Presence Of Hemoperitoneum Research Articles

Rupture of fetal membrane in ectopic tubal pregnancy: A case report and literature review.

Ruptured tubal pregnancies occurring in the second trimester are rare; yet, they pose a critical risk of life-threatening hemorrhage. This study aims to highlight the importance of timely surgical intervention in such cases to prevent fatal outcomes. The case underscores the diagnostic and therapeutic challenges that arise when distinguishing between tubal and abdominal pregnancies, particularly in the presence of hemoperitoneum, which can obscure imaging results. We present a case involving the spontaneous rupture of a tubal pregnancy at 15 weeks and 3 days of gestation. The patient exhibited elevated beta-human chorionic gonadotropin levels. Initial transabdominal ultrasound suggested an abdominal pregnancy, and computed tomography scans supported these findings. Urgent midline laparotomy revealed the condition to be a tubal pregnancy, contrary to initial imaging. The surgical procedure included the removal of the gestational sac and the affected fallopian tube, followed by abdominal closure. Hemoperitoneum was noted to compromise the accuracy of imaging modalities, complicating the preoperative diagnosis. Histopathological examination confirmed the diagnosis of tubal pregnancy. The patient had an uneventful recovery and was discharged 7 days post-surgery with stable hemoglobin levels. This case underscores the importance of considering the differential diagnosis of abdominal versus tubal pregnancy in the presence of hemoperitoneum, due to their differing clinical management needs. It offers insights that may guide clinicians in the timely diagnosis and treatment of advanced tubal pregnancies, where prompt surgical intervention is critical.

Clinical Predictive Factors Affecting Laparoscopic Approach in the Management of Ectopic Pregnancy: A Retrospective Cross-Sectional Study

Introduction: Ectopic pregnancy accounts for approximately 2% of all pregnancies and is the most common cause of pregnancy-related mortality in the first trimester. Our aim was to study the preoperative clinical factors affecting the choice of laparoscopic approach to tubal ectopic pregnancy. 
 Materials and methods: This was a retrospective cross-sectional study of tubal ectopic pregnancy cases that were managed by laparoscopy at an academic university hospital in the period January 2010 to December 2018. Cases that were managed medically or conservatively and laparoscopic cases that were converted to laparotomy were excluded. Cases where the surgical approach of laparoscopy or laparotomy were determined by the patients’ choice were also excluded.
 Results: The laparoscopy rate was 49.4%. The mean age was 32.04 years. Compared with laparotomy, laparoscopy was significantly associated with low parity (less than 3) (p=0.008), a low level of initial beta-human chorionic gonadotrophin (p=0.032), fewer cases of adnexal mass (p=0.000451), hemoperitoneum (p=0.000072), ruptured ectopic (p=0.000261), and more cases of bowel adhesions (p=0.0095). There was no significant difference between laparoscopy and laparotomy regarding the risk factors of ectopic pregnancy. Salpingectomy and salpingostomy were not significantly different between the two surgical approaches (p=0.643). Twenty-eight laparoscopic cases were converted to laparotomy.
 Conclusion: The laparoscopic approach to ectopic pregnancy was affected by parity, presenting symptoms of pain and vomiting, mean initial beta-human chorionic gonadotrophin, the presence of adnexal mass, the presence of hemoperitoneum, and the rupture of the ectopic. Bowel adhesions were seen more frequently in laparoscopy than laparotomy. Salpingectomy and salpingostomy were no different between laparoscopy and laparotomy.

