Massive Hemoperitoneum Research Articles

A case of ovarian hemorrhage at early pregnancy managed by laparoscopic surgery with intraoperative autologous blood transfusion

We report a case of ovarian hemorrhage at 4 weeks of pregnancy that was managed with laparoscopic surgery with intraoperative autologous blood transfusion (IABT) and not homologous blood transfusion. We suspected ectopic pregnancy in a 37-year-old woman (para 2; postmenstrual day 32) because ultrasonography revealed massive hemoperitoneum and no gestational sac in the uterus, in spite of increased serum human chorionic gonadotropin (HCG) (4084 mIU/ml), and an emergency laparoscopic surgery was performed. Continuous bleeding from the surface of the left ovary was apparent. Corpus luteum and not chorion was detected; partial resection and coagulated hemostasis of the left ovary was performed. We aspirated 1350 ml of blood and reinfused 650 ml with IABT. Homologous blood transfusion was not required. Four days post-surgery (5 weeks of pregnancy), the gestational sac was detected in the uterus. Pathological examination revealed normal ovarian tissue with hemorrhage. The course of pregnancy was uneventful, and she delivered at 38 weeks of pregnancy. Although corpus luteum hemorrhage is commonly observed and safely followed without treatment, surgery is required for life-threatening hemorrhage. It is difficult to distinguish the findings of a ruptured corpus luteum without a detectable gestational sac at early pregnancy from ectopic pregnancy, and surgery is required for accurate diagnosis and hemostasis. Laparoscopic surgery with IABT avoids or reduces the need for homologous blood transfusion and is a safe and minimally invasive treatment for massive hemoperitoneum.

Retroperitoneal hemorrhagic shock in a patient on warfarin therapy.

Oral anticoagulants are an established treatment modality in the prophylaxis of thromboembolic events in various clinical scenarios. Needless to say that, bleeding is a natural adverse effect of this drug. Most of the times bleeding is inconsequential. But nevertheless massive and fatal bleeding can occur occasionally. The case reported here is rare, as the patient presented with massive hemoperitoneum due to mesenteric hemorrhage and hemorrhagic infarction of small bowel necessitating Laparotomy resection.

Unusual Causes of Ovarian Rupture Leading to Life Threatening Hemoperitoneum

We report two cases of life threatening hemoperitoneum arising due to ovarian rupture of rare etiology. The first patient, a 28-year-old woman, was a case of ovarian ectopic pregnancy, presented acutely with ovarian rupture and massive hemoperitoneum.Ectopic pregnancy was confirmed with histopathology of the wedge resected ovarian tissue. The second patient was a young girl of 16, who arrived with acute abdomen and in shock.Diagnostic laparoscopy showed massive hemoperitoneum & the only pathology found was bilateral smoothly enlarged ovaries (4 × 4” approx.) appearing like Krukenberg's tumours.

Retroperitoneal Abdominal Pregnancy at Left Paracolic Sulcus

A 33-year-old woman, gravida 3, para 1, abortion 1, visited our emergency department with progressive lower abdominal painand 3 episodesof syncope.She delivered vaginally in a previous pregnancy, and had no history of abdominal surgery. She last had menstruation 2 weeks earlier, but a urine pregnancy test revealed positive findings. Physical examination found obvious peritoneal signs; transvaginal ultrasonography revealed an empty uterus with massive hemoperitoneum.

Massive hemoperitoneum resulting from spontaneous rupture of uterine leiomyoma

Uterine leiomyomas are very common tumors found in women. Rupture of a uterine leiomyoma is an unusual source of hemoperitoneum. This is a case report of such. A 28-year old woman presented to the emergency department with acute onset of abdominal pain after a bowel movement and who had a history of fibroids. The patient was stable and went for a formal ultrasound, which showed a large fibroid and free fluid in the peritoneum. She had a laparotomy, and an actively bleeding fibroid surface vein was found. The patient required transfusion of 2 U of packed red blood cells, and a myomectomy was performed, with an uneventful postoperative course. Because surgical intervention is the only definitive treatment, emergency physicians should be aware of this rare complication.

Décès maternel après rupture spontanée d’une artère utérine dans le post-partum immédiat : à propos d’un cas

We report the case of a maternal death occurring after spontaneous rupture of a uterine artery immediately following delivery. The patient presented abdominal pain and a collapsus one hour after a normal delivery. Laparotomy revealed massive haemoperitoneum and intraperitoneal bleeding from the right uterine artery. Ligature of the uterine artery and hemostasis hysterectomy were performed but the patient died of multivisceral failure 18 h after the delivery. This is the first case report of maternal death occurring after spontaneous rupture of a uterine artery.

