Hemoperitoneum: Difference between revisions

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'''''Synonyms and Keywords: peritonel hemorrhage, Hemorrhage into peritoneal cavity, Intraperitoneal hemorrhage, Intraabdominal hemorrhage, abdominal apoplexy, blood in the belly.'''''
'''''Synonyms and Keywords: peritonel hemorrhage, Hemorrhage into peritoneal cavity, Intraperitoneal hemorrhage, Intraabdominal hemorrhage, abdominal apoplexy, blood in the belly.'''''
==Overview==
==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 nephropathy|thin membrane]] surrounding the [[viscera]] or [[organs]] in the [[abdomen]] in a bag like manner. The [[Space-filling model|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 theory|detection]] and rapid [[treatment]] remain [[Critical Care|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 certificate|death]].  
[[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 nephropathy|thin membrane]] surrounding the [[viscera]] or [[organs]] in the [[abdomen]] in a bag like manner. The [[Space-filling model|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 theory|detection]] and rapid [[treatment]] remain [[Critical Care|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 certificate|death]].
 
==Historical Perspective==
 
*In 1909, Barber first described hemoperitoneum and coined the term "abdominal apoplexy".<ref name="urlIdiopathic spontaneous haemoperitoneum. | Postgraduate Medical Journal">{{cite web |url=http://dx.doi.org/10.1136/pgmj.64.750.322 |title=Idiopathic spontaneous haemoperitoneum. &#124; Postgraduate Medical Journal |format= |work= |accessdate=}}</ref><ref name="urlIdiopathic Spontaneous Haemoperitoneum | Swiss Surgery">{{cite web |url=https://doi.org/10.1024/1023-9332.9.4.184 |title=Idiopathic Spontaneous Haemoperitoneum &#124; Swiss Surgery |format= |work= |accessdate=}}</ref>
*Earlier such cases were divided according to age into differing causes. Patients younger than 45 years old are thought to have congenital aneurysms of the vertebral arteries, but those older than 45 years old are thought to have less well-defined etiology (but causes perhaps related to hypertension and atherosclerosis).
*In 1987, as per Sanderson's study, only 51 occurrences of spontaneous peritoneal hemorrhage had been documented, with 38% of the cases having no identified bleeding site.
*The male-to-female ratio was 3:2, with the majority of cases affecting those between the ages of 55 and 64.
*The typical presentation was with nonspecific abdominal symptoms progressing to an acute abdomen, although cases have also been recorded as presenting as cardiovascular collapse.
 


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


*Trauma to the abdomen caused by blunt force (such as the bat hitting or during the fights hitting fist in the stomach)
*The abdomen has been pierced by a piercing trauma.
*Organ injuries, such as those to the spleen, liver, or pancreatic


A normal blood artery is adjacent to an inflammatory condition or tumor, it might deteriorate or produce a pseudoaneurysm, resulting in hemoperitoneum. Rupture pseudoaneurysm is more common in pancreatitis and Intraabdominal varices caused by liver cirrhosis and portal hypertension are the most common cause of venous rupture.


 
The most common of them is warfarin anticoagulation, while hematoma of the psoas or rectus muscles is the most common complication of warfarin usage.
 
