Massive Intra-abdominal Bleeding Research Articles

Splenic vein rupture in pregnancy: A case report and systematic review of the literature.

Splenic vein aneurysm (SVA) rupture is a rare clinical entity, with few case reports detailing its occurrence during pregnancy. We describe a case of a SVA rupture and present a systematic review of the literature in relation to splenic vein rupture, with or without aneurysm. Our case was of a 30-year-old woman, Para 4 at 37 weeks' gestation who presented with significant abdominal pain and subsequent maternal collapse. Massive intra-abdominal hemorrhage was identified, with splenic vessel rupture suspected. A splenectomy and partial pancreatectomy were performed along with massive blood product transfusion. There was both maternal and fetal survival with no long-term sequelae at follow-up. Histological examination of the spleen and its vessels noted a SVA rupture. In a subsequent systematic review of the literature, we identified 10 cases of splenic vein rupture with only two previously documented cases of SVA rupture in pregnancy. Maternal and fetal survival has only been reported in two cases of splenic vein rupture, with ours being a third.

Peri vesical and retroperitoneal vascular injury following pd catheter insertion in a child: An unusual occurrence

Abstract Peritoneal dialysis (PD) is an important modality of renal replacement therapy (RRT) in children in the acute setting. Despite the favorable outcomes of RRT, PD catheter insertions have various complications that may be related either to variations in procedural technique or infections. We report a case of a child with massive retroperitoneal and intra-abdominal bleeding secondary to injury to the inferior epigastric arterial arcade, near the urinary bladder following the insertion of a PD catheter.

Experience in the Treatment of Wounds of Circulatory Organs in the Chest and Main Vessels of Other Localizations in Wartime

The article presents the principles of providing care for injuries to the heart, aorta, pulmonary artery, or other main vessels. The described principles can be applied in the treatment of civil injuries.
 The aim. Consider a treatment tactic in the cases of heart and main vessels combat injuries using own experience.
 Materials and methods. Twelve cases of combat wounds of blood circulation organs in the chest were analyzed: 5 gunshot injuries of the subclavian vessels, 4 gunshot injuries of the heart, 1 gunshot injury of the ascending aorta, 1 gunshot injury of the pulmonary artery and 1 suspected gunshot injury of the left ventricle.
 Also we analyzed 78 cases of combat gunshot injuries of main vessels of other locations: 3 injuries of vessels of the neck, 68 injuries of main vessels of limbs, 6 injuries of iliac arteries, 1 injury of abdominal aorta.
 Most of the operations, with the exception of those that required artificial blood circulation, were performed in advanced hospitals at the II level of military medical evacuation, which enabled to shorten the time from injury to the performance of the final surgical intervention and save life or limbs.
 Results and discussion. Two cases with penetrating wounds to the chest and damage to the subclavian vessels were fatal. Death was attributed to uncontrolled chest bleeding.
 Among the 78 cases of injury of main vessels of other locations, one case with damage to the iliac arteries was fatal, and death also occurred as a result of uncontrolled massive intra-abdominal bleeding.
 Conclusions. Wounded individuals with unstable hemodynamics against the background of ongoing massive bleeding and with suspicion of injury of the heart or main vessels in the chest should be operated on immediately. Due to the urgency of performing such operations and impossibility of an adequate additional examination, localization and degree of the damage to the organs of the circulatory system is determined during the operation. A thoracoscopic approach can be used in stable patients with non-penetrating gunshot wounds to the heart.
 In the relatively stable condition of patients with an established injury of the heart, aorta, or pulmonary artery, it is advisable to perform additional examinations. Patients with trauma to the main vessels of the extremities and ischemia thereof need rapid revascularization.

A practical guide to the American Society of Anesthesiologists-physical status classification (ASA-PS).

