Intra-abdominal Pathology Research Articles

The appendix: An unexpected band obstruction

Introduction: Small bowel obstruction (SBO) is common surgical pathology, most commonly secondary to adhesions. This case presents a novel cause of small bowel obstruction. Case Report: We present a case of an elderly female who presented to hospital with symptoms, signs, and radiological findings consistent with SBO. After failing non-operative management, and deteriorating clinically, decision was made for operative intervention. A laparotomy revealed a normal-appearing appendix adhering to the pelvic side wall, and consequently forming a band adhesion-like internal hernia and was the cause of the bowel obstruction. Following dissection from the pelvic wall, and appendectomy, the patient recovered and was discharged home. Histopathology demonstrated a normal appendix. Diseased appendices have rarely been described to cause bowel obstructions; however, this is the first case report describing a normal appendix causing a band-like bowel obstruction. Surgical management was necessary to establish a definitive diagnosis, and for resolution of the condition. Conclusion: This case highlights a novel cause of SBO and reiterates the heterogeneity of SBO causes. Abdominal exploration remains the gold standard diagnostic modality for intra-abdominal pathology.

Abstract Sa1104: Head and Pulmonary Artery Chest CT Detect Most but Not All Causes of Sudden Death and Resuscitation Injury Compared to Head to Pelvis CT Angiography in Survivors of Out of Hospital Circulatory Arrest

Introduction: Head-to-pelvis “sudden death computed tomography” angiography (SDCT) has a high diagnostic yield to identify causes and complications of out-of-hospital cardiac arrest (OHCA). The differences in yields of non-contrast head CT (H-CT) and pulmonary embolism chest CT (CT PE) angiography alone or in combination is not clear. Methods: Our prospective observational cohort enrolled patients that survived OHCA resuscitation and had a SDCT (H-CT, ECG-gated chest CT, and non-ECG gated venous phase abdomen/pelvis CT) within 6 hours of arrival (December 2015 – February 2018). For this sub-study, we assessed the same scans for diagnoses obtainable from routine H-CT and CT PE axial coverage alone, excluding any added (SDCT) findings from ECG-gating and abdomen/pelvis assessment. The primary outcome was the difference in diagnostic yield of time-critical and non-time-critical diagnoses by CT PE with or without H-CT compared to SDCT. Results: SDCT identified 86 time-critical diagnoses in 104 enrolled patients, including 39 pneumonias (45% of diagnoses), 13 myocardial infarctions [MI] (15%), 8 pulmonary embolisms (9%), 8 pneumothoraces (9%), 8 abdominal catastrophes (9%), 3 intracranial hemorrhages (3%), and 1 vascular access hemorrhage (1%) [ Table ]. CT PE alone identified 61 of the 86 time-critical diagnoses (71%), missing 25 diagnoses (29%) compared to SDCT. Missing diagnoses included MI (13/13), abdominal catastrophe (8/8), and active vascular access hemorrhage (1/1). H-CT diagnosed all 3 intracranial hemorrhages. Of the 208 non-time-critical diagnoses identified by SDCT, CT PE identified 183 non-time critical diagnoses (88%), missing 25 diagnoses (12%). H-CT did not identify any non-time-critical diagnoses. Conclusions: CT PE imaging with H-CT identifies a majority—but not all—time-critical and non-time-critical diagnoses in OHCA patients, mainly failing to capture coronary and intra-abdominal pathologies. SDCT, which includes ECG-gated chest CT and abdomen/pelvis CT, improves total diagnostic yield, but its incremental utility requires further study.

068. Revealing the Hidden Giant: When Giant Appendicitis Mimics A Mesenteric Cyst in Recurrent Sigmoid Volvulus – A Case Report

Background: Giant appendicitis is an exceptionally rare condition that can mimic other intra-abdominal pathologies, including mesenteric cysts, due to its unusual size and presentation. Distinguishing between these entities is chalenging due to its resemblances. Case: A 56-year-old woman with a history of chronic constipation who was admitted to the emergency department with abdominal distension and inability to defecate. Abdominal examination revealed a distended abdomen with visible bowel contour and an abdominal X-ray showed coffee bean appearance, suggestive of sigmoid volvulus. An exploratory laparotomy revealed twisting of the sigmoid colon. After reducing the volvulus and confirming viability of the sigmoid, a loop sigmoidostomy was performed to prevent recurrent volvulus. Intraoperatively, a mass resembling a mesenteric cyst was identified, which was subsequently confirmed to be a case of giant appendicitis. Conclusion: Considering giant appendicitis in the differential diagnosis of abdominal masses resembling mesenteric cysts is important, particularly in patients with chronic constipation and recurrent volvulus, to ensure timely and appropriate surgical management.

