Hemoperitoneum Research Articles (Page 1)

BackgroundEctopic pregnancies (EP) are a common pregnancy complication that’s associated with significant morbidity and rarely mortality if not managed properly. Ultrasound examination forms the cornerstone of diagnosis of EP with some sonographic features occasionally not correlating with intraoperative findings. We set out to conduct an audit of EP managed surgically at our hospital for a 10-year period and discern the correlation and prediction of sonographic findings to intraoperative findings.MethodsThis study was designed as a Retrospective Observational Study based at the Aga Khan University Hospital (AKUH). Study population was all women admitted to AKUH with a diagnosis of ectopic pregnancy that was surgically managed between the period of January 1st 2011 to December 31st 2020. Analysis of data was done against a pre-set checklist. Descriptive statistics for continuous variables was calculated and tabulated in graphs and tables. SPSS version 22 was used for analysis of data.ResultsA total of 337 patients in this study had ultrasound findings. 99.7% (n = 336) of these patients had an intraoperatively confirmed EP. The commonest ultrasound finding was an adnexal mass in 97.1% (n = 309) of patients. These were confirmed surgically in 290 patients at the following locations: 76.6% (n = 222) were ampullary in location; 10.7% (n = 31) were fimbrial in location; 8.6%(n = 25) were isthmic in location; 2.4%(n = 7) were interstitial in location; 1%(n = 3) were abdominal in location; while 0.3% were located in the ovary(n = 1) or round ligament(n = 1) each. Interstitial EP on ultrasound were all (100%) confirmed in the same location intraoperatively, with ampullary EP also correlating fairly well with intraoperative location (75%). The distribution of location in the minor hemoperitoneum (HP) versus major HP groups were similar except for interstitial EP that increased from 1.4% in the minor HP group to 9.5% in the major HP group.ConclusionIn conclusion, ultrasonography still represents the best imaging modality for EP. The most common finding is usually an adnexal mass with no specific location. Most (99.7%) of the patients with this sonographic finding usually have a confirmed EP. Interstitial EP are the most well localized with ultrasound followed by ampullary EP. Furthermore, the presence of major (> 500mls) hemoperitoneum may act as an adjunct for diagnosis of an interstitial EP.

SummaryThis report describes the likely development and growth of bilateral granulosa cell tumours (GCTs) in a Warmblood pony mare, during the first trimester of pregnancy after artificial insemination. The GCTs were initially suspected to be ovarian haematomas and were managed conservatively. However, they ultimately led to life‐threatening haemoperitoneum (HP) and were later diagnosed as GCTs with histopathology. The case was successfully managed with emergency standing laparoscopic‐assisted bilateral ovariectomy after haemodynamic supportive therapy. The mare made a full recovery and delivered a live filly foal at term. GCTs can be a rare cause of life‐threatening HP and can be successfully managed with haemodynamic support and standing laparoscopic‐assisted removal. Bilateral ovariectomy in a pregnant mare after 70 days of gestation can result in successful delivery of a live foal.

Spontaneous bleeding from uterine leiomyoma is an unusual cause of hemoperitoneum. Fewer than 100 cases have been reported in the literature so far. We report a 30-year-old woman who needed surgical exploration for an acute abdomen. There was massive hemoperitoneum due to bleeding from a subserosal myoma. This case was important because physician should be aware of this rare complication in patient with uterine myoma to avoid any morbidity and mortality. J Med Cases. 2020;11(6):145-147 doi: https://doi.org/10.14740/jmc3049w

A 43-year-old lady, gravida 2 para 0, presented to our emergency department with complaints of vaginal bleeding and lower abdominal pain. Her urine pregnancy test was positive. She was unable to recall her last menstrual period. A trans-vaginal ultrasound revealed a pregnancy with a crown rump length of 47 mm corresponding to 11.4 weeks with no fetal heartbeat detected. She was diagnosed with a missed miscarriage and was sent for a second confirmatory scan. The repeat scan was concordant with the initial scan and she was counseled for an evacuation of uterus. Her serum beta human chorionic gonadotropin level was 45,195 IU/L and her hemoglobin level was 6.5 g/dL. She underwent an evacuation of uterus as planned, but the Hegar dilator was only able to be advanced to a cavity length of 6 cm with minimal products of conception obtained. A bedside ultrasound was performed and it showed that the Hegar dilator was in the uterine cavity but not in continuity with the gestational sac and fetus. The diagnosis of an ectopic pregnancy was made and the surgery was converted to a diagnostic laparoscopy. On entry into the abdominal cavity, there was frank hemoperitoneum with adhesions limiting access to the pelvis, therefore decision was made to convert to laparotomy. The findings at laparotomy revealed a large inflamed left tubo-ovarian complex with tubal rupture and expulsion of the entire fetus and placenta into the Pouch of Douglas (POD). The diagnosis of a secondary implantation of the ectopic pregnancy in the POD after tubal rupture was confirmed and we performed adhesiolysis and left salpingectomy. The patient recovered uneventfully and the final histology showed products of conception within the lumen of the left fallopian tube in keeping with ruptured tubal ectopic pregnancy. J Med Cases. 2020;11(6):169-173 doi: https://doi.org/10.14740/jmc3484

