, Intraabdominal hemorrhage, abdominal apoplexy, blood in the belly.

Overview

Hemoperitoneum is accumulation of blood in the peritoneal cavity. The parietal peritoneum is a thin membrane surrounding the outer abdominal wall, and visceral peritoneum is the thin membrane surrounding the viscera or organs in the abdomen in a bag like manner. The space between these two membranes is called the peritoneal cavity. The most common cause is trauma. Hemoperitoneum is a life-threatening condition that requires prompt medical attention. Early detection and rapid treatment remain critical to a favorable result. Careful observation may be allowed under some circumstances. The abdominal cavity has the capacity to store more than 5 liters of blood, which can build quickly and cause hemorrhagic shock. If left untreated it may lead to death.

Historical Perspective

• In 1909, Barber first described hemoperitoneum and coined the term "abdominal apoplexy".
• Earlier such cases were divided according to age into differing causes. Patients younger than 45 years old are thought to have congenital aneurysms of the vertebral arteries, but those older than 45 years old are thought to have less well-defined etiology (but causes perhaps related to hypertension and atherosclerosis).
• In 1987, as per Sanderson's study, only 51 occurrences of spontaneous peritoneal hemorrhage had been documented, with 38% of the cases having no identified bleeding site.
• The male-to-female ratio was 3:2, with the majority of cases affecting those between the ages of 55 and 64.
• The typical presentation was with nonspecific abdominal symptoms progressing to an acute abdomen, although cases have also been recorded as presenting as cardiovascular collapse.

Classification

Hemoperitoneum can be classified into 3 types depending on its cause.

Type of hemoperitoneum	Description
Traumatic hemoperitoneum	This is most commonly caused by trauma. This condition occurs when there is bleeding in the peritoneum due to an accident or injury.
Nontraumatic hemoperitoneum	This is also called spontaneous hemoperitoneum. This occurs due to an underlying medical condition.
Iatrogenic hemoperitoneum	This is caused by some medicines or as a complication of procedures or surgery.

Pathophysiology

The presence of blood in the peritoneal cavity is known as hemoperitoneum. The area between the inner lining of the abdominal wall and the internal abdominal organs becomes clogged with blood. Hemoperitoneum is considered a surgical emergency in most cases. In selected cases observation under direct supervision of medical staff can be one of the options.

The abdominal cavity in human body is highly distensible, and it can readily accommodate with over five liters of blood, or more than an ordinary person's full circulating blood volume. As a result, large-scale or sudden blood loss into the abdomen will almost always result in hemorrhagic shock, which can quickly lead to death if left untreated.

Patients could be classified into one of three groups based on the intensity and cause of their bleeding:

• Trauma to the abdomen caused by blunt force (such as the bat hitting or during the fights hitting fist in the stomach)
• The abdomen has been pierced by a piercing trauma.
• Organ injuries, such as those to the spleen, liver, or pancreatic

A normal blood artery is adjacent to an inflammatory condition or tumor, it might deteriorate or produce a pseudoaneurysm, resulting in hemoperitoneum. Rupture pseudoaneurysm is more common in pancreatitis and Intraabdominal varices caused by liver cirrhosis and portal hypertension are the most common cause of venous rupture.

The most common of them is warfarin anticoagulation, while hematoma of the psoas or rectus muscles is the most common complication of warfarin usage.

Causes

Injury to intraabdominal organ or vessel with any of the underlying conditions:

• Blunt abdominal trauma, which results in rupture of liver, kidney, spleen or mesenteric vessels. Sometimes displaced pelvic fractures can lacerate the pelvic or iliac arteries, causing hemoperitoneum.
• Highly vascular intraabdominal tumors can lead to spontaneous bleeding or by invasion of blood vessels.
• Iatrogenic bleeding during abdominal surgery (particularly intestinal anastomosis and resection or enterotomy ) or intraabdominal organ biopsy (kidney, spleen or liver).
• Parturition or late-term pregnancy can cause uterine or ovarian artery rupture.
• Gynecologic disorders ruptured
  • ovarian cyst or ruptured corpus luteum
  • uterine rupture
  • ectopic pregnancy rupture