Iatrogenic urinary injuries in colorectal surgery: outcomes and risk factors from a nationwide cohort.

Iatrogenic urinary injury (IUI) can lead to significant complications after colorectal surgery, especially when diagnosis is delayed. This study analyzes risk factors associated with IUI and delayed IUI among patients undergoing colorectal procedures. Adults undergoing colorectal surgery between 2012 and 2021 were identified in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP®) database. Multivariable regression analysis was used to determine risk factors and outcomes associated with IUI and delayed IUI. Among 566,036 patients, 5836 patients (1.0%) had IUI after colorectal surgery, of whom 236 (4.0%) had delayed IUI. Multiple preoperative risk factors for IUI and delayed IUI were identified, with disseminated cancer [adjusted odds ratio (aOR) 1.4, 95% confidence interval (CI) 1.2-1.5; p < 0.001] and diverticular disease [aOR 1.1, 95% CI 1.0-1.2; p = 0.009] correlated with IUI and increased body mass index [aOR 1.6, 95% CI 1.2-2.1; p = 0.003] and ascites [aOR 5.6, 95% CI 2.1-15.4; p = 0.001] associated with delayed IUI. Laparoscopic approach was associated with decreased risk of IUI [aOR 0.4, 95% CI 0.4-0.5; p < 0.001] and increased risk of delayed IUI [aOR 1.8, 95% CI 1.4-2.5; p < 0.001]. Both IUI and delayed IUI were associated with significant postoperative morbidity, with severe multiorgan complications seen in delayed IUI. While IUI occurs infrequently in colorectal surgery, unrecognized injuries can complicate repair and cause other negative postoperative outcomes. Patients with complex intra-abdominal pathology are at increased risk of IUI, and patients with large body habitus undergoing laparoscopic procedures are at increased risk of delayed IUI.

WP7.1 - MRI for suspected acute appendicitis in pregnant females: What is the best imaging modality?

Abstract Introduction/Aims Acute appendicitis (AA) in pregnancy is the commonest non-obstetric cause of acute abdominal pain, but controversy surrounds the most appropriate imaging modality in this group. Ultrasound (USS) and Magnetic Resonance Imaging (MRI) have no known fetal risks. Hence, The World Society of Emergency Surgeons (WSES) recommends MRI in pregnant patients with suspected appendicitis, if available, but emphasises the preferred initial use of USS. This project explored the use of both imaging modalities in pregnant patients with suspected AA. Method Data was collected for all pregnant patients undergoing an MRI for suspected AA between 2015 and 2023. Results Of the 29 patients identified, the mean gestation was 23 weeks (range 2-36), and over half (15, 52%) of MRI scans were performed in 2022/3. Intra-abdominal pathology was seen in 17 (59%) patients, with 8 (47%) having MRI features of AA. 63% of those diagnosed with AA had an USS pre-MRI, and 40% identified the appendix as "normal." Other intra-abdominal pathologies picked up on MRI included pyelonephritis(1), small bowel obstruction(1), stercoral perforation(1), and ovarian torsion(2). Of the 8 patients with MRI-proven AA, all underwent appendicectomy: 3 laparoscopic, 2 open, and 3 with simultaneous Caesarean section, of whom 2 required ileocaecal resection. Conclusions Diagnosis of abdominal pain in pregnancy is a challenge. USS may be reasonably sensitive and specific in dedicated hands, but pathology may still be missed. In this patient group, for which appendicectomy for AA is associated with better outcomes than non-operative management, MRI should be obtained for accurate diagnosis.

A positive scratch collapse test in anterior cutaneous nerve entrapment syndrome indicates its neuropathic character.