BackgroundIn patients with hemodynamically stable blunt splenic injury (BSI), there is no consensus on whether quantity of hemoperitoneum (HP) is a predictor for intervention with splenic artery embolization (SAE) or...

Objective To investigate the feasibility and safety of endoscopic trans-gastric gallbladder-preserving cholecystolithotomy (ETGC) for gallstones. Methods The clinical data of 84 cholecystolithiasis patients, who received ETGC at Endoscopic Center of Zhongshan Hospital from March 2017 to May 2019 were analyzed retrospectively. The operation completion rate, operation time, complications and recurrence of calculus were summarized. Results In the 84 cases of cholecystolithiasis, there were 19 cases (22.6%) of single stone, 53 cases (63.1%) of multiple stones, and 12 cases (14.3%) of gallstones with gallbladder polyps. A total of 82 patients (97.6%) successfully completed ETGC with median operation time of 88 min. Ten patients (12.2%) suffered from abdominal pain after operation, of which 6 patients relieved after conservative treatments. The other 4 cases, including 2 cases of hemoperitoneum, 1 case of biliary fistula, and 1 case of choledocholithiasis with obstructive jaundice, were recovered after corresponding interventions. As of June 14, 2019, 5 cases were lost to follow-up (follow-up rate was 93.9%, 77/82). Residual stones were found in 2 cases (2.6%, 2/77). Stone recurrence was discovered in 4 cases (5.2%, 4/7), and 2 cases (2.6%, 2/77) had cholesterol crystallization in gallbladder. Conclusion ETGC is minimally invasive, feasible and safe in treatment of cholecystolithiasis, and can retain the function of gallbladder. However, how to completely remove the stones and avoid residue by ETGC still needs further exploration, and its long-term efficacy still needs further observation. Key words: Cholecystolithiasis; Endoscopic trans-gastric cholecystolithotomy; Stone residue; Stone recurrence

Hemoperitoneum: From What, Where, and Why?

SummaryThis report describes two cases of successful surgical management of granulosa cell tumours (GCT) in mares presenting with haemoperitoneum (HP). Controlled abdominal drainage was initially attempted in Case 1 but was not successful. A ventral midline exploratory laparotomy allowed removal of a haemorrhaging 13 kg GCT. The mare made a full recovery and returned to normal work as a driving pony 11 months post‐operatively. In Case 2 controlled abdominal drainage was followed by standing left flank laparoscopic visualisation of the bleeding ovary and transection of the ovarian pedicle by electrocautery. The GCT was then removed via a ventral midline incision due to its large size. Haemoperitoneum can be associated with GCTs and in some cases is severe enough to prompt emergency treatment. Stabilisation of the patient and removal of the haemorrhaging GCT can lead to a successful outcome.

Background: Severe symptomatic factor VII deficiency is a very rare condition. Spleen rupture in a neonate with factor VII deficiency is even rarer. There is only one case of hemoperitoneum and intracranial hemorrhage in a neonate with factor VII deficiency reported in the literature. In addition, the manifestation of hemoperitoneum by abdominal distention, abdominal tenderness, and …