Bleeding hepatocellular adenoma: historical series and outcomes.

hepatocellular adenoma - AHC - is a rare benign neoplasm of the liver more prevalent in women at reproductive age and its main complication is hemorrhage. In the literature, case series addressing this complication are limited. between 2010 and 2022, 12 cases of bleeding AHC were attended in a high-complexity university hospital in southern Brazil, whose medical records were retrospectively evaluated. all patients were female, with a mean age of 32 years and a BMI of 33kg/m2. The use of oral contraceptives was identified in half of the sample and also half of the patients had a single lesion. The mean diameter of the largest lesion was 9.60cm and the largest lesion was responsible for bleeding in all cases. The presence of hemoperitoneum was documented in 33% of the patients and their age was significantly higher than the patients who did not have hemoperitoneum - 38 vs 30 years, respectively. Surgical resection of the bleeding lesion was performed in 50% of the patients and the median number of days between bleeding and resection was 27 days. In only one case, embolization was used. The relation between ingrowth of the lesions and the time, in months, was not obtained in this study. it is concluded that the bleeding AHC of the present series shows epidemiological agreement with the literature and may suggest that older patients trend to have hemoperitoneum more frequently, a fact that should be investigated in further studies.

2493 Large Perisplenic Hematoma and Spontaneous Hemoperitoneum as the Initial Presentation of Undiagnosed Burkitt's Lymphoma

INTRODUCTION: Spontaneous hemoperitoneum (SH) is a rare but life-threatening condition of non-traumatic etiology. It usually arises from spleen, hepatic, gynecologic and vascular sources. CASE DESCRIPTION/METHODS: A 61-year-old male with no known medical history presented with acute left sided, non-radiating abdominal pain. On examination, he was hemodynamically stable and had a soft, non-tender abdomen with splenomegaly. His laboratory workup was significant for pancytopenia. CT of abdomen showed a 9 cm perisplenic hematoma with moderate ascites. Patient was admitted to ICU for closer monitoring and a follow-up contrast enhanced CT of abdomen confirmed a perisplenic hematoma and revealed splenomegaly measuring 20 cm with the presence of hemoperitoneum. Sclerotic lesions in multiple thoracolumbar vertebrae, sacrum, and right iliac bone, suspicious for metastasis were also found. Follow-up chest CT revealed mildly enlarged mediastinal lymph nodes. His bone scan was negative. Further malignancy workup was remarkable for a low haptoglobin and high LDH levels. Flow cytometry was positive for CD4, CD5, CD10 and CD19 consistent with B cell lymphoma. Chromosomal analysis confirmed a translocation t(8;14) and FISH analysis showed fusion of MYC and IGH genes in 15.5% of cells, consistent with BL. The patient was managed conservatively. DISCUSSION: The exact mechanism of non-traumatic splenic hematoma leading to hemoperitoneum is unclear. One theory is an increased intra-splenic pressure due to endothelial hyperplasia and vascular occlusion due to a hypercoaguble state leading to spontaneous bleeding from leaking capillaries. Diagnosis is unsuspected and mainly made by CT as seen in our patient whose only findings included abdominal pain and pancytopenia. There have been very few reported cases in literature of SH and even fewer in patients with diagnosed BL. All such cases involved a ruptured spleen. Our patient is unique and to the best of our knowledge, the first ever reported case of SH presenting as an initial feature of a previously undiagnosed BL. Furthermore, his hemoperitoneum was secondary to a large perisplenic hematoma with an intact but enlarged spleen. Therefore, it is important for clinicians to keep lymphoma as a differential in patients presenting with acute abdominal pain and pancytopenia in order to effectively diagnose and treat an underlying malignancy and prevent future complications.

Haemoperitoneum secondary to testicular rupture caused by blunt trauma in a stallion

SummaryTesticular trauma is a commonly reported consequence of injury to the scrotum in humans and horses. In the majority of cases in stallions, injury is caused by a kick from a mare during mating. This case report describes a traumatically induced unilateral testicular rupture in a stallion associated with haemoperitoneum and acute, severe signs of abdominal discomfort. Initially, testicular ultrasound and clinical examinations were inconclusive and the clinical signs led to a diagnosis of an inflammatory abdominal disorder, possibly caused by inguinoscrotal herniation. The patient underwent exploratory celiotomy with unilateral orchiectomy at which time no involvement of the gastrointestinal tract was noted (aside from the presence of haemoperitoneum) and the testicular trauma was discovered. As this case demonstrates, testicular trauma should be considered as a differential diagnosis for inguinoscrotal herniation in stallions with clinical signs of discomfort even when there is no history of recent mating. Detailed clinical examination should be performed to establish a diagnosis but may not be conclusive.