Abdominal apoplexy secondary to spontaneous rupture of the right gastric artery in a coagulopathic patient

Abdominal apoplexy (spontaneous intraperitoneal hemorrhage) is the spontaneous rupture of an intra-abdominal artery in the absence of aneurysmal dilatation or direct trauma [1]. It is a very rare but life-threatening condition, and it usually poses a considerable intraoperative dilemma [2]. A 72-year-old man was admitted with a 12-h history of a sudden onset of constant abdominal pain, associated with nausea and vomiting. The past medical history revealed the presence of coronary heart disease and chronic atrial fibrillation, for which the patient was treated with anticoagulation: acenocoumarol. On admission, the patient demonstrated hypotension (blood pressure of 74/55 mmHg) and tachycardia (pulse rate 100 beats/min). Physical examination revealed a distended abdomen with diffuse mild tenderness. Laboratory tests showed the following: hemoglobin 6.7 g/dl, hematocrit 19.9%, prothrombin time 109.3 s, activated partial thromboplastin time 94.4 s and international normalized ratio (INR) 10. The patient was resuscitated with intravenous fluids (Hydroxyethyl Starch HES 130/0.4, Ringer’s lactate) and packed red blood cells whereas along with an urgent reversal of an excessive coagulopathy including fresh frozen plasma (FFP) in combination with Vitamin K. After stabilization of the vital signs, the patient underwent a contrast-enhanced computed tomography (CT) that revealed a large quantity of intraperitoneal fluid, consistent with blood from perihepatic and perisplenic areas to the pelvis (Fig. 1). At exploratory laparotomy, a massive hemoperitoneum was found along with a severely edematous mesentery. After 4 l of blood and clots were evacuated, the site of bleeding was identified as a ruptured right gastric artery in the absence of aneurysmal dilatation. The vessel was ligated, but due to the presence of the mesenteric edema, an open abdomen technique was applied to avoid intra-abdominal hypertension and abdominal compartment syndrome. The abdomen was closed 48 h later. The patient had an uncomplicated postoperative course and was discharged 10 days later.

Massive Hemoperitoneum from Uterine Leiomyoma Associated with Diffuse Myometrial Venous Congestion

Hemoperitoneum is a rare complication of uterine leiomyomas. Increased abdominal pressure during mechanical stress (i.e., trauma, intercourse, or menstruation) may lead to the rupture of superficial veins overlying the leyomioma. A 39-year-old woman presented with intra-abdominal bleeding without any evidence of mechanical stress. The bleeding was caused by a uterine superficial vein overlying a subserosal leiomyoma. After hysterectomy, histopathologic findings revealed diffuse venous ectasia throughout the whole uterus. Diffuse myometrial venous congestion should be considered a possible predisposing factor to spontaneous rupture of the superficial vessel.

Hemoperitoneum Due to Rupture of a Subserosal Vein Overlying a Uterine Leiomyoma

Uterine leiomyoma is the most common tumor in women of reproductive age, but rarely does it lead to fatal hemoperitoneum. We present an autopsy case in which the cause of death was massive hemoperitoneum due to rupture of a subserosal vein overlying a uterine leiomyoma. We report the case of a 28-year-old Japanese woman who had tuberous sclerosis and was gravida 0, para 0. She had a uterine leiomyoma leading to dysmenorrhea. Autopsy revealed a pinhole-sized rupture of a subserosal vein superficial to the leiomyoma that resulted in fatal hemoperitoneum. Rupture of a subserosal vein overlying a uterine leiomyoma may cause sudden and unexpected death.

Ovarian tumor rupture causing massive hemoperitoneum: an unusual complication of colonoscopy

Ovarian tumor rupture causing massive hemoperitoneum: an unusual complication of colonoscopy

Rupture d’une corne utérine rudimentaire non communicante gravide sur un utérus pseudo-unicorne à 23 semaines d’aménorrhée: À propos d’un cas

Pregnancy in the rudimentary horn of a unicornuate uterus is an extremely rare form of ectopic gestation associated with a high risk of uterine rupture. We report the case of a pregnancy developed in a non communicating rudimentary horn of a unicornuate uterus complicated by horn rupture at 23 weeks of amenorrhea showing as an acute abdominal pain and massive hemoperitoneum. This patient's uterine abnormality was known before, as this woman has delivered two years before at term a healthy boy by cesarean section. This past pregnancy was located in the normal horn and the non communicating rudimentary horn seemed at this time normal. This uterine malformation is presented with its gynecological and obstetrical entailments as well as methods that could prevent such outcome.