Objective To investigate the imaging characteristics of nontraumatic spontaneous intramural hematoma of small bowel secondary to warfarin therapy. Methods The retrospective and descriptive study was conducted. The clinical data of 12 patients with nontraumatic spontaneous intramural hematoma of small bowel secondary to warfarin therapy who were admitted to the First People′s Hospital of Wenling (11 patients) and Taizhou Hospital of Zhejiang Province (1 patient) between January 2010 and December 2016 were collected. Patients received plain and enhanced scans of computed tomography (CT). Patients stopped warfarin therapy, received intramuscular injection of vitamin K1 and fresh-frozen plasma transfusion. Observation indicators: (1) primary signs of CT: ① small bowel wall thickening; ② increased density of small bowel wall; (2) secondary signs of CT: intestine lumen stenosis, intestinal pneumatosis, perienteric changes and other concomitant signs; (3) treatment situations. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range). Results Twelve patients received total abdomen plain scans of CT, and 7 received total abdomen enhanced scans of CT. (1) Primary signs of CT: ① Small bowel wall thickening. CT of 12 patients showed solitary, homogeneously symmetric, consecutive and diffuse thickening of small bowel wall, including ileal involvement in 7 patients and jejunum involvement in 5 patients. Ascending part of duodenum of 3 patients involved the 2nd and 3rd groups small bowel. The average length of involved small bowel was 30.7 cm (range, 11.0-58.0 cm). There was no multifocal thickening or colonic involvement. Of 12 patients, 10 and 2 showed moderate thickening (thickness was 1.0-2.0 cm) and severe thickening (thickness > 2.0 cm), and the thickest small bowel wall was 2.5 cm. ② Increased density of small bowel wall. Twelve patients showed varying degrees of increased density of small bowel wall, with an average value of 49.7 HU (range, 36.0-63.4 HU). Of 12 patients, homogeneously increased whole layer density of small bowel wall were detected in 4 patients, higher submucous layer density of small bowel compared with serosal layer density in 4 patients, and all of the above characteristics in 4 patients. Enhanced scans of CT in 7 patients showed enhancement in small bowel mucosal layer and serosal layer, no obvious enhancement in the submucous layer of small bowel wall, clear layers, and a target sign when small bowel lumen was perpendicular to scan slice, including 5 patients with obvious enhancement in small bowel mucosal layer, spring-like change, and clear imaging in portal vein phase. (2) Secondary signs of CT: ① Intestine lumen stenosis: 12 patients had varying degrees of intestine lumen stenosis. Five patients were complicated with small bowel obstruction, showing a gas-liquid level. ② Intestinal pneumatosis: 2 of 12 patients showed patchy and mottled gas shadow. ③ Perienteric changes and other concomitant signs: 12 patients showed obviously increased fat density in surrounding area of involved small bowel and corresponding mesenteric area, and indistinct outside small bowel, including 8 with lots of lath-like high density shadow in surrounding area of small bowel and mesenteric area. The varying degrees of hemoperitoneum were seen in 12 patients. (3) Treatment situations: of 12 patients, 9 underwent correct treatments, 8 of them were improved, and 1 of them with persistently severe abdominal pain underwent urgent explorative laparotomy, showing hemorrhage and necrosis, and then underwent surgery; 3 didn′t undergo correct treatment, without improved or severe symptoms. Conclusion Patients undergoing anticoagulant therapy show acute abdominal pain with abnormal coagulation function, small bowel wall thickening and increased density by CT scans, hemoperitoneum complicated with intestine lumen stenosis, small bowel obstruction and hematocele in surrounding area of small bowel and mesenteric area, these are highly indicative of nontraumatic spontaneous intramural hematoma of small bowel secondary to warfarin therapy. Key words: Intramural hematoma of small bowel; Warfarin; Tomography, X-ray computed; Diagnosis; Jejunum

Ectopic pregnancy is a major health issue in reproductive age group female. Incidence of primary ovarian ectopic pregnancy as mentioned in literature of India is variable from 0.001% to 0.014% of normal pregnancies. Only 0.15% to 3.0% of all ectopic pregnancy occurs in ovary and it is 2ndmost common site of ectopic pregnancy after fallopian tube. Annual incidence of extra uterine cavity pregnancy is rising over past 3 yrs. The aim of ourpresent study isto find out the incidence of ovarian ectopic pregnancy, role of USG in pre-operative diagnosisand risk factors, feasibility of conservative management with medical method or conservative management e.g. minimal invasive surgery in developing countries like India. We analysed the incidence, management of ovarian pregnancy & reviewed the literature, risk factors and clinical presentation of ovarian ectopic pregnancies managed at NIMS Medical College and Hospital jaipur. According to Spielberg criteria, it is a diagnostic challenge to obstetrician. Diagnosis of ectopic pregnancy can be missed radio logically and intra operatively. It Should be suspected in patients presented with rupturedectopic pregnancy, ultrasound features suggestive of normal bilateralfallopian tube with hemo peritoneum with breached ovarian surface. Conservative surgical approach is preferred, now days Medical management is preferred for unruptured ectopic pregnancy. Confirmation of ovarian pregnancy done only after histopathological report. Now daysMedical management with single dose of Methotrexate is very successful for un ruptured ovarian pregnancy