Evaluation of Nodular Splenic Lesions in 370 Small-Breed Dogs (

Three hundred seventy small-breed dogs (<15 kg) undergoing splenectomy for the presence of nodular splenic lesions were evaluated in a retrospective study to assess associations with breeds, malignancy, hemoperitoneum, and median survival time compared with previous studies. Data analyzed included signalment, histopathologic diagnosis, presence or absence of hemoperitoneum, breed associations, and survival times. In the current study, 44% (163/370) of dogs had nonneoplastic splenic lesions and 56% (207/370) had neoplastic lesions. Hemangiosarcoma was present in 27% (100/370) of splenic lesions. Hemoperitoneum was present in 31% (115/370) of dogs, and of this population, 66% (76/115) had malignant splenic lesions. The most common breeds were miniature schnauzers, dachshunds, and beagles, with beagles exhibiting a positive association with malignancy. The presence of hemoperitoneum was associated with malignancy. Distribution for nodular splenic lesions, correlation of hemoperitoneum to malignancy, and median survival time were similar to previous reports in large-breed dogs. Small-breed dogs who present with hemoperitoneum are 2.6 times more likely to have a diagnosis of a malignant splenic lesion. The most common small-breed dogs with nodular splenic lesions were miniature schnauzers, dachshunds, and beagles. Beagles and small-breed terriers were more likely to have malignant splenic lesions, and small-breed terriers were more likely to present with hemoperitoneum.

Death due to non-traumatic hemoperitoneum in Milan 2002-2016, with focus on two cases of abdominal apoplexy (idiopathic spontaneous hemoperitoneum) and review of the literature.

Abdominal apoplexy, also known as idiopathic spontaneous hemoperitoneum, is a rare event related to sudden death, whose diagnosis and treatment is extremely challenging and whose pathologic mechanisms are still mainly unknown. It is frequently associated with vascular disorders (alterations in the vascular structures) and mainly linked to liver cirrhosis. However, the presence of hemoperitoneum may in such cases pose many challenges to forensic post-mortem examinations since the source of bleeding remains often unknown even after a careful and thorough dissection. The Authors present two cases of sudden death related to massive hemoperitoneum (4,650ml in case 1 and 5,100ml in case 2) occurred in two cirrhotic males aged 49 and 51: no traumatic injuries were detected and the source of bleeding was not identified although a careful dissection of organs and vascular structures was performed. Rare cases have been already described in the literature, only as case reports, and no systematic studies have been performed on this issue. Nevertheless, this event ought to be taken into account asa cause of sudden death in people with advanced liver disease. A general glimpse is provided among the different causal mechanisms and the challenges within forensic pathology.

Splenomegaly in small-breed dogs: 45 cases(2005-2011).

OBJECTIVE To assess causes of splenomegaly and postsurgical outcomes in small-breed (ie, < 16-kg [< 35.2-lb]) dogs that underwent splenectomy and evaluate associations among malignant disease, hemoperitoneum, and survival time in these patients. DESIGN Retrospective case series. ANIMALS 45 client-owned dogs. PROCEDURES Medical records of 2 veterinary facilities were reviewed to identify small-breed dogs that underwent splenectomy and had a histologic diagnosis recorded. Data analyzed included signalment, diagnosis, presence or absence of hemoperitoneum, and survival time. RESULTS 21 dogs had malignant neoplasia and 24 had benign splenic diseases. Hemangiosarcoma was the most common malignancy (14/21 [67%] dogs) and lymphoid nodular hyperplasia, hematoma, or extramedullary hematopoiesis (alone or in combination) was most commonly diagnosed in dogs with benign disease (17/24 [71%]). Wheaton Terriers were significantly more likely to have malignant splenic disease than were dogs of other breeds. Malignant splenic disease and the presence of hemoperitoneum had significant negative associations with survival time. Malignant disease was not significantly associated with the presence of hemoperitoneum. CONCLUSIONS AND CLINICAL RELEVANCE Causes for splenomegaly and survival times were similar to those previously reported for populations that primarily included large-breed dogs. There were approximately equal numbers of benign and malignant causes for splenomegaly in this population. Results suggested that Wheaton Terriers with splenomegaly had a higher likelihood of malignant neoplasia than other breeds and that hemoperitoneum may not be a significant predictor of malignancy in small-breed dogs. However, further research including a larger number of dogs is needed to confirm these findings. (J Am Vet Med Assoc 2017;250:1148-1154).