• Coagulopathy can cause spontaneous hemoabdomen on rare occasions.
• Umbilical vessel rupture inside the abdomen in neonates.
• Acute cholecystitis eroding the cystic artery
• Ruprure of renal or hepatic cyst
• Peritoneal membrane abnormalities
  • Radiation injury
  • Peritoneal calcification
  • Sclerosing peritonitis
  • Peritoneal carcinomatosis
• IgA nephropathy
• Bleeding due to a perforated gastric ulcer
• Aortic or other vascular rupture
• Acute hemorrhagic pancreatitis
• Hepatic hematoma in syndromic hemolysis with elevated liver enzymes and low platelet count (HELLP syndrome)

Differential diagnosis of hemoperitoneum

The common conditions which present similar to hemoperitoneum are:

Hepatic	Splenic	Gynecological	Biliary
Hemangioma Hepatocellular carcinoma Hepatic adenoma/adenomatosis Primary hepatic angiosarcoma Focal Nodular Hyperplasia Metastatic cancer Peliosis hepaticus Amyloid	Iatrogenic Spontaneous splenic rupture Torsion and rupture of wandering spleen Spontaneous rupture of splenic vein Primary splenic angiosarcoma Hamartoma Chronic myelomonocytic leukemia Infectious mononucleosis Hamartoma Primary splenic angiosarcoma	Ruptured ovarian cyst Ruptured corpus luteum cyst Spontaneous uterine rupture Uterine leiomyoma/leiomyosarcoma Ectopic pregnancy Ovarian granulosa cell tumor Endometriosis Hyperemesis gravidarum	Transhepatic rupture of gall bladder Ruptured cholangiocarcinoma
Vascular	Colonic	Gastric	Pancreatic
Ruptured splenic artery aneurysm Ruptured cystic artery pseudoaneurysm Segmental mediolytic arteriopathy	Meckel’s diverticulitis GIST	GIST Mixed cavernous-capillary hemangioma	Ruptured pseudocyst
Miscellaneous
Ruptured benign solitary fibrous tumor

Epidemiology and Demographics

Hemoperitonium also known as Bloody peritoneal dialysate is common in peritoneal dialysis patients, ranging from 6% overall to 57 percent in premenopausal women. Peritoneal dialysate usually relates to the peritoneal dialysis procedure or relates to underlying kidney disease such as PKD or acquired cystic diseases or the multiple factors unrelated to kidney diseaseLike catheter implantation related, gynecological related (retrograde menstruation, endometriosis, after ovarian cyst), catheter related trauma (exercise related) or coagulopathy related. Peritoneal dialysis exchanges helps him assessing the peritoneal cavity and early detection of blood in the peritoneum that could be related to benign causes of bleeding or it can be simply a silent bleed in peritoneal cavity.

In a study done with a goal to correlate hemoperitoneum to a variety of causes. A total of 424 individuals were enrolled in the clinical trial, and only 6% of them suffered one or more episodes of bloody peritoneal dialysis (hemoperitoneum). Patients were split into many categories in the setting based on the severity and cause of bleeding:

• In most of the patient's or in most of the groups, the bleeding was mild and asymptomatic with pink to reddish discoloration of peritoneal fluid.
• Minor bleeding was found in only 1 patient with underlying pancreatitis or sclerosing peritonitis on the other hand svere bleeding that required intervention was observed in 6-8 patient's having underlying ovarian cyst rupture
• Only a single increase was observed related to peritoneal bleeding following transplant nephrectomy, catheter repositioning, enhanced physical activity and or neural hematoma.

Over 50% of menstrual women on peritoneal dialysis develop benign hemoperitoneum, which is most likely caused by ovulation, endometriosis or retrograde menstruation.

It's worth noting that a very small amount of blood (less than 1 mL) is adequate to tint 2 liters of peritoneal dialysate.