Objective To verify the feasibility and accuracy of the quantitative evaluation of the volume of internal abdominal hemorrhage based on CT images. Methods The clinical data of 76 patients diagnosed as abdominal hemorrhage or hemoperitoneum and performed with emergency surgery in the Second Affiliated Hospital to Wenzhou Medical University from January 2009 to September 2016 were retrospectively analyzed by case-control study. The Noboru Oriuchi's formula was used to calculate the volume of abdominal hemorrhage based on CT images, and the results were compared and adjusted with the volume of actual abdominal hemorrhage recorded during the operation. SPSS 21.0 was used to statistically analyze the data. The linear regression was analyzed on the results measured by the two methods. Results The volume of abdominal hemorrhage measured by the CT calculation method ranged from 10 to 4 335 ml, while the corresponding volume measured by operational calculation method ranged from 200 ml to 4 490 ml. The absolute difference in the volume measured by these two methods ranged from 4.8 ml to 500 ml. The ratio of the absolute difference to the volume of abdominal hemorrhage by operational calculation method ranged from 0.2% to 95.0%, the median of which was 4.5% (2.8%, 8.9%). When the exact volume of abdominal hemorrhage was <500 ml, the absolute difference in the exact volume ranged from 30.0% to 95.0%, the median of which was 69.1% (51.2%, 78.6%). When the volume was less than 500 ml, the ratio ranged from 0.2%-13.6%, the median of which was 4.2% (2.7%, 6.4%). Analysis of the numbers of the two measuring methods with linear correlation method after eliminating the cases in which the bleeding volume was less than 500 ml showed that two methods presented a linear correlation (r=0.971, P<0.05). Conclusion After the conventional abdominal CT scanning, the Noboru Oriuchi's formula can be used to accurately calculate the volume of abdominal hemorrhage in patients with volume of abdominal hemorrhage more than 500 ml. Key words: Hemoperitoneum; Multidetector computed tomography; Abdominal injuries; Quantitative study

We present an interesting case of a 63-year-old patient who was having lunch with friends in a restaurant when, suddenly, bystanders witnessed him “seize” for 1- minute, after which he became he had a 1-minute witnessed “seizure” followed by unresponsive and pulseless. Cardiopulmonary resuscitation (CPR) was initially performed by these bystanders at the scene, and then subsequently by EMS personnel, who achieved return of spontaneous circulation (ROSC) in the field. The patient was emergently transferred to the hospital where he remained hemodynamically unstable requiring multiple pressors. Due to an acute drop in hematocrit, along with metabolic acidosis, a computed tomography (CT) scan of the abdomen and pelvis was performed. which The scan revealed a large volume of intraperitoneal hemoperitoneum which was largely attributed to CPR. The patient He underwent an exploratory laparotomy during which and the hepatic laceration was repaired and the abdomen was packed. Intraoperatively and postoperatively, the patient remained hemodynamically unstable developing multi-organ failure and requiring multiple products including fresh frozen plasma, packed red blood cells, and cryoprecipitate. Electroencephalogram (EEG) results were consistent with anoxic brain injury and the patient’s family opted for comfort care measures only and he expired the next day. Although CPR induced injuries to hepatic structures have scarcely been reported in the literature, this may underestimate their true incidence given the high mortality rate of sudden cardiac arrest requiring CPR. Our case demonstrates that intra-abdominal trauma following CPR, though rare, must needs to always be considered taken into account. and a Importantly, a high index of clinical suspicion is often necessary to make an early diagnosis of liver trauma as a potential life-threatening complication of CPR. J Med Cases. 2017;8(3):93-97 doi: https://doi.org/10.14740/jmc2775w

Successful conservative therapy severe hemoperitoneum of 11 cases caused by ovarian bleeding after transvaginal oocyte retrieval

Ovarian pregnancy is a rare form of ectopic pregnancy that remains a diagnostic enigma. We report a 39-year-old nulliparous female undergoing in vitro fertilization (IVF) and presenting with severe abdominal pain to a hospital after embryo transfer. Serum beta-hCG after embryo transfer was low at 5.4 IU/L. Repeated serum beta-hCG in the hospital was elevated at 1,528 IU/L. Transabdominal ultrasound revealed a 9.8 cm complex mass in the midline in the pouch of Douglas. No intrauterine gestational sac was seen. She underwent emergency diagnostic laparoscopy revealing a small 2 × 2 cm ruptured right ovarian ectopic pregnancy with active hemorrhage seen. A wedge resection of the right ovarian ectopic was performed and hemoperitoneum was drained. Ovarian tissue sent for histopathology confirmed the diagnosis of a ruptured ovarian ectopic. Post-operative hCG level was negative after follow-up. Consequently, the patient was treated successfully with fertility-conserving laparoscopy. J Med Cases. 2016;7(4):150-152 doi: http://dx.doi.org/10.14740/jmc2464w

Diagnosis, management and prognosis for haemoperitoneum in the horse

A large number of central venous catheters (CVC) are placed each year in the emergency room, operation theatre and critical care unit. Although rarely associated with life threatening complications, femoral CVC is known to have the highest incidence of mechanical complications. It is important that clinicians are aware of wrong positioning of CVC even in the presence of good backflow of blood through all the lumens, especially in patients with haemo peritoneum. This article outlines a rare complication of misplaced femoral CVC into the peritoneal cavity in a patient with haemo peritoneum, its consequences and management. We further want to emphasize the importance of real time imaging during CVC insertion to improve safety and reduce complications rate.