Spontaneous splenic rupture in the postpartum period

A 24-year-old woman, who was 8 weeks postpartum, presented to the surgical emergency unit with sudden onset of severe generalized abdominal pain. Apart from a previous ovarian cyst, there were no other significant past medical problems. She denied any recent abdominal trauma or strain. On examination, the patient had a very tender upper abdomen. Ultrasound scan demonstrated free fluid in both the abdomen and the pelvis. It also showed a large complex focal lesion in the spleen, close to the hilum, measuring 80×76 mm (Figure 1). Conservative management was planned initially, but surgery was performed as the patient developed signs of generalized peritonitis along with severe pain in both shoulders. A diagnostic laparoscopy revealed massive haemoperitoneum and bleeding from the upper pole of the spleen (grade II splenic rupture). Haemostasis could not be achieved, and hence a splenectomy was performed via an upper midline laparotomy. The patient made an uneventful recovery. Appropriate vaccinations were given post splenectomy (Haemophilus influenzae, Neisseria meningitides and pneumococcus). On macroscopic examination, the spleen measured 160×120×75 mm and weighed 342 g (Figure 2). Transverse section revealed a unilocular cyst of 85–90 mm in diameter containing haemorrhagic material. Histological examination revealed that the cyst was an epidermoid cyst and showed the presence of both old and new clots. Further additional history from the patient after splenectomy disclosed an admission to the medical ward 4 weeks after her delivery with left shoulder pain, left-sided chest pain and left-sided neck pain that was worse on movement and with cough. There was no history of trauma or fall. She was stable haemodynamically and all her haematological investigations were normal. She was treated as having musculoskeletal pain, given analgesics and was discharged home on the day of presentation. She had two further episodes of left shoulder pain that were treated similarly at a different hospital.

The complications of percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy (PEG) has become the primary procedure for the long-term nutrition of patients with swallowing disorders. It has been shown to be an effective method with a lower complication rate than surgical placement [1]. It can be performed in the intensive care unit, but complications may occasionally occur. The estimated incidence of major complications is 8% [2]. Abscess and wound infections are the most frequent complications, but necrotizing fasciitis, colon or small bowel injuries, gastrocolic fistula, duodenal hematoma, liver injury, gastric perforation, and catheter migration have also been described [3]. Unexpectedly, acute hemorrhage following PEG is rarely reported. In the literature, we found only one case report of a fatal retroperitoneal hemorrhage occurring 2 hours after a PEG [4]. In a series of 263 cases, Schurink and colleagues [2] described only two cases of intra-abdominal bleeding. A 59-year-old man was admitted to our hospital with intracerebral hemorrhage. On day 40, a PEG was performed in the intensive care unit using the 'pull' technique as previously described [5]. The needle puncture of the stomach was accomplished only on the second attempt, although the rest of the procedure was completed uneventfully. The material used was the Bard®Fastrac™ Pull PEG Kit (Bard Access Systems, Salt Lake City, USA). One hour after the end of the procedure, the patient presented a tachycardia (120 beats per minute), with cardiovascular collapse (arterial pressure 70/50 mmHg). Physical examination revealed a distended abdomen. The hemoglobin concentration was 5.5 g/dL. Abdominal echography showed the presence of intraperitonal liquid. An emergency laparotomy was performed, revealing a massive hemoperitoneum due to active bleeding from a small vessel of the minor curvature. X-sutures were applied and the bleeding stopped. A gastrostomy was recreated at the end of surgery. The massive hemoperitoneum we described is a rare complication in relation to its rapidity and its severity. We think that the initial, unsuccessful passage of the needle could have caused the gastric artery branch laceration. Indeed, such a mechanism of injuries has already been suggested as an explanation for a fatal retroperitoneum due to breaches in the splenic and superior mesenteric veins [4]. In the patient we described, prompt recognition could minimize morbidity. Although generally considered safe, PEG can be associated with life-threatening bleeding, especially when multiple needle punctures have been made. It presents with unexplained postprocedure hypotension. Intensivists who are used to performing PEG should be aware of this complication because early recognition and treatment are essential.

