Hemoperitoneum

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Sunita Kumawat, M.B.B.S[2]

Synonyms and Keywords: peritonel hemorrhage, Hemorrhage into peritoneal cavity, Intraperitoneal hemorrhage, Intraabdominal hemorrhage, abdominal apoplexy, blood in the belly.

Overview

Hemoperitoneum is accumulation of blood in the peritoneal cavity. The parietal peritoneum is a thin membrane surrounding the outer abdominal wall, and visceral peritoneum is the thin membrane surrounding the viscera or organs in the abdomen in a bag like manner. The space between these two membranes is called the peritoneal cavity. The most common cause is trauma. Hemoperitoneum is a life-threatening condition that requires prompt medical attention. Early detection and rapid treatment remain critical to a favorable result. Careful observation may be allowed under some circumstances. The abdominal cavity has the capacity to store more than 5 liters of blood, which can build quickly and cause hemorrhagic shock. If left untreated it may lead to death.

Classification

Hemoperitoneum can be classified into 3 types depending on its cause.

Type of hemoperitoneum	Description
Traumatic hemoperitoneum	This is most commonly caused by trauma. This condition occurs when there is bleeding in the peritoneum due to an accident or injury.
Nontraumatic hemoperitoneum	This is also called spontaneous hemoperitoneum. This occurs due to an underlying medical condition.
Iatrogenic hemoperitoneum	This is caused by some medicines or as a complication of procedures or surgery.

Pathophysiology

The presence of blood in the peritoneal cavity is known as hemoperitoneum. The area between the inner lining of the abdominal wall and the internal abdominal organs becomes clogged with blood. Hemoperitoneum is considered a surgical emergency in most cases. In selected cases observation under direct supervision of medical staff can be one of the options.

The abdominal cavity in human body is highly distensible, and it can readily accommodate with over five liters of blood, or more than an ordinary person's full circulating blood volume. As a result, large-scale or sudden blood loss into the abdomen will almost always result in hemorrhagic shock, which can quickly lead to death if left untreated.

Patients could be classified into one of three groups based on the intensity and cause of their bleeding:

Causes

Injury to intraabdominal organ or vessel with any of the underlying conditions:<

• Blunt abdominal trauma, which results in rupture of liver, kidney, spleen or mesenteric vessels. Sometimes displaced pelvic fractures can lacerate the pelvic or iliac arteries, causing hemoperitoneum.
• Highly vascular intraabdominal tumors can lead to spontaneous bleeding or by invasion of blood vessels.
• Iatrogenic bleeding during abdominal surgery (particularly intestinal anastomosis and resection or enterotomy ) or intraabdominal organ biopsy (kidney, spleen or liver).
• Parturition or late-term pregnancy can cause uterine or ovarian artery rupture.
• Gynecologic disorders ruptured
  • ovarian cyst or ruptured corpus luteum
  • uterine rupture
  • ectopic pregnancy rupture

• Coagulopathy can cause spontaneous hemoabdomen on rare occasions.
• Umbilical vessel rupture inside the abdomen in neonates.
• Acute cholecystitis eroding the cystic artery
• Ruprure of renal or hepatic cyst
• Peritoneal membrane abnormalities
  • Radiation injury
  • Peritoneal calcification
  • Sclerosing peritonitis
  • Peritoneal carcinomatosis
• IgA nephropathy
• Bleeding due to a perforated gastric ulcer
• Aortic or other vascular rupture
• Acute hemorrhagic pancreatitis
• Hepatic hematoma in syndromic hemolysis with elevated liver enzymes and low platelet count (HELLP syndrome)