Chronic abdominal pain is occasionally caused by an abdominal wall entity such as anterior cutaneous nerve entrapment syndrome (ACNES). This syndrome is thought to occur due to intercostal nerve branches (T7-12) that are entrapped in the rectus abdominis muscles. The diagnosis is largely based on subjective clues in patient history and physical examination. A test referred to as the scratch collapse test (SCT) is used as an additional diagnostic tool in peripheral nerve entrapment syndromes such as the carpal tunnel syndrome. The aim of the present study is to investigate whether an SCT was positive in patients with suspected ACNES. If so, this finding may support its hypothesized neuropathic character. A prospective, case-control study was performed among patients with ACNES (n = 20) and two control groups without ACNES (acute intra-abdominal pathology n = 20; healthy n = 20), all were consecutively included. ACNES was diagnosed based on previously published criteria. The SCT test was executed at the painful abdominal area in both patient groups and at a corresponding area in healthy controls. Predictive values, sensitivity, and specificity were calculated. Videos of tests were evaluated by blinded observers. SCT was judged positive in 19 of 20 ACNES patients but not in any of the 40 controls. A 95% sensitivity (confidence interval [CI]: 75-99) and optimal specificity (100%; CI: 83-100) were calculated. The positive SCT supports the hypothesis that ACNES is an entrapment neuropathy. A positive SCT should be considered a major diagnostic criterion for ACNES.

Peritoneal bile granuloma formation at the site of caesarean surgical scar

Bile granuloma is a rare complication associated with cholecystectomy about which few case reports have been written. Herein we present the case of a patient who underwent laparoscopic bilateral salpingectomy for the purpose of sterilization and was incidentally found to have a linear collection of bile granulomas along the site of adhesions from her cesarean section. We also present a review of case reports on bile granuloma that have presented in OB/GYN and suggest that this rare pathology should be cited as a differential more often when considering intra-abdominal pathology, particularly for pelvic surgeons. We argue that this condition is likely more common than previously thought and suggest that without further research into this topic, routine biopsy or removal of encountered lesions may not always be necessary in patients at low likelihood for having a malignant pathology.

Small Bowel Perforation by a Toothpick: A Case Report and Literature Review

Abstract This case report and literature review present a rare case of small bowel perforation caused by an accidental ingestion of a toothpick. The patient’s subtle presentation with nonspecific symptoms posed diagnostic challenges, emphasizing the need for a high index of suspicion for foreign body ingestion in similar clinical scenarios. A 17-year-old male presented to the emergency department with a long history of abdominal pain, which had worsened over the past three days and localized to the right iliac fossa. The initial suspicion was acute appendicitis; however, an abdominal CT scan revealed a toothpick penetrating the small bowel wall. The patient underwent a diagnostic laparoscopy, during which the toothpick was removed and the perforated segment of the bowel was sutured intracorporeally. The patient had an uneventful postoperative recovery course and was discharged on the third postoperative day. Toothpick perforation poses diagnostic challenges due to its subtle presentation and lack of recollection of ingestion. Imaging plays a crucial role in identifying the foreign body and guiding appropriate treatment. Prompt surgical management involving removal of the foreign body and repair of the perforation is recommended, as nonoperative approaches generally have poor outcomes. Laparotomy or diagnostic laparoscopy is the most common and effective treatment depending on surgical experience and availability. Resection of the affected bowel segment may be required in cases of significant inflammation or large perforations. Overall prognosis is good with early diagnosis and intervention. This case emphasizes the importance of maintaining a high index of suspicion for perforations caused by sharp foreign bodies in patients with cryptogenic intra-abdominal pathology. A thorough history, physical examination, imaging studies, and timely surgery are crucial in preventing morbidity and mortality. Increased awareness of this rare but dangerous complication can lead to improved patient outcomes.

Open Retromuscular Sugarbaker vs Keyhole Mesh Placement for Parastomal Hernia Repair