<br />
 
==Causes==
==Causes==
Injury to intraabdominal organ or vessel with any of the underlying conditions:<ref name="pmid16129236">{{cite journal |vauthors=Lucey BC, Varghese JC, Soto JA |title=Spontaneous hemoperitoneum: causes and significance |journal=Curr Probl Diagn Radiol |volume=34 |issue=5 |pages=182–95 |date=2005 |pmid=16129236 |doi=10.1067/j.cpradiol.2005.06.001 |url=}}</ref><ref name="pmid12723734">{{cite journal |vauthors=Paulvannan S, Pye JK |title=Spontaneous rupture of a normal spleen |journal=Int J Clin Pract |volume=57 |issue=3 |pages=245–6 |date=April 2003 |pmid=12723734 |doi= |url=}}</ref><ref name="pmid2824302">{{cite journal |vauthors=McInerney PD, van Dessel MG, Berstock DA |title=Spontaneous haemoperitoneum from rupture of a primary hepatic adenoma in an adult man |journal=Gut |volume=28 |issue=9 |pages=1170–2 |date=September 1987 |pmid=2824302 |pmc=1433237 |doi=10.1136/gut.28.9.1170 |url=}}</ref><ref name="pmid2843591">{{cite journal |vauthors=Clarkston W, Inciardi M, Kirkpatrick S, McEwen G, Ediger S, Schubert T |title=Acute hemoperitoneum from rupture of a hepatocellular carcinoma |journal=J Clin Gastroenterol |volume=10 |issue=2 |pages=221–5 |date=April 1988 |pmid=2843591 |doi=10.1097/00004836-198804000-00025 |url=}}</ref>
Injury to intraabdominal organ or vessel with any of the underlying conditions: <ref name="pmid2781000">{{cite journal |vauthors=Rizzo MJ, Federle MP, Griffiths BG |title=Bowel and mesenteric injury following blunt abdominal trauma: evaluation with CT |journal=Radiology |volume=173 |issue=1 |pages=143–8 |date=October 1989 |pmid=2781000 |doi=10.1148/radiology.173.1.2781000 |url=}}</ref><ref name="pmid4082612">{{cite journal |vauthors=Donohue JH, Crass RA, Trunkey DD |title=The management of duodenal and other small intestinal trauma |journal=World J Surg |volume=9 |issue=6 |pages=904–13 |date=December 1985 |pmid=4082612 |doi=10.1007/BF01655395 |url=}}</ref><ref name="pmid12535">{{cite journal |vauthors=McCort JJ |title=Intraperitoneal and retroperitoneal hemorrhage |journal=Radiol Clin North Am |volume=14 |issue=3 |pages=391–405 |date=December 1976 |pmid=12535 |doi= |url=}}</ref><ref name="urlAnticoagulants and Abdominal Pain: The Role of Computed Tomography | JAMA | JAMA Network">{{cite web |url=https://jamanetwork.com/journals/jama/article-abstract/394803 |title=Anticoagulants and Abdominal Pain: The Role of Computed Tomography &#124; JAMA &#124; JAMA Network |format= |work= |accessdate=}}</ref><ref name="pmid1317090">{{cite journal |vauthors=Kanematsu M, Imaeda T, Yamawaki Y, Seki M, Goto H, Sone Y, Iinuma G, Mochizuki R, Doi H |title=Rupture of hepatocellular carcinoma: predictive value of CT findings |journal=AJR Am J Roentgenol |volume=158 |issue=6 |pages=1247–50 |date=June 1992 |pmid=1317090 |doi=10.2214/ajr.158.6.1317090 |url=}}</ref><ref name="pmid12741455">{{cite journal |vauthors=Molina E, Hernandez A |title=Clinical manifestations of primary hepatic angiosarcoma |journal=Dig Dis Sci |volume=48 |issue=4 |pages=677–82 |date=April 2003 |pmid=12741455 |doi=10.1023/a:1022868221670 |url=}}</ref><ref name="pmid10227900">{{cite journal |vauthors=Hertzberg BS, Kliewer MA, Paulson EK |title=Ovarian cyst rupture causing hemoperitoneum: imaging features and the potential for misdiagnosis |journal=Abdom Imaging |volume=24 |issue=3 |pages=304–8 |date=1999 |pmid=10227900 |doi=10.1007/s002619900502 |url=}}</ref>


*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]].
*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]].
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*[[Acute]] [[hemorrhagic]] [[pancreatitis]]
*[[Acute]] [[hemorrhagic]] [[pancreatitis]]
*[[Hepatic]] [[hematoma]] in [[Syndromic HH|syndromic]] [[hemolysis]] with [[Elevated LFTs|elevated]] [[liver]] [[enzymes]] and [[platelet|low platelet]] count ([[HELLP syndrome|HELLP]] [[syndrome]])
*[[Hepatic]] [[hematoma]] in [[Syndromic HH|syndromic]] [[hemolysis]] with [[Elevated LFTs|elevated]] [[liver]] [[enzymes]] and [[platelet|low platelet]] count ([[HELLP syndrome|HELLP]] [[syndrome]])