Sir, We read the brief communication, “Reliability of American Society of Anaesthesiologists physical status classification” by Nicola Parenti in the Indian Journal of Anaesthesia with great interest.[1] This systematic review on the reliability of the American Society of Anesthesiologists physical status (ASA-PS) classification showed a wide inter-rated agreement range and suggested a reliability test for the users before using it for general communication. We are of the opinion that the training on ASA-PS classification system should be uniform, up to date and standardised for the results of reliability tests to be commendable. The ASA-PS classification was amended on December 13, 2020 (original approval: October 15, 2014) and it includes the paediatric and obstetric examples.[2] We intend to highlight the salient features of this amendment to improve the understanding and ultimately narrow the gap in the variability of its use. The purpose of the ASA-PS classification is pre-operative assessment and communication of the patients’ medical condition.[2] In combination with other factors like type of surgery and frailty, it can imply perioperative risks and complications, though stand-alone it does not predict perioperative risks.[23] Currently, there is tremendous emphasis on improving the perioperative assessment and ultimately patient outcomes using the ever-advancing healthcare information technology.[45] The definitions and examples of the ASA-PS classification serve as guidelines for the clinicians to follow. The clinicians may develop their institution-specific ASA classification allocation examples incorporated into their health care information technology system. ASA-PS assessment is done during each preanesthetic visit. The final assessment is done after the evaluation of the patient on the day of anaesthesia care by the anaesthesiologist in-charge. The status of the patient at the time of operation is important e.g., presence of rhonchi in a previously well-controlled chronic mild lung disease patient at the time of operation. There are mainly five points to consider for assigning ASA-PS classification. i) presence of co-morbidities like diabetes, hypertension, asthma, and other systemic diseases with or without functional limitations, ii) social habits like smoking, alcohol use iii) whether the patient is pregnant or not, iv) body mass index (BMI) of the patient, and v) whether the operation belongs to the elective or emergency category. For instance, a 21-year-old man who is an active smoker and posted for emergency acute appendicectomy, would be assigned ASA-PS II E in view of being an ‘active smoker’ and emergency nature of the operation. Similarly, a 50-year-old lady who is posted for elective mesh hernioplasty and has well controlled diabetes mellitus on regular medication with no functional limitations, would be assigned ASA-PS II in view of the well-controlled diabetes. Likewise, a 21-year-old primigravida, with a BMI of 50, posted for emergency lower segment caesarean section for cord prolapse with no known medical illness, would be ASA-PS III E, in view of a BMI of 50. Though pregnancy is ASA-PS II, a BMI >39 is ASA-PS III, and thus, a higher class is assigned. Furthermore, a 19-year-old boy with polytrauma with massive intraabdominal bleeding in hypotensive shock, posted for emergency exploratory laparotomy, would be ASA-PS V E because he is not expected to survive without operation. Also, a 50-year-old man who is a known case of chronic obstructive airway disease on regular medication, posted for knee arthroscopy and is currently having rhonchi on examination, would be ASA-PS III in view of the active rhonchi. The ASA-PS classification does not consider the age of the patient, the risk of difficult airway, Mendelson syndrome, intraoperative bleeding, and complexity of the operation. These factors can significantly increase the perioperative morbidity and mortality. There is considerable variation in ASA-PS classification allocation due to the inconsistent understanding of the definitions.[6] Nevertheless, despite its limitations, the ASA-PS classification is widely used in anaesthesia practice. This insight is worth an evaluation for simplified training and teaching of ASA-PS classification. The uniform and standardised teaching can prompt reduction in inter-user variance and improve reliability. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

A case of vascular Ehlers\u2013Danlos syndrome with a ruptured hepatic artery after surgical treatment of peritonitis caused by the perforation of the colon

BackgroundEhlers–Danlos syndrome (EDS) is an inherited disorder that causes connective tissue fragility. The vascular type of EDS (vEDS) caused by defective collagen type III production accounts for 5%–10% of all EDS cases. Patients can develop gastrointestinal or arterial ruptures, which cause poor prognosis. We report a case of a patient who experienced colonic rupture, which was immediately followed by arterial rupture.Case presentationA 40-year-old man who had been genetically diagnosed with vEDS 6 years previously was admitted to our hospital with ischemic colitis. After 3 days of conservative treatment, his abdominal pain worsened, and computed tomography (CT) revealed free air in the abdominal cavity. Pan-peritonitis due to perforation of the sigmoid colon was diagnosed. Intraperitoneal lavage and drainage and Hartmann’s operation were urgently performed. Because the patient had confirmed vEDS, we performed the surgery in a protective manner. The postoperative course was initially good, and he was transferred to the general ward 3 days after surgery. However, 5 days after surgery, massive intra-abdominal hemorrhage suddenly occurred, and contrast-enhanced CT showed an aneurysm in the common hepatic artery that had ruptured; this aneurysm was not present before surgery and was far from the surgical field. Although we considered an emergency operation, the patient suddenly experienced cardiac arrest and was unresponsive to resuscitation.ConclusionsIn cases of vEDS, vascular rupture can occur immediately after surgery for intestinal rupture. We recommend paying special attention to vascular complications in patients in their forties, as such complications are the most common causes of death.