Durable parastomal hernia repair remains elusive. There is limited evidence comparing the durability of the open retromuscular Sugarbaker and keyhole mesh configurations. To determine if the open retromuscular Sugarbaker mesh placement technique would lower parastomal hernia recurrence rates. In this single-center, randomized clinical trial, 150 patients with a permanent stoma and associated parastomal hernia who were candidates for open retromuscular parastomal hernia repair were enrolled and randomized from April 2019 to April 2022 and followed up for 2 years. Following intraoperative assessment to determine the feasibility of either technique, enrolled patients were randomized to receive either retromuscular Sugarbaker or keyhole synthetic mesh placement. The primary outcome was parastomal hernia recurrence at 2 years. Secondary outcomes included mesh-related complications, wound complications, reoperations, as well as patient-reported pain, abdominal wall-specific quality of life, stoma-specific quality of life, and decision regret at 1 year and 2 years. A total of 150 patients were randomized, and with 91% follow-up at 2 years, there were 13 (17%) parastomal hernia recurrences in the retromuscular Sugarbaker arm and 18 (24%) in the keyhole arm (adjusted risk difference, -0.029; 95% CI, -0.17 to 0.153, and adjusted risk ratio, 0.87; 95% CI, 0.42 to 1.69). There were no statistically significant differences between the Sugarbaker and keyhole groups regarding reoperations for recurrence (2 vs 7, respectively), nonhernia intra-abdominal pathology (4 vs 10, respectively), stoma necrosis (1 vs 0, respectively), mesh-related complications (4 vs 1, respectively), patient-reported pain, abdominal wall-specific quality of life, stoma-specific quality of life, and decision regret at any time point. In the setting of open parastomal hernia repair, a retromuscular Sugarbaker mesh placement technique was not superior to a keyhole configuration 2 years after repair. Further innovation is necessary to improve parastomal hernia repair outcomes. ClinicalTrials.gov Identifier: NCT03972553.

Empyema associated with peritoneal dialysis peritonitis.

A 65-year-old woman on peritoneal dialysis (PD) was admitted due to abdominal pain with cloudy PD effluent. The white blood cell count in PD effluent was 5860/µL with 85% polymorphonuclear neutrophils. Therefore, she was clinically diagnosed with peritonitis. The cultures of PD effluent were negative. Initial abdominal computed tomography did not find suggest any intraabdominal pathology. The patient was treated with empirical intraperitoneal antibiotics. Because abdominal pain with cloudy PD effluent persisted, the PD catheter was removed eventually. The culture of the removed PD catheter grew Klebsiella pneumoniae. However, intermittent fever was noted over the following days and empyema developed approximately 2 weeks after PD catheter removal. The culture of pleural fluid also grew K. pneumoniae. Another computed tomography revealed multiple intraabdominal abscesses that was assumed to come from a complication of PD-associated peritonitis. We postulate that the empyema might be caused by transdiaphragmatic extension of the intraabdominal abscesses into the pleural space.

Case Report: A case of disseminated cutaneous listeriosis following appendicitis from Lao PDR

Background Listeria monocytogenes is a food-borne pathogen that is a rare cause of bacteraemia and meningitis in immunosuppressed patients, and carries a high mortality rate. Cutaneous manifestations of listeriosis are rare, and are usually associated with direct inoculation of the skin. Case A 41-year-old woman who initially presented to a hospital in Laos with appendicitis was diagnosed with disseminated listeriosis with cutaneous involvement. Intra-abdominal pathology probably contributed to bacterial bloodstream invasion. Initial treatment with meropenem was switched to ampicillin based on best practice, however our patient died 5 days after diagnosis. Conclusions This case highlights listeriosis as an important cause of mortality in low- and middle-income countries, exacerbated by poor availability of laboratory diagnostics and ineffective empiric antibiotic regimens. Improvements in food hygiene, surveillance, and increased laboratory capacity are important strategies to reduce rates of infection and clinical outcomes.

The “Spiked Helmet Sign”, a Mimic of ST-Elevation Myocardial Infarction in Post-Nephrectomy Ileus

There are many causes of ST-elevation on electrocardiogram (ECG). ECG changes in the setting of intra-abdominal pathology is a rare and under characterised and includes the “spiked helmet sign”. We report a rare case of the “spiked helmet sign” that presented with ST-elevation in the precordial leads due to post-operative ileus.

Bladder Perforation and Vesico-Haematoma Fistula: An Uncommon Complication of Rectus Sheath Haematoma.

Rectus sheath haematoma (RSH) has become increasingly common but is often underdiagnosed. Prompt diagnosis will avoid unnecessary investigations and procedures, resulting in early treatment and a better outcome. We described a case of a spontaneous RSH with intraperitoneal extension and formation of a vesico-haematoma fistula, which was initially misdiagnosed as a urinary tract infection. The diagnosis was made ten days after admission, when a CT scan showed an over-16 cm RSH with intraperitoneal extension, bladder perforation and a vesico-haematoma fistula. The patient was managed conservatively. RSH accounts for less than 2% of acute abdomen cases and is often unrecognised. Its presentation can mimic other intra-abdominal pathologies, and the diagnosis is often delayed or missed. Complications can arise from an RSH although it is generally viewed as a self-limiting condition. RSH has become increasingly common, and we would like to highlight the need to include abdominal wall pathologies in the initial differential diagnoses of acute abdomen to avoid delay in diagnosis. Rectus sheath haematoma has become increasingly common due to the use of anticoagulants.The presentation can be non-specific and mimic other intra-abdominal pathologies. Misdiagnosis or delayed diagnosis can result in complications and unnecessary invasive procedures.Abdominal wall pathologies including rectus sheath haematomas should be included in initial differentials of acute abdomen.