*
*
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==Differential diagnosis of hemoperitoneum==
==Differential diagnosis of hemoperitoneum==
The common conditions which present similar to hemoperitoneum are:<ref name="urlRedirecting">{{cite web |url=https://doi.org/10.1016/j.ijscr.2016.07.040 |title=Redirecting |format= |work= |accessdate=}}</ref>
<br />
{| class="wikitable"
{| class="wikitable"
|+
|+
<ref name="pmid20414383">{{cite journal |vauthors=Freeman BB, Critchlow JF, Cohen S, Edlow JA |title=Spontaneous intraperitoneal hemorrhage as the initial presentation of a gastrointestinal stromal tumor: a case report |journal=Int J Emerg Med |volume=3 |issue=1 |pages=53–6 |date=February 2010 |pmid=20414383 |pmc=2850982 |doi=10.1007/s12245-009-0141-8 |url=}}</ref><ref name="pmid16927155">{{cite journal |vauthors=Burt BM, Tavakkolizadeh A, Ferzoco SJ |title=Meckel's hemoperitoneum: a rare case of Meckel's diverticulitis causing intraperitoneal hemorrhage |journal=Dig Dis Sci |volume=51 |issue=9 |pages=1546–8 |date=September 2006 |pmid=16927155 |doi=10.1007/s10620-005-9004-1 |url=}}</ref><ref name="urlRedirecting">{{cite web |url=https://doi.org/10.1016/j.jemermed.2015.02.050 |title=Redirecting |format= |work= |accessdate=}}</ref>
!Hepatic
!Hepatic
!Splenic
!Splenic
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|
|
|
|
|}
|}<br />
 
==Epidemiology and Demographics==
==Epidemiology and Demographics==


Hemoperitonium also known as Bloody peritoneal dialysate is common in peritoneal dialysis patients, ranging from 6% overall to 57 percent in premenopausal women. Peritoneal dialysate usually relates to the peritoneal dialysis procedure or relates to underlying kidney disease such as PKD or acquired cystic diseases or the multiple factors unrelated to kidney diseaseLike catheter implantation related, gynecological related (retrograde menstruation, endometriosis, after ovarian cyst), catheter related trauma (exercise related) or coagulopathy related. Peritoneal dialysis exchanges helps him assessing the peritoneal cavity and early detection of blood in the peritoneum that could be related to benign causes of bleeding or it can be simply a silent bleed in peritoneal cavity.


In a study done with a goal to correlate hemoperitoneum to a variety of causes. A total of 424 individuals were enrolled in the clinical trial, and only 6% of them suffered one or more episodes of bloody peritoneal dialysis (hemoperitoneum). Patients were split into many categories in the setting based on the severity and cause of bleeding:


''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.''
*In most of the patient's or in most of the groups, the bleeding was mild and asymptomatic with pink to reddish discoloration of peritoneal fluid.
 
*Minor bleeding was found in only 1 patient with underlying pancreatitis or sclerosing peritonitis on the other hand svere bleeding that required intervention was observed in 6-8 patient's having underlying ovarian cyst rupture
''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:''
*Only a single increase was observed related to peritoneal bleeding following transplant nephrectomy, catheter repositioning, enhanced physical activity and or neural hematoma.
 
''●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.''
Over 50% of menstrual women on peritoneal dialysis develop benign hemoperitoneum, which is most likely caused by ovulation, endometriosis or retrograde menstruation.


''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.''
It's worth noting that a very small amount of blood (less than 1 mL) is adequate to tint 2 liters of peritoneal dialysate.


''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.''
In 5% of cases, bleeding into the peritoneal cavity occurs after the peritoneal catheter is inserted
 
''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==
==Risk Factors==
A person having [[Conditions|underlying conditions]] is more prone to spontaneous [[hemoperitoneum]]
A person having [[Conditions|underlying conditions]] is more prone to spontaneous [[hemoperitoneum]]<ref name="urlSpontaneous Hemoperitoneum in Endometriosis: A Case Report | Journal of Gynecologic Surgery">{{cite web |url=https://doi.org/10.1089/gyn.2020.0045 |title=Spontaneous Hemoperitoneum in Endometriosis: A Case Report &#124; Journal of Gynecologic Surgery |format= |work= |accessdate=}}</ref>