In 5% of cases, bleeding into the peritoneal cavity occurs after the peritoneal catheter is inserted

Risk Factors

A person having underlying conditions is more prone to spontaneous hemoperitoneum

• Highly vascular intra-abdominal tumors
• Aneurysm or pseudoaneurysm of intrabdominal vessels
• Coagulation disorders
• HELLP syndrome
• Gastric ulcer
• Endometriosis
• Difficult labour
• Anticoagulation therapy
• Iatrogenic eg. colonoscopy
• Meckel's diverticulum

Natural History, Complications, and Prognosis

If hemoperitoneum is not treated immediately, severe complications might occur. The peritoneal cavity is unusual in that it can store nearly all of a person's circulating blood volume. The blood can collect quickly in the peritoneal cavity.

This can lead to shock due to blood loss, make you unconscious, and even cause death.

Prognosis varies depending on the underlying etiology and associated injuries.

Diagnosis

The various methods of diagnosing hemoperitoneum are:

• Ultrasound: An ultrasound is a process that uses sound waves to create pictures of the inside of the body.  The presence of fluid or blood in the peritoneal cavity can be detected using ultrasounds. For example, Focused Assessment with Sonography for Trauma (FAST). FAST is used for the quick diagnosis of blood in the peritoneal cavity but does not tell anything about the source of bleeding
• CT Scan: The term CT scan (also known as CAT scan) refers to computerized axial tomography (CT scan). This method creates cross-sectional x-rays of the interior of the body and can aid in the detection of blood or fluid in the peritoneal cavity. It is used in hemodynamically stable patients. It is used for the determination of solid organ injury and to find the source of bleeding.
• MRI: The term "magnetic resonance imaging" refers to the use of magnetic and radio waves to create pictures of the inside of the body, which can aid in the diagnosis of hemoperitoneum.

• Paracentesis or diagnostic peritoneal lavage: It is a surgical diagnostic technique used to see if there is any free-floating fluid in the abdominal cavity.
• Diagnostic laparoscopy or exploratory laparotomy: Laparoscopy is a procedure that uses tiny incisions and a camera to examine the abdomen or pelvis. With a few tiny cuts in the belly, the laparoscope assists therapeutic or diagnostic treatments.

• Exploratory laparotomy: The abdomen is opened and the abdominal organs are inspected for damage or illness during an exploratory laparotomy. It is the standard of treatment in a variety of blunt and penetrating trauma scenarios when numerous life-threatening injuries may exist, as well as in many diagnostic cases where the operation is performed to find a unifying reason for several signs and symptoms of illness.

CT Scan findings in diagnosing Hemoperitoneum

Traumatic
Solid organ injury	Accumulation of high-attenuation fluid close to or surrounding the injured organ, in the pelvis, and the paracolic gutters appearing as Sentinel clot sign. A high attenuation area with a serpiginous border suggests active extravasation of contrast material.
Mesenteric or bowel injury	Bowel wall thickening; triangular high-attenuation interloop mesenteric fluid collections; high attenuation free fluid indicates extravasation of oral contrast material from site of bowel injury, or intravenous contrast material from mesenteric tear.
Nontraumatic
Iatrogenic injury ( interventional procedure, complication of surgery, or anticoagulation therapy)	High-attenuation fluid around spleen or liver in patients on anticoagulants, at the site of intervention, or in the surgical bed.
Tumor-associated hemorrhage	Sentinel clot sign; high-attenuation fluid at the tumor site in peritoneum, spleen, liver
Gynecologic condition (ectopic pregnancy, ruptured ovarian cyst, HELLP syndrome)	Fluid with high attenuation or internal echogenicity around the uterus and adnexa; associated mixed attenuation adnexal mass with fluid-fluid level or a high-attenuation component.
Vascular lesion (visceral artery aneurysm or pseudoaneurysm)	An apparent aneurysmal sac surrounded by high-attenuation free fluid accumulating contrast material; pancreatitis or clinical history of systemic vascular disease (eg, Ehlers-Danlos syndrome).