Long-term mesh-related complications from minimally invasive intraperitoneal onlay mesh for small to medium-sized ventral hernias

IntroductionIntraperitoneal onlay mesh (IPOM) placement for small to medium-sized hernias has garnered negative attention due to perceived long-term risk of mesh-related complications. However, sparse data exists supporting such claims after minimally invasive (MIS) IPOM repairs and most is hindered by the lack of long-term follow-up. We sought to report long-term outcomes and mesh-related complications of MIS IPOM ventral hernia repairs.Methods and proceduresAdult patients who underwent MIS IPOM ventral hernia repair at our institution were identified in the Abdominal Core Health Quality Collaborative database from October 2013 to October 2020. Outcomes included hernia recurrence and mesh-related complications or reoperations up to 6 years postoperatively.ResultsA total of 325 patients were identified. The majority (97.2%) of cases were elective, non-recurrent (74.5%), and CDC class I (99.4%). Mean hernia width was 4.16 ± 3.86 cm. Median follow-up was 3.6 (IQR 2.8–5) years. Surgeon-entered or patient-reported follow-up was available for 253 (77.8%) patients at 3 years or greater postoperatively. One patient experienced an early small bowel obstruction and was reoperated on within 30 days. Two-hundred forty-five radiographic examinations were available up to 6 years postoperatively. Twenty-seven patients had hernia recurrence on radiographic examination up to 6 years postoperatively. During long-term follow-up, two mesh-related complications required reoperations: mesh removed for chronic pain and mesh removal at the time of colon surgery for perforated cancer. Sixteen additional patients required reoperation within 6 years for the following reasons: hernia recurrence (n = 5), unrelated intraabdominal pathology (n = 9), obstructed port site hernia (n = 1), and adhesive bowel obstruction unrelated to the prosthesis (n = 1). The rate of reoperation due to intraperitoneal mesh complications was 0.62% (2/325) with up to 6 year follow-up.ConclusionIntraperitoneal mesh for repair of small to medium-sized hernias has an extremely low rate of long-term mesh-related complications. It remains a safe and durable option for hernia surgeons.

Vernix caseosa peritonitis: a mimic for post-partum appendicitis

Vernix caseosa peritonitis is an uncommon pathology predominantly affecting post-partum women who have undergone caesarean section and has symptomatology identical to common intra-abdominal surgical pathology. Cross-sectional imaging may not differentiate this from an alternative aetiology, thus a broad range of differentials must be considered in the early post-partum patient. This case of a 26 year-old post-partum patient who underwent an appendicectomy for CT-confirmed appendicitis had a histological diagnosis of vernix caseosa peritonitis. This case demonstrates the diagnostic challenge of acute abdominal pain in the early post-partum period and the high index of suspicion that clinicians must have to reach these uncommon diagnoses.

In-person prospective audit and feedback on an oncology ward: development of an immunocompromised antimicrobial stewardship program.

To describe clinical syndromes, opportunities for antimicrobial optimization, and acceptance of recommendations made by an immunocompromised antimicrobial stewardship program performing in-person prospective audit and feedback (IPPAF) on inpatient oncology services. Retrospective cohort study. Three inpatient oncology services including patients with solid tumor malignancies in an academic cancer center. Hospitalized adults with oncologic malignancies receive antimicrobials for any indication. We reviewed all patients receiving antimicrobials on inpatient oncology services who were included in IPPAF and prospectively documented clinical syndromes represented, most common recommendations, and acceptance rate. We also examined the standardized antimicrobial administration ratio (SAAR) for oncology units over the study period. Over 34 weeks, we performed 154 interventions for 138 patients. Metastatic malignancy was common (52%) and 90-day mortality was high (43%). Diagnostic uncertainty was common (33/154, 21%), as were cases of intra-abdominal pathology (30/154, 19%), pneumonia (25/154, 16%), and urinary tract infection (12/154, 8%). The most common recommendations were changes in duration (63/154, 41%) and stopping antimicrobials for syndromes determined to be noninfectious (29/154, 19%). Acceptance of interventions was high (77% overall) and several SAARs on the primary oncology unit significantly decreased after starting IPPAF. We identified numerous opportunities for antimicrobial optimization among solid tumor malignancy patients. Most clinical syndromes were ones also encountered frequently in non-oncology populations, but several were unique and represented opportunities for targeted education.