Differential diagnosis of hemoperitoneum

Hepatic	Splenic	Gynecological	Biliary
Hemangioma Hepatocellular carcinoma Hepatic adenoma/adenomatosis Primary hepatic angiosarcoma Focal Nodular Hyperplasia Metastatic cancer Peliosis hepaticus Amyloid	Iatrogenic Spontaneous splenic rupture Torsion and rupture of wandering spleen Spontaneous rupture of splenic vein Primary splenic angiosarcoma Hamartoma Chronic myelomonocytic leukemia Infectious mononucleosis Hamartoma Primary splenic angiosarcoma	Ruptured ovarian cyst Ruptured corpus luteum cyst Spontaneous uterine rupture Uterine leiomyoma/leiomyosarcoma Ectopic pregnancy Ovarian granulosa cell tumor Endometriosis Hyperemesis gravidarum	Transhepatic rupture of gall bladder Ruptured cholangiocarcinoma
Vascular	Colonic	Gastric	Pancreatic
Ruptured splenic artery aneurysm Ruptured cystic artery pseudoaneurysm Segmental mediolytic arteriopathy	Meckel’s diverticulitis GIST	GIST Mixed cavernous-capillary hemangioma	Ruptured pseudocyst
Miscellaneous
Ruptured benign solitary fibrous tumor

Epidemiology and Demographics

The incidence of hemoperitoneum in patients on peritoneal dialysis varies from 6 percent overall to as high as 57 percent in premenopausal women [1,2]. Bloody peritoneal dialysate may be related to the peritoneal dialysis catheter, related to the peritoneal dialysis procedure, related to the underlying kidney disease (such as polycystic kidney disease or acquired cystic changes), or due to factors unrelated to kidney disease (table 1). Performance of peritoneal dialysis exchanges allows a daily view of the peritoneal cavity and, as such, an early detection of intra-abdominal bleeding, including benign causes of bleeding that would be otherwise clinically silent.

Causes of hemoperitoneum were reviewed in a single-center series of 424 patients; 26 patients (6 percent) developed one or more episodes of hemoperitoneum [1]. Based upon severity and cause of bleeding, patients could be divided into different groups:

●In the largest group (n = 21) of cases, bleeding was mild, asymptomatic, and resulted in pinkish or red discoloration of the fluid. These patients were treated conservatively and did not receive extensive evaluation. Menstrual bleeding was believed responsible in seven cases, while a bleeding diathesis (use of warfarin or thrombocytopenia) was responsible in four patients.

●Peritoneal bleeding after transplant nephrectomy, increased physical activity, catheter repositioning, and femoral hematoma were responsible for single cases.

●Minor bleeding with significant pathology was found in single patients with pancreatitis, sclerosing peritonitis, and postcolonoscopy, respectively.

●Severe bleeding requiring intervention was observed in six patients, three with likely ovarian cyst rupture, one postsplenectomy, one post-catheter placement, and one with sclerosing peritonitis.

●The cause was uncertain in six patients.

Menstrual bleeding — Benign hemoperitoneum occurs in over one-half of menstruating women on peritoneal dialysis; this is likely caused by ovulation, retrograde menstruation, or endometriosis [2-4]. In one study of 27 reproductive-age women undergoing continuous ambulatory peritoneal dialysis (CAPD) for more than three months, four of seven who menstruated developed hemoperitoneum [2]. Of 37 episodes of hemoperitoneum, 22 and 15 occurred at midcycle and with menstruation, respectively.

Such intra-abdominal bleeding would rarely be observed if peritoneal dialysis was not being performed. It is important to note that a very small amount of blood (<1 mL) is enough to make 2 liters of peritoneal dialysate appear blood tinged.

When such episodes occur, the woman should be reassured that the hemoperitoneum is benign and that it will likely resolve spontaneously. Rapid flushes (instillation of 500 mL to 1 L of dialysate allowed to dwell over one hour) and instillation of heparin (typically 500 units/L of instilled volume) in the dialysate to prevent catheter clotting are usually done. Infusing cool dialysate (ie, room temperature) may also be helpful [5]. Most commonly, the hemoperitoneum will clear after one to three rapid flushes. (See 'Treatment' below.)