*Highly [[vascular]] [[Intra-abdominal abscess|intra-abdominal]] [[tumor]]<nowiki/>s
*Highly [[vascular]] [[Intra-abdominal abscess|intra-abdominal]] [[tumor]]<nowiki/>s
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*[[Iatrogenic]] eg. [[colonoscopy]]
*[[Iatrogenic]] eg. [[colonoscopy]]
*[[Meckel's diverticulum]]
*[[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==
==Natural History, Complications, and Prognosis==
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[[Prognosis]] varies depending on the underlying [[etiology]] and associated [[injuries]].
[[Prognosis]] varies depending on the underlying [[etiology]] and associated [[injuries]].
==Diagnosis==


The various [[Methods in Organic Synthesis|methods]] of diagnosing [[hemoperitoneum]] are:<ref name="urlHemoperitoneum studied by computed tomography. | Radiology">{{cite web |url=https://doi.org/10.1148/radiology.148.1.6856833 |title=Hemoperitoneum studied by computed tomography. &#124; Radiology |format= |work= |accessdate=}}</ref><ref name="urlEvaluation of abdominal trauma by computed tomography. | Radiology">{{cite web |url=https://doi.org/10.1148/radiology.138.3.6450962 |title=Evaluation of abdominal trauma by computed tomography. &#124; Radiology |format= |work= |accessdate=}}</ref><ref name="urlCT of blunt abdominal trauma in adults. | Radiology">{{cite web |url=https://doi.org/10.1148/radiology.205.2.9356606 |title=CT of blunt abdominal trauma in adults. &#124; Radiology |format= |work= |accessdate=}}</ref><ref name="urlBlunt upper abdominal trauma: evaluation by CT. : American Journal of Roentgenology : Vol. 158, No. 3 (AJR)">{{cite web |url=https://www.ajronline.org/doi/abs/10.2214/ajr.158.3.1738983 |title=Blunt upper abdominal trauma: evaluation by CT. : American Journal of Roentgenology : Vol. 158, No. 3 (AJR) |format= |work= |accessdate=}}</ref><ref name="pmid23543985">{{cite journal |vauthors=Katz MJ, Peters MN, Wysocki JD, Chakraborti C |title=Diagnosis and management of delayed hemoperitoneum following therapeutic paracentesis |journal=Proc (Bayl Univ Med Cent) |volume=26 |issue=2 |pages=185–6 |date=April 2013 |pmid=23543985 |pmc=3603744 |doi=10.1080/08998280.2013.11928956 |url=}}</ref><ref name="pmid14661665">{{cite journal |vauthors=Mortele KJ, Cantisani V, Brown DL, Ros PR |title=Spontaneous intraperitoneal hemorrhage: imaging features |journal=Radiol Clin North Am |volume=41 |issue=6 |pages=1183–201 |date=November 2003 |pmid=14661665 |doi=10.1016/s0033-8389(03)00118-0 |url=}}</ref><ref name="pmid10217217">{{cite journal |vauthors=Shackford SR, Rogers FB, Osler TM, Trabulsy ME, Clauss DW, Vane DW |title=Focused abdominal sonogram for trauma: the learning curve of nonradiologist clinicians in detecting hemoperitoneum |journal=J Trauma |volume=46 |issue=4 |pages=553–62; discussion 562–4 |date=April 1999 |pmid=10217217 |doi=10.1097/00005373-199904000-00003 |url=}}</ref>


==Diagnosis==
*[[Ultrasound]]: An [[ultrasound]] is a process that uses [[sound waves]] to [[Creating pages|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]]).  FAST is used for the quick diagnosis of blood in the peritoneal cavity but does not tell anything about the source of bleeding
*[[CT Scan]]: The term [[CT scan]] (also known as [[CAT scan]]) refers to [[computerized axial tomography]] ([[CT scan]]). This [[Method of Factors|method]] creates [[cross-sectional]] [[x-rays]] of the [[Interior Health|interior]] of the [[body]] and can [[Aid to Families with Dependent Children|aid]] in the [[Detection theory|detection]] of [[blood]] or [[fluid]] in the [[peritoneal cavity]]. It is used in hemodynamically stable patients.  It is used for the determination of solid organ injury and to find the source of bleeding.
*[[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.


The various [[Methods in Organic Synthesis|methods]] of diagnosing [[hemoperitoneum]] are:
*[[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 surgery|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.