Signs and Symptoms

It is difficult to detect signs and symptoms of internal bleeding unless there is a severe trauma or accident that necessitates a hospital visit. Vital indicators like blood pressure and heart rate, may vary considerably from case to instance. Internal bleeding in the abdominal or pelvic area may progress to symptoms of shock. Signs and symptoms of hemoperitoneum are:

• Nausea or vomiting
• Light headedness
• Tenderness at the site of abdomen
• Stabbing or sharp pain
• Cold and clammy extremities
• Dizziness or confusion

Physical Examination

On physical examination numerous signs ans symptoms can be appreciated:

• Hypotension, tachycardia, shock

• Abdominal pain or tenderness

• Abdominal deformity, abrasion, contusion

• Absent or decreased bowel sounds

• Hemorrhagic pancreatitis

Diagnostic signs

• Cullen's sign: periumbilical bruising

• Grey turner's sign: discoloration around the flanks
• Danforth sign: On inspiration there is shoulder pain
• Kehr's sign: left shoulder pain on supine or pressure applied to Left Upper Quadrant
• Prominent veins on the abdominal wall in portal hypertension
  

Laboratory Findings

Serum labs

• Complete blood count: To evaluate the need for transfusion.
• Blood type and crossmatch

Invasive studies:

• Diagnostic peritoneal lavage (abdominal paracentesis)  : Rapid method to determine blood in the peritoneal cavity.

Used in hemodynamically unstable patients when FAST exam is not possible.

Electrocardiogram

An ECG may be helpful in the diagnosis of hemoperitoneum. If a patient presents with shock due to massive intra peritoneal bleeding then the EKG may show sinus tachycardia.

X-ray

If the hemoperitoneum is due to perforation of any hollow visceral organ, then it may show air under the diaphragm.

Treatment

The main goals of treatment for hemoperitoneum are arrest of bleeding, the preservation and restoration of effective blood volume, and the restoration and maintenance of oxygen carrying capacity.

The options to achieve these goals are fluid resuscitation, the delivery of blood products or hemoglobin-based oxygen carriers, abdominal counterpressure, and surgical intervention.

Bleeding intra-abdominal neoplasms almost always necessitate surgery. Hemorrhaging patients with splenic torsion, liver lobe torsion, bleeding cysts, penetrating injuries, stomach dilatation and volvulus, and any other condition leading in organ ischemia should have emergency surgery.

The initial treatment for large hemoperitoneum is an urgent blood transfusion if the patient is in hemorrhagic shock.

Hemoperitoneum treatment include both the evacuation of blood from the peritoneal cavity and the cessation of bleeding.

Hemoperitoneum is a sign that emergent surgery is needed to find the cause of the bleeding as well as to recover spilled blood from the peritoneal cavity and utilize it for auto-transfusion if it isn't polluted by burst bowel contents.

The control method is determined by the cause of blood loss.

• Clamping and ligation of the offending artery, or repair of the vessel, would be used to treat vascular bleeding.
• Removal of spleen or splenectomy is required for bleeding from the spleen. Low-grade lacerations of slpeen may be observed until clinical condition deteriorates.
• Application of thrombin, hemostatic sponges or argon beam cauterization is required to control bleeding from the liver.
• Endovascular technique is used for the repair of ruptured abdominal aortic aneurysm.

Methods of treatment for hemoperitoneum

Paracentesis	A big syringe is inserted into the peritoneal cavity during paracentesis. The plunger is then pushed back, allowing the fluid from the peritoneal cavity to be drawn into the syringe.
Ligation	Ligation is the tying off or clamping a bleeding blood vessed which is injured.
Cauterization	Cauterization is the process of burning tissue in order to seal it off and stop the bleeding.
Medications	To slow or stop bleeding, coagulant medicines (drugs that assist the blood clot) can be administered.
Laparotomy	A laparotomy is a procedure that includes making an incision in the abdomen to drain fluids that have collected there. Hemoperitoneum can also be diagnosed using this technique.
Surgery	In traumatic cases, the blood vessels and organs need surgical repair. To fix or block a blood vessel, or to remove a ruptured organ, in most cases spleen, surgery is required.

Prevention

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