Catheter related — After insertion of the peritoneal catheter, bleeding into the peritoneal cavity occurs in <5 percent of cases [1,2]. Such bleeding is usually mild and resolves with the performance of several exchanges. (See "Placement and maintenance of the peritoneal dialysis catheter".)

Rarely, the peritoneal dialysis catheter may cause enough blunt trauma, resulting in a local laceration. There has been one case report of a peritoneal catheter eroding into a mesenteric artery [6]. There have also been several reports of splenic lacerations resulting in massive hemoperitoneum [7,8]. This is unusual and likely will be much less common now that "coiled tip" rather than "straight tip" peritoneal dialysis catheters are becoming standard. More commonly, but still rarely, the peritoneal dialysis catheter may cause a mild contusion of the surface of the peritoneal cavity, resulting in some bleeding.

Intra-abdominal pathology — Hemoperitoneum may also develop as the result of intra-abdominal pathology, which could occur in nondialysis patients. Potential causes include:

●Splenic rupture and infarct [9,10]

●Carcinomatosis of the liver [11]

●Liver rupture and liver cyst rupture [10]

●Retroperitoneal hematoma [12]

●Iliopsoas hematoma [13]

●Bleeding from the outer uterine wall in a pregnant patient [14]

●Spontaneous rectal sheath hematoma [15]

●Post-cardiac catheterization from a retroperitoneal hematoma [16]

Additional causes include hemorrhagic luteal cyst, ovarian cyst rupture, pregnancy, ectopic pregnancy [17], aneurysm rupture, vascular catastrophe, colonoscopy, and bleeding diathesis [10].

Retroperitoneal pathology — Hemoperitoneum may be the result of pathology in the retroperitoneum, often involving the kidney. Cyst rupture in patients with autosomal dominant polycystic kidney disease, acquired cystic disease [18], and renal tumors are potential causes of bloody dialysate [19,20]. These patients may also have hematuria. Although very rare, and in this case not related to the peritoneal dialysis catheter, hemoperitoneum has also been reported in a peritoneal dialysis patient as a result of a leaking and, subsequently, a ruptured aortic aneurysm [21].

●(See "Autosomal dominant polycystic kidney disease (ADPKD): Renal manifestations".)

●(See "Acquired cystic disease of the kidney in adults".)

●(See "Clinical manifestations, evaluation, and staging of renal cell carcinoma".)

Additional causes — Encapsulating peritoneal sclerosis (EPS) is an important and ominous cause of bloody dialysate. It should be considered in patients who have been on peritoneal dialysis for greater than one year, and risk for EPS increases with time on peritoneal dialysis. Peritoneal calcification has also been associated with bloody peritoneal dialysate [22]. (See "Inadequate solute clearance in peritoneal dialysis".)

Bloody dialysate will occasionally present posttransplant or when peritoneal dialysis is temporarily stopped for other reasons. In such cases, the patient is noted to have blood-tinged fluid when the peritoneal cavity is flushed. This is usually due to peritoneal inflammation and likely an early stage of peritoneal sclerosis or EPS [23]. (See "Encapsulating peritoneal sclerosis in peritoneal dialysis patients", section on 'Clinical features'.)

Although anecdotally reported, bloody peritoneal dialysate is not a common presenting sign of peritonitis. In a review of 103 episodes of peritonitis in CAPD patients, for example, bloody peritoneal dialysate was not mentioned as a presenting sign in any case [24].

Risk Factors

A person having underlying conditions is more prone to spontaneous hemoperitoneum

• Highly vascular intra-abdominal tumors
• Aneurysm or pseudoaneurysm of intrabdominal vessels
• Coagulation disorders
• HELLP syndrome
• Gastric ulcer
• Endometriosis
• Difficult labour
• Anticoagulation therapy
• Iatrogenic eg. colonoscopy
• Meckel's diverticulum

Screening

There is insufficient evidence to recommend routine screening for [disease/malignancy].

OR

According to the [guideline name], screening for [disease name] is not recommended.