CONCURRENT PULMONARY AND JEJUNAL SARCOMATOID CARCINOMA WITH BRAIN METASTASES

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pulmonary sarcomatoid carcinoma (SCA) is a poorly differentiated, aggressive type of non-small cell lung cancer accounting for 0.1-0.3% of all lung cancers1-3. It is commonly seen in male smokers in their sixties. We present a rare case of concurrent pulmonary and jejunal SCA with brain metastases. CASE PRESENTATION: 75-year-old male with 40-pack year smoking history presents to the hospital with two weeks of nausea, vomiting, weight loss and dyspnea. CXR revealed a 10.1 x 7.4 cm right perihilar mass. Subsequent chest CT showed a 7.8 x 6.6 x 8.7 cm mass involving the posterior segment of right upper lobe, right middle lobe, and right lower lobe. PET scan showed avid lesions involving jejunum, brain, and adrenal glands. Endobronchial biopsy of the lung mass obstructing the lumen of posterior segment of right upper lobe revealed SCA with focal pleomorphism. Immunohistochemical staining was positive for Keratin AE1/AE3 and vimentin. A subsequent jejunal mass biopsy was also consistent with SCA with staining positive for keratin CAM5.2 and ß-hCG. Patient underwent whole brain radiotherapy as well as palliative pembrolizumab therapy. DISCUSSION: SCA is an aggressive cancer with average survival of 8.8 months and 13 months when involving small intestine and lung respectively. 5,7 Immunohistochemical staining is crucial in differentiating metastases versus primary SCA. In our case, TTF-1, Napsin-A, and CK7 staining of the jejunal mass were negative, which contradicts lung derivation. 4 This is a rare case of primary pulmonary SCA and concurrent primary jejunal SCA with brain metastases. Most SCA tumors involving small intestine are polypoid with central ulceration and frequently necrotic and hemorrhagic. 6,7 In contrast, pulmonary SCA usually arises as a solitary central airway mass with an average size of 7 cm.3 Symptoms in pulmonary SCA are non-specific such as chest pain, dyspnea and weight loss.1,4 This makes early diagnosis challenging. Patients often present in advanced stages with extra-thoracic metastases.4 Findings of brain metastasis is rare due to aggressive course of disease with low survival time.3 Both pulmonary and jejunal SCA are resistant to traditional therapeutic methods. Novel therapies like immunotherapy appears promising. CONCLUSIONS: This case is unique as it has two concurrent primaries for SCA, lung and jejunum. It is imperative to perform a complete oncological evaluation to assess for metastases. Early diagnosis and proper adjuvant therapy could prolong survival and improve quality of life. Reference #1: Arshad, H., Dudekula, R., Niazi, M., Malik, S., and Khaja, M. (2017). A Rare Case of Sarcomatoid Carcinoma of the Lung with Spine Metastasis, Including a Literature Review. Am J Case Rep. 2017; 18: 760-765. Beasley, M., Brambilla, E., and Travis, W. (2005). The 2004 World Health Organization classification of lung tumors. Semin Roentgenol. 2005 Apr, 40 (2): 90-7. Reference #2: Oliveira MF, Watanabe SC, Andrade MP, Rotta JM, Pinto FC. Sarcomatoid carcinoma of the lung with brain metastases. J Bras Pneumol. 2013;39(6):753-756. doi:10.1590/S1806-37132013000600016 Jia J, Ren J, Gu J, Di L, Song G. Predominant sarcomatoid carcinoma of the lung concurrent with jejunal metastasis and leukocytosis. Rare Tumors. 2010;2(3):e44. Published 2010 Sep 30. doi:10.4081/rt.2010.e44 Reference #3: Huang, S., Shen, S., and Li, X. (2013). Pulmonary sarcomatoid carcinoma: a clinicopathologic study and prognostic analysis of 51 cases. World J Surg Oncol 2013; 11: 252. Kwok CM. Sarcomatoid carcinoma of the jejunum with gastric metastases: A case report and review of the literature. Int J Surg Case Rep. 2016;28:161-164. doi:10.1016/j.ijscr.2016.09.046 Zhang B, Cheng BO, Wang L, Zhao KE, Zhuo GZ, Ding JH. Primary sarcomatoid carcinoma of the jejunum with massive intra-abdominal hemorrhage: A case report and review of the literature. Mol Clin Oncol. 2016;4(5):811-816. doi:10.3892/mco.2016.809 DISCLOSURES: No relevant relationships by Kushagra Gupta, source=Web Response No relevant relationships by Anthony Loschner, source=Web Response No relevant relationships by Elizabeth McCaskey, source=Web Response No relevant relationships by Toribiong Uchel, source=Web Response