Hallazgos laparoscópicos en pacientes con diagnóstico de embarazo ectópico

Objetivos: Determinar los hallazgos más frecuentes en pacientes con diagnóstico de embarazo ectópico sometidas a intervención quirúrgica vía laparoscópica. Diseño: Estudio descriptivo, retrospectivo, transversal. Institución: Servicio de Emergencia de Gineco Obstetricia, Hospital Alberto Sabogal Sologuren. Participantes: Pacientes con diagnóstico de embarazo ectópico, tratadas quirúrgicamente vía laparoscópica. Intervenciones: Se incluyó 26 pacientes con diagnóstico de embarazo ectópico y consideradas aptas (lo más importante fue la estabilidad hemodinámica de la misma y sin contraindicaciones para la anestesia general) para ser tratadas quirúrgicamente vía laparoscópica. Se tomó datos como la edad, estado hemodinámico, ubicación del embarazo ectópico, tamaño de la tumoración, presencia de liquido libre en la cavidad, tipo de cirugía realizada, conversión a laparotomía. Principales medidas de resultados: Características del embarazo ectópico y resultados de la laparoscopia. Resultados: La edad media fue 31,1 años. Se presentaron en la misma proporción el embarazo tubárico ístmico y el ampular. El tamaño de la tumoración tubárica fue menor de 5 cm en 23 (88,5%) pacientes. La salpingectomía fue la intervención quirúrgica más realizada, en 87,5%, mientras la salpingostomía y la anexectomía fueron poco realizadas. La conversión laparoscópica se presentó en 7,7% de las pacientes. Conclusiones: La laparoscopia mostró ser un método seguro, una buena opción para el tratamiento quirúrgico del embarazo ectópico. Una evaluación adecuada de la paciente es el paso más importante para la decisión del tipo de abordaje. No se encontró mayor asociación entre la presencia de hemoperitoneo mayor de 100 mL y la tasa de conversión a laparotomía.

Is non-operative management of severe blunt splenic injury safer than embolization or surgery? Results from a French prospective multicenter study

The management of the severe blunt splenic injuries remains debated. The aim of this study is to evaluate the morbidity and mortality of splenic injury according to severity and management (surgery, embolization, non-operative management [NOM]). A prospective multicenter study was conducted including patients aged 16 years and older with diagnosed splenic injury. We evaluated severity according to the AAST classification, the presence of hemoperitoneum or a contrast blush on initial CT scan. The initial hemodynamic status, patients co-morbidities, the ISS (injury severity score), management and morbidity were also noted. Between May 2010 and May 2012, 91 patients were included. Thirty-seven patients (41%) had mild splenic injury (AAST I or II and a small hemoperitoneum) while 54 patients (59%) had severe splenic injury (AAST III or greater). The management included 18 splenectomies (20%), 15 embolizations (16%). Among 67 patients undergoing NOM without initial embolization, five (7%) developed secondary bleeding, five required surgery and nine underwent secondary embolization. No patient died and morbidity was 44% (n=40), 13% for mild injuries vs. 65% for severe injuries (P<0.01). For severe injuries, total morbidity was 58% after NOM, 73% after embolization and 70% after surgery. Specific morbidity related to the management was 10% after NOM vs. 47% after embolization (P=0.02). Specific morbidity after surgery was 15%. Embolization, because of its important specific morbidity, should not be performed as a prophylactic measure, but only in presence of clinical or laboratory signs of bleeding.