*[[Ultrasound]]: An [[ultrasound]] is a process that uses [[sound waves]] to [[Creating pages|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 of Factors|method]] creates [[cross-sectional]] [[x-rays]] of the [[Interior Health|interior]] of the [[body]] and can [[Aid to Families with Dependent Children|aid]] in the [[Detection theory|detection]] of [[blood]] or [[fluid]] in the [[peritoneal cavity]].
*[[Exploratory surgery|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.
*
*
*
*
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<br />
<br />
|+
|+
CT Scan findings in diagnosing Hemoperitoneum<ref name="urlBlood in the Belly: CT Findings of Hemoperitoneum | RadioGraphics">{{cite web |url=https://doi.org/10.1148/rg.271065042 |title=Blood in the Belly: CT Findings of Hemoperitoneum &#124; RadioGraphics |format= |work= |accessdate=}}</ref>
!'''Nontraumatic'''
!'''Nontraumatic'''
!
!
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*
*
*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===
===Signs and Symptoms===
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*[[Dizziness]] or [[confusion]]
*[[Dizziness]] or [[confusion]]


<br />
===Physical Examination===
===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].
On physical examination numerous signs ans symptoms can be appreciated:


OR
*Hypotension, tachycardia, shock


Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
*Abdominal pain or tenderness


OR
*Abdominal deformity, abrasion, contusion


The presence of [finding(s)] on physical examination is diagnostic of [disease name].
*Absent or decreased bowel sounds


OR
*Hemorrhagic pancreatitis


The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
 
Diagnostic signs
 
*Cullen's sign: periumbilical bruising
 
*Grey turner's sign: discoloration around the flanks
*Danforth sign: On inspiration there is shoulder pain
*Kehr's sign: left shoulder pain on supine or pressure applied to Left Upper Quadrant
*Prominent veins on the abdominal wall in portal hypertension<br />


===Laboratory Findings===
===Laboratory Findings===
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===Electrocardiogram===
===Electrocardiogram===
There are no ECG findings associated with [disease name].
An ECG may be helpful in the diagnosis of hemoperitoneum. If a patient presents with shock due to massive intra peritoneal bleeding then the EKG may show sinus tachycardia.


OR
<br />
 
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===
===X-ray===
There are no x-ray findings associated with [disease name].
If the hemoperitoneum is due to perforation of any hollow visceral organ, then it may show air under the diaphragm.
 
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===
<br />
 
*'''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].
 
<br />


==Treatment==
==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 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]].<ref name="pmid8392305">{{cite journal |vauthors=Di Martino G |title=[The emergency surgical treatment of hemoperitoneum due to the spontaneous rupture of a hepatocarcinoma in a cirrhotic liver] |language=Italian |journal=Ann Ital Chir |volume=64 |issue=1 |pages=83–5; discussion 86 |date=1993 |pmid=8392305 |doi= |url=}}</ref><ref name="urlSuccessful Conservative Management of Ruptured Ovarian Cysts with Hemoperitoneum in Healthy Women">{{cite web |url=+https://doi.org/10.1371/journal.pone.0091171 |title=Successful Conservative Management of Ruptured Ovarian Cysts with Hemoperitoneum in Healthy Women |format= |work= |accessdate=}}</ref>


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

Latest revision as of 20:36, 19 September 2021

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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.

Historical Perspective

  • In 1909, Barber first described hemoperitoneum and coined the term "abdominal apoplexy".[1][2]
  • Earlier such cases were divided according to age into differing causes. Patients younger than 45 years old are thought to have congenital aneurysms of the vertebral arteries, but those older than 45 years old are thought to have less well-defined etiology (but causes perhaps related to hypertension and atherosclerosis).
  • In 1987, as per Sanderson's study, only 51 occurrences of spontaneous peritoneal hemorrhage had been documented, with 38% of the cases having no identified bleeding site.
  • The male-to-female ratio was 3:2, with the majority of cases affecting those between the ages of 55 and 64.
  • The typical presentation was with nonspecific abdominal symptoms progressing to an acute abdomen, although cases have also been recorded as presenting as cardiovascular collapse.