Segmental Arterial Mediolysis with Supra-Aortic Vascular Involvement: Report of Two Cases

AbstractSegmental arterial mediolysis (SAM) is a rare noninflammatory vasculopathy predominantly involving the visceral arteries of the abdomen. The most common presentation described is massive intra-abdominal hemorrhage secondary to aneurysm rupture. In this report, we describe two cases with characteristic findings of aneurysm, dissection, and beading involving the visceral arteries and the supra-aortic vessels. SAM involving the supra-aortic vessels is extremely rare.

A Rare Case of Recurrent Non-Communicating Rudimentary Horn Pregnancy

Introduction: A unicornuate uterus with a rudimentary horn is a uterine anomaly resulting from the incomplete development of one of the Müllerian ducts and an incomplete fusion with the contralateral side. Pregnancy in a rudimentary horn of the uterus is a rare clinical condition with a reported incidence of 1 in 100,000 to 140,000 pregnancies. It carries grave consequences for the mother and fetus as the diagnosis may be missed and subsequently result in an emergency due to spontaneous rupture of the enlarging rudimentary horn and massive intraabdominal bleeding. The standard treatment is the surgical excision of the rudimentary horn. The authors present a case of a rare recurrent rudimentary horn pregnancy that contained a viable pregnancy diagnosed in first trimester and managed with complete excision of the rudimentary horn along with the pregnancy in-situ.

Left anterolateral thoracotomy with cross-clamping of the descending thoracic aorta and open cardiac massage to control massive intra-abdominal bleeding

Left anterolateral thoracotomy with cross-clamping of the descending thoracic aorta and open cardiac massage to control massive intra-abdominal bleeding

Massive Bleeding From Inferior Mesenteric Vein With Hypovolemic Shock: A Rare Complication of Acute Pancreatitis

BackgroundAcute pancreatitis may cause massive intra-abdominal bleeding as vascular complications caused by the erosion of a major pancreatic or peripancreatic vessel. In terms of treatment, the differentiation between arterial bleeding and venous bleeding using abdominal computed tomography (CT) angiography is important. In addition, hypovolemic shock caused by bleeding from the inferior mesenteric vein (IMV) in acute pancreatitis has not been reported. Case ReportA 58-year-old man presented to our emergency department with complaints of abdominal pain of 10 hours’ duration. The pain had an abrupt onset and started with alcohol consumption. After performing initial laboratory tests and an abdominal CT scan, he was diagnosed with acute pancreatitis. However, he complained of severe abdominal pain and was drowsy 2 h later. Follow-up CT angiography revealed acute necrotizing pancreatitis with massive hemoperitoneum and hypovolemic shock. We also found active bleeding from the IMV. We did not consider emergency catheter angiography with embolization; instead, exploratory laparotomy and hematoma evacuation with IMV ligation was performed. He was discharged without complications 14 days later. Why Should an Emergency Physician Be Aware of This?Massive bleeding from the IMV accompanied by shock bowel syndrome is a rare complication of acute pancreatitis that can be confused with arterial bleeding. Emergency physicians should consider this diagnosis in acute pancreatitis as a possible cause of hypovolemic shock and anatomic course of the IMV and prevent fulminant shock by administering appropriate treatment.