Splenic rupture following colonoscopy

Colonoscopy is a safe and routinely performed diagnostic and therapeutic procedure for different colorectal diseases. Although the most common complications are bleeding and perforation, extracolonic or visceral injuries have also been described. Splenic rupture is a rare complication following colonoscopy, with few cases reported. We report a 60-year-old female who presented to surgical consultation 8 h after a diagnostic colonoscopy. Clinical, laboratory and imaging findings were suggestive for a massive hemoperitoneum. At surgery, an almost complete splenic disruption was evident, and an urgent splenectomy was performed. After an uneventful postoperative period, she was discharged home. Splenic injury following colonoscopy is considered infrequent. Direct trauma and excessive traction of the splenocolic ligament can explain the occurrence of this complication. Many times the diagnosis is delayed because the symptoms are due to colonic insufflation, so the most frequent treatment is an urgent splenectomy. A high index of suspicion needs an early diagnosis and adequate therapy.

A case of spontaneous rupture perforation of leiomyosarcoma in the urachus of a young boy

A case of spontaneous rupture of the urachal leiomyosarcoma in a 12-year-old boy is presented. This is of interest because massive hemoperitoneum due to spontaneous rupture of the urachal leiomyosarcoma is remarkably rare. We diagnosed based on histopathological features. Partial cystectomy and adjuvant chemo-radiation therapy was done with no sign of local recurrence or metastasis until 6 months after the operation.

Massive occult haemoperitoneum following spontaneous rupture of duodenal gastrointestinal stromal tumour

Gastrointestinal stromal tumours are an uncommon subset of mesenchymal tumour that can occur anywhere along the gastrointestinal tract. Diagnosis of gastrointestinal stromal tumours is often difficult, as presentation is variable. This case report identifies massive haemoperitoneum as an initial finding, which is an unusual mode of presentation in gastrointestinal stromal tumours.

MDCT diagnosis of ruptured tubal pregnancy with massive hemoperitoneum

We report a case of ruptured tubal pregnancy with massive life-threatening hemoperitoneum. The 38 year-old woman presented with gynaecologic haemorrhage, pelvic pain and hypovolemic shock. Without any ambiguity, the diagnosis was directly made during contrast enhanced Multidetector Computed Tomography (MDCT). Massive hemoperitoneum with fresh blood clots in the hypogastric area, active free peritoneal extravasation of intravascular contrast material and dramatic peripheral enhancement, - "ring of fire" sign - of an adnexal cystic structure were the key signs. These signs must be known by the emergency radiologist because of the more and more use of CT as the first imaging modality in emergency departments particularly for patients with abdominal pain and presenting life-threatening symptoms.

Massive Hemoperitoneum Caused by Rupture of an Aneurysm of the Marginal Artery of Drummond

Aneurysms of visceral arteries are uncommon and their rupture is rare. We report a case of an aneurysm of the marginal artery of Drummond, which was complicated by rupture leading to massive hemoperitoneum. A selective superior mesenteric arteriogram suggested the possibility of segmental arterial mediolysis (SAM) as a possible etiology and this was confirmed by histological examination. This is the first report of symptomatic SAM of the marginal artery of Drummond to date. This case demonstrates that the marginal artery of Drummond should be considered during the angiographic explorations for the source of hemoperitoneum. Management options are discussed.

Massive haemoperitoneum due to uterine artery erosion by endometriosis and a review of the literature

The aim of the literature review was to compile and compare similar cases of massive haemoperitoneum in an asymptomatic woman where the bleeding was from the right uterine artery, which had been eroded by pelvic endometriosis. To our knowledge this is the second case reported in the literature. Case reports of other sources of bleeding leading to haemoperitoneum were studied, comparisons were made, and the results compiled. Although several cases of massive haemoperitoneum have been reported, spontaneous bleeding from uterine artery erosion is a rare occurrence. The abdominal surgeon should be vigilant and alert to localise rare sites of bleeding. This literature review emphasises that endometriosis can present in many ways and a high level of clinical suspicion is necessary.

Urgent Medical Decision Making Regarding a Jehovah’s Witness Minor: A Case Report and Discussion

Physicians strive to respect the autonomy of patients. The emergent care of Jehovah's Witnesses, however, leaves health care providers struggling with ethical and legal questions. These are further compounded when the patient in question is a minor. A girl aged 15 years presented with anemia, a large ovarian mass, massive hemoperitoneum, and parents who were devout Jehovah's Witnesses who refused administration of blood products. Following discussion of the patient's condition and treatment options with the patient, her family, members of the treatment team, and consultants, the patient was transferred to a hospital that offered a blood conservation program for surgical patients. The patient received surgical management without the need for blood transfusion. Her surgeons, however, reserved the legal right to give blood if an emergent need arose despite the lack of parental consent. Society grants considerable legal latitude in dealing with Jehovah's Witness minors, and physicians must be aware of the legal and ethical parameters surrounding the care of such patients.