Laparoscopic management of an abdominal pregnancy.

Background. Ectopic pregnancy is one of the leading causes of significant maternal morbidity and mortality. Abdominal surgeries increase the risk of postoperative adhesions. We here present a case of omental ectopic pregnancy in a patient with a prior history of cesarean section. Case. A 20-year-old female presented with a two-day history of crampy lower abdominal pain. Patient was hemodynamically stable with a beta HCG of 1057 mI/mL. Transvaginal ultrasound did not show an intrauterine pregnancy but revealed an ill-defined mass in the midline pelvis extending to the right of the midline. Diagnostic laparoscopy revealed large clots in the pelvis with normal uterus and adnexa. Intra-abdominal survey revealed an omental adhesion close to the right adnexa with a hematoma. Partial omentectomy was completed and the portion of the omentum with the hematoma was sent to pathology for confirmation. Final pathology confirmed the presence of chorionic villi consistent with products of conception. Conclusion. Omental ectopic pregnancy is a rare diagnosis and often missed. We recommend careful intra-abdominal survey for an ectopic pregnancy in the presence of hemoperitoneum with normal uterus and adnexa. This can be safely achieved using laparoscopy in early gestational ages when the patient is hemodynamically stable.

The Utility of FAST for Initial Abdominal Screening of Major Pelvic Fracture Patients

Focused Assessment with Sonography for Trauma (FAST) is widely used in pelvic fracture patients. We examined the performance of FAST for detecting hemoperitoneum and predicting the need for intra-abdominal hemorrhage control in major pelvic fracture patients. A 5-year retrospective study of major pelvic fracture patients was performed. The presence of hemoperitoneum was confirmed on CT or at laparotomy. The need for hemorrhage control was defined as requiring a surgical or radiological intervention for intra-abdominal bleeding. Hemorrhagic shock (HS) patients had a systolic blood pressure ≤ 90 mmHg or base deficit of ≥ 6 mEq/L on admission. A total of 120 patients were included, 42 (35 %) of which had any hemoperitoneum and 21 (18 %) had a moderate-large amount. The sensitivity, specificity, and positive and negative predictive values of FAST for any hemoperitoneum were 64, 94, 84, and 83 % and for a moderate-large amount they were 86, 86, 56, and 97 %. In HS patients the indices were 68, 93, 88, and 78 % for any hemoperitoneum and 79, 83, 65, and 91 % for a moderate-large amount. For the need for hemorrhage control, FAST had a positive predictive value of 50 % (16/32) in all and 71 % (12/17) in HS patients. The negative predictive value was 99 % (87/88) in all and 97 % (31/32) in HS patients. FAST had a good to excellent diagnostic accuracy, depending on the size of hemoperitoneum. A positive FAST result (even in HS patients) does not reliably predict the need for immediate intra-abdominal hemorrhage control but a negative FAST result renders the need for an intervention highly unlikely.

Emergency Ultrasound Predicting the Need for Therapeutic Laparotomy among Blunt Abdominal Trauma Patients in a Sub-Saharan African Hospital

Background. The trauma burden globally accounts for high levels of mortality and morbidity. Blunt abdominal trauma (BAT) contributes significantly to this burden. Patient's evaluation for BAT remains a diagnostic challenge for emergency physicians. SSORTT gives a score that can predict the need for laparotomy. The objective of this study was to assess the accuracy of SSORTT score in predicting the need for a therapeutic laparotomy after BAT. Method. A prospective observational study. Eligible patients were evaluated for shock and the presence of haemoperitoneum using a portable ultrasound machine. Further evaluation of patients following the standard of care (SOC) protocol was done. The accuracy of SSORTT score in predicting therapeutic laparotomy was compared to SOC. Results. In total, 195 patients were evaluated; M : F ratio was 6 : 1. The commonest injuries were to the head 80 (42%) and the abdomen 54 (28%). A SSORTT score of >2 appropriately identified patients that needed a therapeutic laparotomy (with sensitivity 90%, specificity 90%, PPV 53%, and NPV 98%). The overall mortality rate was 17%. Conclusion. Patients with a SSORTT score of 2 and above had a high likelihood of requiring a therapeutic laparotomy. SSORTT scoring should be adopted for routine practice in low technology settings.