One case of concurrent hemorrhage after pancreatic islet transplantation by percutaneous transhepatic portal approach

The percutaneous transhepatic portal approach is the most commonly used technique for islet transplantation, largely owing to its safety and minimally invasive characteristic. Bleeding complications after islet transplantation are rare. A case of type 1 diabetes mellitus (T1DM) was treated in Tianjin First Center Hospital, who had a massive intra-abdominal hemorrhage after percutaneous transhepatic portal vein catheterization for islet transplantation. Through the review of the overall development of the case, we aim to improve the awareness of the complications of islet transplantation, to reduce the incidence of complications after percutaneous transhepatic portal vein transplantation, and to provide experience.

Emergency Viabahn covered stenting in treatment of postoperative ruptured hepatic artery pseudoaneurysm

Objective To evaluate the safety and efficacy of Viabahn covered stent in treatment of hepatic artery pseudoaneurysm (HAPA) caused by surgery. Methods Clinical data of 7 patients with postoperative massive intra-abdominal hemorrhage and diagnosed as HAPA with emergency angiography were collected from November 2015 to May 2016. All the patients underwent Viabahn covered stent implantation. Perioperative and postoperative clinical data of the patients were recorded, and with 1-month follow-up. Results All the 7 cases were diagnosed as extrahepatic HAPA and successfully completed Viabahn covered stent procedure, and curative rate was up to 100%. One case experienced transient vasospasm in the hepatic artery proximal to the stent. All the patients repeated hepatic artery CT angiography scans one week after surgery, with no evidence of bleeding. With 1-month follow-up, all the patients were in stable conditions. Conclusion Viabahn covered stent is minimally invasive, simple and effective interventional approach for HAPA. Key words: Pseudoaneurysm; Hepatic artery; Covered stent; Hemorrhage

Massive intra-abdominal Haemorrhage in a Pregnant Patient with Cirrhosis of Liver - A Case Report

Pregnancy is a rare event in patients with cirrhosis. Recent improvements in the treatment of chronic liver disease have resulted in higher conception rates and more successful pregnancy outcomes. Still pregnancy in cirrhosis is associated with high incidence of foetal loss as well as higher maternal mortality both during pregnancy and in the post-partum period. In this paper we described a case of a successful pregnancy in a young woman with advanced cirrhosis facing life threatening condition in her last trimester and perioperative period.Bangladesh J Obstet Gynaecol, 2013; Vol. 28(2) : 100-102

Outcomes of abdominal trauma patients with hemorrhagic shock requiring emergency laparotomy: efficacy of intra-aortic balloon occlusion.

The aims of this study were to investigate outcomes of abdominal trauma in patients with hemorrhagic shock requiring emergency laparotomy and clarify the beneficial effects of intra-aortic balloon occlusion (IABO) for intra-abdominal hemorrhage in patients with critically uncontrollable hemorrhagic shock (CUHS). We reviewed 44 hemorrhagic shock patients who underwent emergency laparotomy for intra-abdominal hemorrhage over a 6-year period. Of these patients, we examined data for 19 subjects who underwent IABO during initial resuscitation to control massive intra-abdominal bleeding leading to CUHS. The average Injury Severity Score and probability of survival (Ps) of the 44 patients were 27.6 ± 15.4 and 0.735 ± 0.304, respectively, and the overall survival rate was 77.3%. The differences in the Glasgow Coma Scale, lactate level, prothrombin time - international normalized ratio, and Ps between the two groups (21 responders and 23 non-responders) were statistically significant (P < 0.05). Intra-aortic balloon occlusion was attempted in 19 of 23 patients (82.6%) with CUHS, and there were no statistically significant differences in presenting Glasgow Coma Scale, body temperature, lactate, prothrombin time - international normalized ratio, or Revised Trauma Score between the survivors (n = 12) and non-survivors (n = 7). The only significant differences between these two groups were observed in Injury Severity Score (P = 0.047) and Ps (P = 0.007). In all patients, the balloons were successfully placed in 8.1 ± 3.3 min in the thoracic aorta, and a significant increase in systolic blood pressure was observed immediately after IABO. The IABO procedure can be life-saving in the management of patients with CUHS arising from intra-abdominal hemorrhage, permitting transport to surgery.

Primary sarcomatoid carcinoma of the jejunum with massive intra-abdominal hemorrhage: A case report and review of the literature.