We present an unusual case of a 23-year-old Hispanic male with no past medical history, who presented with 2 days history of diffuse abdominal pain. CT scan showed widely bleeding metastatic lesions in the retroperitoneum, lungs and liver causing large hemothorax and hemoperitoneum. He developed acute symptomatic anemia and needed interventional radiology-guided embolization of hepatic artery in addition with an urgent chest tube to relieve the symptoms along with transfusion. Subsequent exam found a true choriocarcinoma of the right testis. Following chemotherapy, the patient’s lesions shrunk and his anemia improved. A review of literature shows that testicular choriocarcinoma is a rare aggressive malignancy which metastasizes hematogenously and bleeds extensively due to their high vascularity. They can present with acute symptoms and signs that often lead patients to seek emergency care. Acute bleeding manifestation could be also the first presentation often leading to the final diagnosis of choriocarcinoma like in this case. J Med Cases. 2014;5(12):639-642 doi: http://dx.doi.org/10.14740/jmc1943w

A young multipara presented with acute abdominal pain. She had history of dilatation and evacuation for a missed miscarriage 2 months back. The diagnosis of ectopic pregnancy was made on the basis of clinical presentation and laboratory investigations. Laparoscopy was performed which revealed features of invasive mole. The procedure was converted to laparotomy and hysterectomy was performed. Patient recovered well. Histopathology confirmed the diagnosis of invasive mole. Follow-up till 12 weeks reported return to normal ßhCG (beta subunit of human Chorionic Gonadotropin) levels.

Objective To assess the safety and efficacy of modified transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of portal hypertension of liver cirrhosis.Methods From January 2005 to December 2009,the clinical data of 280 patients with liver cirrhosis accompanied with portal hypertension accepted TIPS treatments were collected.All the patients received liver enhanced computed tomography (CT) and hepatic blood vessel CT three-dimensional reconstruction to analyze the anatomical relationship of hepatic vein and portal vein and select the puncture location of portal vein branches.During operation,the puncture location of portal vein branches,the opening of the right hepatic vein and the distribution of portal vein branches were analyzed through directly portal vein portography.After operation safety was assessed,gastric coronary vein which caused esophageal varices was embolismed and the metal stent was implanted.Paired t-test was performed for measured data comparison before and after treatment.Mann-Whitney U or H test was used for correlation analysis between clinical data of patients and post-operation complication of TIPS and efficacy.Results Among 280 patients,TIPS operations of 278 were successfully performed and the success rate was 99.3％ (278/280).Hemoperitoneum occurred in two cases.The case number of puncture in biliary tract,gallbladder,hepatic artery and liver capsule was 10,5,8 and 18,respectively,however no hemoperitoneum or bile duct hemorrhage was observed.Among 278 cases with successful operation,198 were the right branch of portal vein puncture and 80 were the left branch puncture.By anteroposterior angiography,the location of portal vein puncture was beyond the portal vein bifurcation.Short-term hemostasis rate was 100％.The pressure of portal vein decreased from (46.5 ± 3.4) cmH2 O(1 mmH2 O =0.098 kPa) before TIPS to (26.8±3.6) cmH2O after TIPS and the difference was statistically significant (t=56.044,P＜0.01).The postoperative stent stenosis incidence was 24.1％ (67/278) at the 12th month and 34.2％ (95/278) at the 24th month.The postoperative hepatic encephalopathy rate was 18.0％ (50/278) at the 6th month and 19.1％ (53/278) at the 12th month.There were no differences in the gradient pressure of portal vein before and after TIPS,re-hemorrhage rate,hepatic encephalopathy and stent stenosis rate between patients of different etiology,gender,age,Child-Pugh classification and the puncture location (all P＞ 0.05).Conclusion The modified TIPS was safe and effective in the treatment of portal hypertension of liver cirrhosis and its complication. Key words: Portosystemic shunt; Transjugular intrahepatic; Liver cirrhosis; Hypertension, portal; Stents