Traumatisme thoraco-abdominal : stratégie en imagerie

The imaging work up of patients following trauma to the thorax and/or abdomen is dependent upon the hemodynamic and respiratory status. In patients with respiratory distress, management is based on a chest radiograph to detect pleural effusion or pneumothorax requiring immediate drainage. In patients with hemodynamic shock despite adequate resuscitation, FAST US may be the only imaging study performed, along with a chest radiograph, prior to laparotomy in the presence of hemoperitoneum. CT is the key to the management of patients with potentially severe trauma based on clinical findings and/or the nature of the trauma. CT analysis must be rigorous and exhaustive to detect lesions responsible for the clinical findings but also to identify dangerous lesions even if not currently symptomatic, such as contained isthmic aortic transection, bowel perforation or diaphragmatic injury. In patients with less severe trauma, the choice between chest radiographs and abdominal US, more economical, and with less radiation, and CT of the thorax and abdomen, more exhaustive and more accurate, will be discussed on a case by case analysis.

Abdominal Ultrasound is an Unreliable Modality for the Detection of Hemoperitoneum in Patients With Pelvic Fracture

Detection of hemoperitoneum in patients with pelvic fracture and hemodynamic instability is important to determine the need for laparotomy versus pelvic angiography. The use of ultrasound (FAST [Focused Assessment with Sonography for Trauma]) for the evaluation of hemoperitoneum after blunt abdominal trauma has become widespread. However, its sensitivity and specificity in patients with pelvic fracture remain poorly defined. The purpose of this study was to determine the sensitivity and specificity of FAST for the detection of hemoperitoneum in patients with pelvic fracture and an increased risk for hemorrhage. The medical records for all admissions to our Level I trauma center from November 2003 to February 2005 were retrospectively reviewed. Inclusion criteria were presence of pelvic fracture with at least one of the following risk factors for hemorrhage: age > or =55, hemorrhagic shock (systolic blood pressure <100 mm Hg), or unstable fracture pattern. Emergency department FAST results were recorded. Surgery residents trained and certified in ultrasonography in the acute setting performed all FAST examinations and an in house attending surgeon reviewed them. Presence of hemoperitoneum was confirmed by laparotomy or abdominopelvic computed tomography (CT) scan. There were 146 patients who met entry criteria, 126 of who had a FAST examination performed. A total of 104 patients underwent a confirmatory evaluation of their abdomen with either operative exploration (n = 20) or CT scan (n = 84). Eight patients underwent diagnostic peritoneal lavage before CT confirmation and were excluded. Ninety-six patients constituted the study group. Nineteen patients presented in hemorrhagic shock. There were 11 true-positive, 52 true-negative, 2 false-positive, and 31 false-negative results. Sensitivity and specificity were 26% and 96%, respectively. Positive and negative predictive values were 85% and 63%, respectively. A FAST examination with negative result does not aid in determining the need for laparotomy versus pelvic angiography in patients with pelvic fracture at risk for hemorrhage. These patients should undergo additional confirmatory evaluation to exclude intraperitoneal hemorrhage.

Diagnostic Peritoneal Lavage for Diagnosing Blunt Hollow Visceral Injury: The Accuracy of Two Different Criteria and Their Combination