Primary sarcomatoid carcinoma of the jejunum is an extremely rare condition, with only 16 cases reported in the literature to date. We herein report an additional case of a giant sarcomatoid carcinoma of the jejunum in a 62-year-old male patient, presenting as massive intra-abdominal hemorrhage. During emergency laparotomy, ~5 litres of bloody ascites was found in the peritoneal cavity and the tumor was located in the proximal jejunum. The tumor involved the entire wall of the jejunum and had directly invaded the neighboring parietal peritoneum, omentum, transverse colon and mesentery, with metastatic lymph nodes. The patient underwent palliative resection of the tumor; however, the course was rapidly progressive and he succumbed to progression of abdominal and liver metastases 4 weeks after surgery. The tumor was found to be positive for epithelial and mesenchymal markers on immunohistochemical analysis. This case emphasizes the aggressive clinical course and metastatic nature of this malignant tumor, with a supplementary review of the previously published literature.

An Unusual Case of Acquired Hemophilia a and Factor XIII Consumption

BACKGROUND: Acquired hemophilia A (AHA) results from auto-antibodies that neutralize factor VIII (FVIII) coagulant function. AHA is rare, usually occurring late in life, and occasionally post-partum. It is most often idiopathic, but can be associated with malignancy, autoimmunity, or drugs. In contrast to congenital hemophilia, AHA generally manifests as mucocutaneous bleeding, with poor correlation to antibody titer or residual FVIII activity. Management goals are the achievement of hemostasis and antibody eradication. Here we describe an unusual case of AHA and concomitant factor XIII consumption in a young nulliparous woman.CASE REPORT: A 24-year-old woman with a symptomatic congenital choledochal cyst underwent a Roux-en-Y bypass, bile duct resection and cholecystectomy. Abdominal sepsis ensued from extended spectrum beta-lactamase Klebsiella, with ertapenem initiation on post-operative day (POD) 5. On POD6 she developed severe intra-abdominal bleeding associated with prolongation of the activated partial thromboplastin time (aPTT) from 35 seconds (pre-operative) to 40 seconds (reference interval 28-35 seconds). On POD10, FVIII activity and FVIII inhibitor titer, using the modified Nijmegen Bethesda assay, were measured at 0.08 U/ml and 4.5 BU/ml, respectively. In addition to supportive transfusion therapy, the patient received a sequence of desmopressin (0.3 mcg/kg IV), recombinant FVIII (50 U/kg), and activated prothrombin complex concentrate (aPCC) (50-75 U/kg IV q8h) with tranexamic acid (10-20 mg/kg IV q8h) from POD13-20. Prednisone was concomitantly initiated (1.5 mg/kg/day) (Figure 1). Bleeding persisted despite reduction in clotting time on rotational thromboelastometry post-aPCC. As neither intensified aPCC nor recombinant factor VIIa (rFVIIa) (80 mcg/kg IV q2h) provided substantial benefit, recombinant porcine factor VIII (rpFVIII) was administered from POD20-28 (100 U/kg IV qd). RpFVIII resulted in hemostatic improvement until anti-porcine FVIII antibodies developed on POD27. On POD28, she was transferred to the local hemophilia treatment center where complete factor analysis identified concurrent FXIII deficiency [0.08 U/ml] using a latex immunoassay. FXIII inhibitor analysis using a chromogenic assay was negative. The peak FVIII inhibitor titer and nadir FVIII activity were 74 BU/ml and <0.01 U/ml, respectively. APCC was resumed [POD28-37] and plasma derived factor XIII (pdFXIII) was given every 4 days to maintain FXIII >0.20 U/ml. The patient was also treated with rituximab [POD28,36,43,50]. On POD37, massive intra-abdominal bleeding prompted sequential aPCC, rFVIIa and pd von Willebrand factor (VWF):FVIII concentrate. Once the FVIII inhibitor titer began to wane, bypassing therapy was discontinued and she was managed solely with pdVWF:FVIII. On POD47 all FVIII-related support was discontinued, as the FVIII inhibitor was undetectable and endogenous FVIII normalized. Her FXIII consumption and requirement for FXIII replacement, however, persisted.DISCUSSION: The unusual features of this case of AHA include the patient's young age, the possible triggers for the FVIII inhibitor (extensive abdominal surgery, sepsis, and/or carbapenem use), and concomitant FXIII deficiency. We hypothesize that FXIII deficiency was secondary to consumption from the massive abdominal wound given its persistence despite normalization of hepatic function. Repeated life-threatening bleeding required trials of multiple hemostatic agents. Persistent and prolonged bleeding despite ongoing FVIII replacement should trigger investigation for a concomitant hemostatic deficiency. AHA is a rare condition, and treatment requires intensive monitoring, clinical experience and specialized laboratory support. Current guidelines are largely derived from expert opinion, and contemporary case descriptions for rare disorders are essential to advance options in best care. [Display omitted] DisclosuresSt. Louis:Baxter/Baxalta: Consultancy. Sholzberg:CSL Behring: Honoraria, Research Funding; Baxalta: Honoraria, Research Funding; Amgen: Honoraria.