Vermicular enterobius: incidental intraoperative finding during laparoscopic appendectomy

Acute appendicitis is the most common intra-abdominal pathology requiring emergency surgery. The etiology of acute appendicitis includes both infectious and non-infectious causes. Although parasitic diseases are rare in developed countries, they are more common in developing countries. Pinworm is a highly contagious infection, considered to be the most common helminthic infection. The association of this parasitic infestation with the pathogenesis of acute appendicitis has been studied for many years and is still unclear. We report the case of a patient with symptoms of acute appendicitis in whom intramural parasites were discovered during laparoscopic surgery.

The Efficiency of Focused Assessment with Sonography for Trauma in Pediatric Patients with Blunt Torso Trauma.

Focused Assessment with Sonography for Trauma (FAST) has attracted attention for its use in the detection of intra-abdominal pathology for pediatric patients. However, computed tomography (CT) remains the gold standard for the assessment of blunt torso trauma. The study examines the effectiveness of FAST both in the detection of intra-abdominal pathology in pediatric patients (<19 years) with blunt torso trauma and in the determination of the need for CT for further examination. The study was designed as a retrospective observational investigation of diagnostic value. The pediatric patients who were admitted to the Emergency Department with blunt torso trauma between January 2013 and October 2016 were included in the study. The sample of the study comprised 255 patients who met the inclusion criteria. The primary outcome was the effectiveness of FAST in the detection of intra-abdominal pathology and the determination of the need for CT. The secondary outcome was to identify the agreement between CT and FAST for intra-abdominal injuries. The Chi-square test and Fisher's exact test were used for comparisons. A logistic regression model was developed to determine the variables that independently affect the agreement between FAST and CT. FAST was determined to have low sensitivity (20.3%) despite its high specificity (87%). However; FAST had a good negative likelihood ratio. There was a poor agreement between CT and FAST in terms of the presence of both intra-abdominal and intrathoracic injuries in pediatric patients with blunt trunk trauma. The error rate of FAST increased by five-fold, especially in the presence of concomitant thorax trauma. However, FAST had a good negative likelihood ratio. FAST should not be regarded as an equivalent tool to CT for pediatric patients with blunt torso trauma. It is, instead, a noteworthy complementary tool that is a negative predictor.

Pneumo-mediastinum, pneumoperitoneum, and pneumo-scrotum with extensive increasing subcutaneous emphysema: a rare presentation of colonic perforation

BackgroundColonic perforation usually presents with classical signs of peritonitis. However, isolated retroperitoneal colonic perforation can present with varied clinical signs and symptoms and pose diagnostic challenges. Pneumo-mediastinum and abdominal subcutaneous emphysema can be one of the presenting signs of colonic perforation.Case reportA 33-year-old male presented with abdominal distension and extensive subcutaneous emphysema over the abdomen, pneumo-mediastinum, and pneumo-scrotum secondary to sigmoid colon perforation from a foreign body. The patient did not have classical signs of peritonitis.ConclusionBeing vigilant about the potential of colonic perforation is crucial when observing a significantly increasing subcutaneous emphysema across different parts of the body. Attending clinicians should always keep intraabdominal pathology in mind when a direct cause for these symptoms cannot be found and the patient’s symptoms become progressive.

Hemoperitoneum due to deep endometriosis in a patient on peritoneal dialysis with a good response to progestin

Hemoperitoneum is common in patients undergoing peritoneal dialysis. Its varied causes include catheter-related complications, obstetric and gynecological etiologies, coagulopathies, and vascular, infectious, and intra-abdominal pathologies. A gynecological etiology, whether pathological or physiological, is the most common cause of hemoperitoneum in adult women undergoing peritoneal dialysis, with more than one-third of cases related to the menstrual cycle. Endometriosis can also cause hemoperitoneum, and the bleeding may originate from endometrial tissue implanted in the peritoneal cavity or that detaches from the intrauterine endometrium during the menstrual period. We report a case of hemoperitoneum in a patient with deep endometriosis and previous hysterectomy who had an excellent response to oral progestin.