To test the usefulness of diagnostic peritoneal lavage (DPL) for identifying blunt hollow visceral injury with two different sets of criteria or a combination of the two. Fifty victims with physical examinations and/or computed tomography findings equivocal for blunt hollow visceral injury underwent DPL. Whether or not to perform surgery was determined based on Otomo's DPL criteria [lavage white blood cell counts (L-WBC) over lavage red blood cell counts (L-RBC) divided by 150 (L-WBC > or = L-RBC/150) in the presence of hemoperitoneum, or L-WBC over 500/mm(3) (L-WBC > or = 500) in the absence of hemoperitoneum]. The cell count ratio, a comparison of L-WBC, L-RBC, peripheral WBC (P-WBC), and peripheral RBC (P-RBC) [(L-WBC/L-RBC)/(P-WBC/P-RBC) > or = 1] were all calculated retrospectively. There were one and two false-positive cases based on Otomo's criteria and the cell count ratio, respectively, with corresponding accuracies of 97.8% and 95.7%, respectively. There were no false-positive or -negative cases according to the combined use of Otomo's criteria and cell count ratio, yielding an accuracy of 100%. Although each criterion alone is very accurate in predicting the presence of blunt hollow visceral injury, the combined use of the two would further improve the accuracy of the diagnosis and thereby reduce the number of unnecessary celiotomies.

Intestinal ischemia versus intramural hemorrhage: CT evaluation.

We evaluated the capability of CT to depict findings that allowed differentiation of small-bowel ischemia from intramural hemorrhage. Findings of 35 CT examinations (19 patients with small-bowel ischemia and 16 patients with intramural hemorrhage) were analyzed by two abdominal radiologists for the degree of wall thickening, location and length of involvement (short, <or = 15 cm; medium, 16-30 cm; or long, >30 cm), presence of hemoperitoneum, and pattern of attenuation. Patency and caliber of the superior mesenteric artery and vein were noted. Diagnosis was confirmed by laboratory findings, clinical parameters, and follow-up examinations, or at surgery. A Mann-Whitney U or Fisher's exact test was used to compare the two conditions for the following features: wall thickening, location and length of involvement, presence of hemoperitoneum, and appearance of the target sign. Among the 35 examinations, 18 abnormal segments with intramural hemorrhage and 19 abnormal segments with ischemia were identified. (Two patients with intramural hemorrhage each had two segments involved.) Mean bowel wall thickness was 11.7 mm (range, 4-25 mm) in patients with intramural hemorrhage and 4.0 mm (range, 1-9 mm) in patients with ischemia. Length of involvement was short in 14 segments with intramural hemorrhage and medium in four segments with intramural hemorrhage; none of the segments with intramural hemorrhage had long involvement. Among the segments with ischemia, length of involvement was medium in three and long in 16; none of the ischemic segments had short involvement. Fifteen (94%) of 16 segments with intramural hemorrhage and six (32%) of 19 segments with ischemia had hemoperitoneum. Seven of the 18 segments with intramural hemorrhage and nine of the 19 with ischemia had a target sign. Segments with intramural hemorrhage exhibited a higher statistically significant degree of wall thickening (p < 0.001), a shorter length of involvement (p < 0.0001), and a higher incidence of hemoperitoneum (p < 0.001) than did segments with ischemia. The two groups were not statistically different in location of involvement (p = 0.12) or in the incidence of the target sign (p = 0.18). Although some of the CT features overlap, a short segment involvement with wall thickening of 1 cm or greater is typical of intramural hemorrhage; a long segment involvement with wall thickening of less than 1 cm is typical of ischemia.

The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruptions.