Risk Factors and Outcome for Massive Intra-Abdominal Bleeding Among Patients With Infected Necrotizing Pancreatitis.

The incidence of acute bleeding is reported to be 13.5% in patients with acute necrotizing pancreatitis. However, of all the bleeding events, intra-abdominal bleeding was less studied in the literature and its risk factors have not been well defined yet. The purpose of the present study was to investigate the risk factors for massive intra-abdominal bleeding among the patients with infected necrotizing pancreatitis and assessed the outcome of these patients.Both univariate and multivariate logistic regression models were applied for evaluating risk factors for intra-abdominal bleeding using 33 indices, including age, sex, etiology of acute pancreatitis (AP), APACHE II score, etc. Outcome assessments such as mortality, hospital and intensive care unit (ICU) durations, and cost were also compared between patients with or without intra-abdominal bleeding.Acute kidney injury (AKI) (odds ratio [OR]: 7.54, 95% confidence interval [CI]: 2.53–22.52, P < 0.001) and number of operation (OR: 8.84, 95% CI: 2.01–38.86, P = 0.004) were 2 predictors for massive intra-abdominal bleeding in the patients with infected necrotizing pancreatitis. In addition, AP patients with intra-abdominal bleeding also showed significantly higher mortality rate, prolonged hospital and ICU durations, more complications and invasive treatments, as well as increased cost.Our study revealed that AKI and multiple operations were 2 critical factors increasing the risk of intra-abdominal bleeding among patients with infected necrotizing pancreatitis. Additionally, massive intra-abdominal bleeding was also associated with poor prognosis.

Severe Maternal Pre- and Postpartum Intra-Abdominal Bleeding due to Deciduosis.

The term "deciduosis" is used to describe the severe pregnancy-associated occurrence of ectopic decidua with a usually asymptomatic course. We report on two cases of massive maternal intra-abdominal bleeding due to such symptomatic changes. The complications arose at different time points for the two cases: prepartum (26th week of pregnancy) or, respectively, - reported here for the first time - seven days postpartum. As well as differential diagnostic aspects we describe the management of the disease and its possible effects on subsequent pregnancies.

Haemangiosarcoma in a captive Asiatic lion (Panthera leo persica)

A 2.7-year-old male captive Asiatic lion (Panthera leo persica) died unexpectedly without preceding symptoms. Gross necropsy revealed liver and lung tumours, which proved to be haemangiosarcomas by histopathology. Some of the liver tumours were ruptured, leading to massive intra-abdominal haemorrhage and death. Haemangiosarcomas are rare in domestic and exotic felids, occurring in skin, thoracic-abdominal cavity and bones. Although these tumours mainly appear to be occurring in older cats, they are sometimes observed in younger animals, as in the present case. This is the first description of haemangiosarcoma in a young Asiatic lion.

A case of spontaneous splenic rupture in pregnancy

The article provides an observation case of spontaneous splenic rupture in 33/34 weeks of pregnancy. The patient was under active-expectant management, because of premature rupture of membranes at term of 33 weeks. Suddenly, against a background of well-being, emerged clinical signs of massive intra-abdominal bleeding. During the revision of the abdominal cavity the rupture of the capsule of the spleen was detect. Cesarean section and splenectomy were performed. The postoperative period was uncomplicated, the patient was discharged home with the baby.