OR

According to the [guideline name], screening for [disease name] by [test 1] is recommended every [duration] among patients with [condition 1], [condition 2], and [condition 3].

Natural History, Complications, and Prognosis

If hemoperitoneum is not treated immediately, severe complications might occur. The peritoneal cavity is unusual in that it can store nearly all of a person's circulating blood volume. The blood can collect quickly in the peritoneal cavity.

This can lead to shock due to blood loss, make you unconscious, and even cause death.

Prognosis varies depending on the underlying etiology and associated injuries.

Diagnosis

The various methods of diagnosing hemoperitoneum are:

• Ultrasound: An ultrasound is a process that uses sound waves to create pictures of the inside of the body.  The presence of fluid or blood in the peritoneal cavity can be detected using ultrasounds. For example, Focused Assessment with Sonography for Trauma (FAST).
• CT Scan: The term CT scan (also known as CAT scan) refers to computerized axial tomography (CT scan). This method creates cross-sectional x-rays of the interior of the body and can aid in the detection of blood or fluid in the peritoneal cavity.

Traumatic
Solid organ injury	Accumulation of high-attenuation fluid close to or surrounding the injured organ, in the pelvis, and the paracolic gutters appearing as Sentinel clot sign. A high attenuation area with a serpiginous border suggests active extravasation of contrast material.
Mesenteric or bowel injury	Bowel wall thickening; triangular high-attenuation interloop mesenteric fluid collections; high attenuation free fluid indicates extravasation of oral contrast material from site of bowel injury, or intravenous contrast material from mesenteric tear.
Nontraumatic
Iatrogenic injury ( interventional procedure, complication of surgery, or anticoagulation therapy)	High-attenuation fluid around spleen or liver in patients on anticoagulants, at the site of intervention, or in the surgical bed.
Tumor-associated hemorrhage	Sentinel clot sign; high-attenuation fluid at the tumor site in peritoneum, spleen, liver
Gynecologic condition (ectopic pregnancy, ruptured ovarian cyst, HELLP syndrome)	Fluid with high attenuation or internal echogenicity around the uterus and adnexa; associated mixed attenuation adnexal mass with fluid-fluid level or a high-attenuation component.
Vascular lesion (visceral artery aneurysm or pseudoaneurysm)	An apparent aneurysmal sac surrounded by high-attenuation free fluid accumulating contrast material; pancreatitis or clinical history of systemic vascular disease (eg, Ehlers-Danlos syndrome).

• MRI: The term "magnetic resonance imaging" refers to the use of magnetic and radio waves to create pictures of the inside of the body, which can aid in the diagnosis of hemoperitoneum.

• Paracentesis or diagnostic peritoneal lavage: It is a surgical diagnostic technique used to see if there is any free-floating fluid in the abdominal cavity.
• Diagnostic laparoscopy or exploratory laparotomy: Laparoscopy is a procedure that uses tiny incisions and a camera to examine the abdomen or pelvis. With a few tiny cuts in the belly, the laparoscope assists therapeutic or diagnostic treatments.

• Exploratory laparotomy: The abdomen is opened and the abdominal organs are inspected for damage or illness during an exploratory laparotomy. It is the standard of treatment in a variety of blunt and penetrating trauma scenarios when numerous life-threatening injuries may exist, as well as in many diagnostic cases where the operation is performed to find a unifying reason for several signs and symptoms of illness.

Signs and Symptoms

It is difficult to detect signs and symptoms of internal bleeding unless there is a severe trauma or accident that necessitates a hospital visit. Vital indicators like blood pressure and heart rate, may vary considerably from case to instance. Internal bleeding in the abdominal or pelvic area may progress to symptoms of shock. Signs and symptoms of hemoperitoneum are:

• Nausea or vomiting
• Light headedness
• Tenderness at the site of abdomen
• Stabbing or sharp pain
• Cold and clammy extremities
• Dizziness or confusion

Physical Examination

Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].

OR

Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

The presence of [finding(s)] on physical examination is diagnostic of [disease name].