Pelvic fractures may be associated with significant hemorrhage. Although this hemorrhage may emanate from the pelvic vasculature, it may also be secondary to abdominal visceral injury. The purpose of this study was to determine factors associated with pelvic and/or abdominal visceral bleeding in hypotensive patients with pelvic fractures to guide the appropriate therapeutic intervention sequence for these difficult-to-manage patients. Medical records of all hypotensive (systolic blood pressure < or = 90 mm Hg) patients with pelvic fractures seen at a Level I trauma center from January 1995 to December 1999 were evaluated. Records were abstracted for age, base deficit, 24-hour blood requirement, hemoperitoneum (positive ultrasound, diagnostic peritoneal lavage, or computed tomographic scan), abdominal hemorrhage discovered at celiotomy, pelvic hemorrhage discovered at angiography, emergency department disposition, Injury Severity Score, and mortality. Pelvic fracture categories were derived by adapting the Young-Burgess pelvic fracture classification scheme. Lateral compression (LC) I and anteroposterior compression (APC) I fractures were characterized as stable fracture patterns (SFPs), and APC II, APC III, LC II, LC III, and vertical shear were characterized as unstable fracture patterns (UFPs). Of 231 hypotensive patients, 38 patients died in the emergency department, leaving 193 surviving initial resuscitation. One hundred seven patients stabilized (group I) and were transferred to the intensive care unit. Eighty-six patients (group II) required ongoing resuscitation and underwent celiotomy and/or angiography in an attempt to manage their hemorrhage. Within group II, in the SFP population, abdominal hemorrhage was responsible for hypotension in 34 of 40 (85%), and 10 patients died (25%). In patients with UFP injury, hemorrhage was predominantly from a pelvic source, as shown by 27 positive angiograms in the 46 patients (59%). Twenty-four of 46 (52%) UFP patients died. In patients with a UFP, 14 had both angiography and celiotomy. Four patients underwent angiography before celiotomy and one of four (mortality, 25%) died. In contrast, 10 patients underwent celiotomy before angiography and 6 of 10 died (mortality, 60%). Patients with signs of ongoing shock with SFP pelvic injury and hemoperitoneum require celiotomy as the initial intervention, as the hemorrhagic focus is predominantly intraperitoneal. In patients with UFP, even in the presence of hemoperitoneum, consideration should be given to angiography before celiotomy.

Hemoretroperitoneum associated with liver bare area injuries: CT evaluation.

In hepatic injury restricted to the postero-superior region of segment VII (bare area), hemoperitoneum may be absent and this condition may be associated with hemoretroperitoneum. The aim of this paper is to present the association between bare area injuries and hemoretroperitoneum evaluated by CT. The CT examinations of 32 patients with blunt liver trauma were reviewed and the number and location of lesions were evaluated. Right lobe involvement was identified, focusing on the bare area lesions. The presence of hemoperitoneum and hemoretroperitoneum were determined. In the 32 patients 44 parenchymal lesions were detected. Segment VII was involved in 16 cases: 5 patients presented an intraparenchymal lesion, 11 patients a lesion emerging to the liver surface. In 8 cases the lesion was localized in the bare area. In the 16 patients presenting a segment-VII lesion, hemoperitoneum was detected in 3 cases, hemoretroperitoneum in 4 cases, and both conditions in 4 cases. A traumatic hepatic lesion may be associated with hemoretroperitoneum rather than hemoperitoneum. This justifies the absence of clinical signals of peritoneal irritation; the negativity of both US scan and peritoneal lavage may cause an inappropriate therapeutic management. Computed tomography yields both the detection of the parenchymal damage and the correct localization of the intraperitoneal and retroperitoneal hemorrhage.

Ultrasound detection of blunt splenic injury

The purpose of this study was to determine the sensitivity of emergency ultrasound (US) for the detection of blunt splenic injury (BSI), and to describe sonographic parenchymal patterns. Over 3 years, 2138 emergency US were performed, and 162 patients had BSI. CT was performed for 76 patients, and there were 86 laparotomies. Seventy patients (43%) had concomitant intraabdominal injuries. Ultrasound detected free fluid in 109 patients (67%), and parenchymal injury in 31 patients (19%). There were 48 false negative US (30%). Sonographic patterns included a diffuse heterogeneous appearance, hyperechoic and hypoechoic perisplenic crescents, and discrete hypoechoic or hyperechoic areas within the spleen. Overall sensitivity of US for detection of BSI was 69%, but was 86% for grade III or higher injuries. Ultrasound is most sensitive for the detection of grade III or higher BSI based on the presence of haemoperitoneum. Ultrasound may also identify BSI on the basis of parenchymal abnormality, with a diffuse heterogeneous pattern most commonly encountered. Sonographic evaluation for both free fluid and parenchymal injury improves sensitivity of US.