Clinical History
A HIV-seropositive woman presented to emergency department complaining of acute epigastric pain for the past 24 hours. Physical findings revealed hypotension and peritonitis, without signs of gastrointestinal bleeding at digital rectal examination. Using endovaginal ultrasound, the consulting gynaecologist excluded genital emergencies, particularly bleeding luteal cyst.
Laboratory assays revealed blood loss (haemoglobin 9.2g/dL).
Imaging Findings
The patient denied trauma and recent medical procedures. Her past medical history included laparoscopic biopsy of necrotic mesenterial and retroperitoneal lymphadenopathies (Fig. 1a, b) and subsequent long-term antibiotic treatment for atypical (non-tuberculous) mycobacteriosis seven years earlier. CT follow-up (Fig. 1c, d) demonstrated complete regression of abdominal changes over the following years.
Currently, bedside ultrasound (Fig. 2) revealed moderate peritoneal effusion and an infrahepatic echogenic mass suspicious for haematoma. Therefore, multidetector CT (Fig. 3) was immediately performed and confirmed multicompartmental peritoneal effusion with higher-than-water attenuation consistent with haemoperitoneum, communicating with a large hyperattenuating (60 Hounsfield Units) infrahepatic haematoma without contrast extravasation indicating active haemorrhage. No abnormalities were seen in the parenchymal organs and abdominal vessels.
Laparoscopic findings confirmed free haemoperitoneum without active bleeding, associated with transverse mesocolon haematoma from lacerated omental adhesions. The surgical procedure included evacuation of haematoma, peritoneal drainage and lavage, multiple omental haemostasis and adhesiolysis. The subsequent postoperative course was uneventful.
Discussion
Intraperitoneal haemorrhage without history of recent medical procedures, blunt or penetrating trauma represents an uncommon, life-threatening emergency. Clinical presentation is nonspecific with more or less severe abdominal pain, tenderness and distension, decreased haematocrit and variable haemodynamic impairment. Due to widespread use of multidetector CT to investigate patients with acute abdominal complaints, haemoperitoneum is most usually diagnosed at imaging [1, 2].
Although ultrasound may detect haemoperitoneum, CT represents the mainstay technique to assess presence, topography, entity and underlying cause of haemorrhage. The CT appearance of blood varies over time: fresh blood measures 30-40 Hounsfield Units (HU) attenuation due to its high protein content, becomes more hyperdense (HU >60) after a few hours due to clotting. The highest attenuation (“sentinel clot”) nearest to the bleeding site often allows localization of the origin of the haemorrhage. Haemoperitoneum appears as peritoneal effusion with higher-than-water (30…70 HU) attenuation, sometimes with a fluid-fluid level. Furthermore, CT allows identification of active bleeding as a hyperdense ‘‘blush’’ corresponding to extravascular pooling of contrast medium, with similar attenuation to the adjacent enhanced vessels and greater than that of the surrounding organ. This finding is associated with increased morbidity and mortality and dictates the need for emergency surgical or endovascular treatment [1, 2].
The commonest causes of non-traumatic, non-iatrogenic haemoperitoneum are gynaecologic conditions including ovarian cyst rupture, ectopic pregnancy, and haemolysis with elevated liver enzymes and low platelet count (HELLP syndrome) in descending order of frequency. Alternatively, bleeding may be secondary to hypervascular liver tumours (hepatocellular carcinoma or adenoma), rupturing splenomegaly in haematologic malignancies or infections, therapeutic anticoagulation or blood dyscrasias, aneurysms or pseudoaneurysms of the splanchnic arteries, vessel erosion by tumours or acute pancreatitis, or ruptured varices in portal hypertension [1-3].
When interpreting emergency CT, thorough knowledge of possible causes of spontaneous haemoperitoneum is necessary, along with careful search of active bleeding, vascular abnormalities and previously unknown tumours. In exceptional cases haemoperitoneum may result from ruptured intraperitoneal adhesions from previous surgery or peritonitis, sometimes associated with trivial trauma such as during running, sexual intercourse or patient mobilization under general anaesthesia [4-6]. As well as in the trauma setting, CT is the preferred imaging modality to depict mesenterial and omental injuries in comparison with ultrasound and peritoneal lavage. As this case exemplifies, CT and intraoperative findings include predominant clot localization within the greater omentum. Prompt surgical treatment of both haemorrhage and omental adhesions is usually necessary [4-6].
Differential Diagnosis List
Spontaneous haemoperitoneum and omental haematoma from bleeding lacerated adhesions
Spontaneous (non-traumatic) splenic rupture
Bleeding liver tumour
Splanchnic artery (pseudo)aneurysm
Ruptured varices
Bleeding corpus luteum cyst
Ruptured ectopic pregnancy
HELLP syndrome
Final Diagnosis
Spontaneous haemoperitoneum and omental haematoma from bleeding lacerated adhesions