OR

The presence of [finding(s)] on physical examination is highly suggestive of [disease name].

Laboratory Findings

Serum labs

• Complete blood count: To evaluate the need for transfusion.
• Blood type and crossmatch

Invasive studies:

• Diagnostic peritoneal lavage (abdominal paracentesis)  : Rapid method to determine blood in the peritoneal cavity.

Used in hemodynamically unstable patients when FAST exam is not possible.

Electrocardiogram

There are no ECG findings associated with [disease name].

OR

An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

X-ray

There are no x-ray findings associated with [disease name].

OR

An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with [disease name].

OR

Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

CT scan

• Focused assessment with sonography for trauma (FAST)
  • indication
    • rapid diagnosis of hemoperitoneum
    • may not determine source of hemorrhage
  • findings
    • blood in peritoneal cavity
• Computed tomography
  • indications
    • detection of solid organ injury
    • can determine source of hemorrhage
    • hemodynamically stable patients
  • findings
    • solid organ injury

There are no CT scan findings associated with [disease name].

OR

[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

MRI

There are no MRI findings associated with [disease name].

OR

[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Treatment

The main goals of treatment for hemoperitoneum are arrest of bleeding, the preservation and restoration of effective blood volume, and the restoration and maintenance of oxygen carrying capacity.

The options to achieve these goals are fluid resuscitation, the delivery of blood products or hemoglobin-based oxygen carriers, abdominal counterpressure, and surgical intervention.

Bleeding intra-abdominal neoplasms almost always necessitate surgery. Hemorrhaging patients with splenic torsion, liver lobe torsion, bleeding cysts, penetrating injuries, stomach dilatation and volvulus, and any other condition leading in organ ischemia should have emergency surgery.

The initial treatment for large hemoperitoneum is an urgent blood transfusion if the patient is in hemorrhagic shock.

Hemoperitoneum treatment include both the evacuation of blood from the peritoneal cavity and the cessation of bleeding.

Hemoperitoneum is a sign that emergent surgery is needed to find the cause of the bleeding as well as to recover spilled blood from the peritoneal cavity and utilize it for auto-transfusion if it isn't polluted by burst bowel contents.

The control method is determined by the cause of blood loss.

• Clamping and ligation of the offending artery, or repair of the vessel, would be used to treat vascular bleeding.
• Removal of spleen or splenectomy is required for bleeding from the spleen. Low-grade lacerations of slpeen may be observed until clinical condition deteriorates.
• Application of thrombin, hemostatic sponges or argon beam cauterization is required to control bleeding from the liver.
• Endovascular technique is used for the repair of ruptured abdominal aortic aneurysm.

Methods of treatment for hemoperitoneum

Paracentesis	A big syringe is inserted into the peritoneal cavity during paracentesis. The plunger is then pushed back, allowing the fluid from the peritoneal cavity to be drawn into the syringe.
Ligation	Ligation is the tying off or clamping a bleeding blood vessed which is injured.
Cauterization	Cauterization is the process of burning tissue in order to seal it off and stop the bleeding.
Medications	To slow or stop bleeding, coagulant medicines (drugs that assist the blood clot) can be administered.
Laparotomy	A laparotomy is a procedure that includes making an incision in the abdomen to drain fluids that have collected there. Hemoperitoneum can also be diagnosed using this technique.
Surgery	In traumatic cases, the blood vessels and organs need surgical repair. To fix or block a blood vessel, or to remove a ruptured organ, in most cases spleen, surgery is required.

Prevention

There are no established measures for the primary prevention of [disease name].

OR

There are no available vaccines against [disease name].

OR

Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

OR

[Vaccine name] vaccine is recommended for [patient population] to prevent [disease name]. Other primary prevention strategies include [strategy 1], [strategy 2], and [strategy 3].

There are no established measures for the secondary prevention of [disease name].

OR

Effective measures for the secondary prevention of [disease name] include [strategy 1], [strategy 2], and [strategy 3].