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:

  • Trauma to the abdomen caused by blunt force (such as the bat hitting or during the fights hitting fist in the stomach)
  • The abdomen has been pierced by a piercing trauma.
  • Organ injuries, such as those to the spleen, liver, or pancreatic

A normal blood artery is adjacent to an inflammatory condition or tumor, it might deteriorate or produce a pseudoaneurysm, resulting in hemoperitoneum. Rupture pseudoaneurysm is more common in pancreatitis and Intraabdominal varices caused by liver cirrhosis and portal hypertension are the most common cause of venous rupture.

The most common of them is warfarin anticoagulation, while hematoma of the psoas or rectus muscles is the most common complication of warfarin usage.

Causes

Injury to intraabdominal organ or vessel with any of the underlying conditions: [3][4][5][6][7][8][9]

Differential diagnosis of hemoperitoneum

The common conditions which present similar to hemoperitoneum are:[10]

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

Hemoperitonium also known as Bloody peritoneal dialysate is common in peritoneal dialysis patients, ranging from 6% overall to 57 percent in premenopausal women. Peritoneal dialysate usually relates to the peritoneal dialysis procedure or relates to underlying kidney disease such as PKD or acquired cystic diseases or the multiple factors unrelated to kidney diseaseLike catheter implantation related, gynecological related (retrograde menstruation, endometriosis, after ovarian cyst), catheter related trauma (exercise related) or coagulopathy related. Peritoneal dialysis exchanges helps him assessing the peritoneal cavity and early detection of blood in the peritoneum that could be related to benign causes of bleeding or it can be simply a silent bleed in peritoneal cavity.

In a study done with a goal to correlate hemoperitoneum to a variety of causes. A total of 424 individuals were enrolled in the clinical trial, and only 6% of them suffered one or more episodes of bloody peritoneal dialysis (hemoperitoneum). Patients were split into many categories in the setting based on the severity and cause of bleeding:

  • In most of the patient's or in most of the groups, the bleeding was mild and asymptomatic with pink to reddish discoloration of peritoneal fluid.
  • Minor bleeding was found in only 1 patient with underlying pancreatitis or sclerosing peritonitis on the other hand svere bleeding that required intervention was observed in 6-8 patient's having underlying ovarian cyst rupture
  • Only a single increase was observed related to peritoneal bleeding following transplant nephrectomy, catheter repositioning, enhanced physical activity and or neural hematoma.

Over 50% of menstrual women on peritoneal dialysis develop benign hemoperitoneum, which is most likely caused by ovulation, endometriosis or retrograde menstruation.

It's worth noting that a very small amount of blood (less than 1 mL) is adequate to tint 2 liters of peritoneal dialysate.

In 5% of cases, bleeding into the peritoneal cavity occurs after the peritoneal catheter is inserted

Risk Factors

A person having underlying conditions is more prone to spontaneous hemoperitoneum[11]

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:[12][13][14][15][16][17][18]

  • 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.
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.



CT Scan findings in diagnosing Hemoperitoneum[19]
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).

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:


Physical Examination

On physical examination numerous signs ans symptoms can be appreciated:

  • Hypotension, tachycardia, shock
  • Abdominal pain or tenderness
  • Abdominal deformity, abrasion, contusion
  • Absent or decreased bowel sounds
  • Hemorrhagic pancreatitis


Diagnostic signs

  • Cullen's sign: periumbilical bruising
  • Grey turner's sign: discoloration around the flanks
  • Danforth sign: On inspiration there is shoulder pain
  • Kehr's sign: left shoulder pain on supine or pressure applied to Left Upper Quadrant
  • Prominent veins on the abdominal wall in portal hypertension

Laboratory Findings

Serum labs

Invasive studies:

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

Electrocardiogram

An ECG may be helpful in the diagnosis of hemoperitoneum. If a patient presents with shock due to massive intra peritoneal bleeding then the EKG may show sinus tachycardia.


X-ray

If the hemoperitoneum is due to perforation of any hollow visceral organ, then it may show air under the diaphragm.

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.[20][21]

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].

References

  1. ↑ "Idiopathic spontaneous haemoperitoneum. | Postgraduate Medical Journal".
  2. ↑ "Idiopathic Spontaneous Haemoperitoneum | Swiss Surgery".
  3. ↑ Rizzo MJ, Federle MP, Griffiths BG (October 1989). "Bowel and mesenteric injury following blunt abdominal trauma: evaluation with CT". Radiology. 173 (1): 143–8. doi:10.1148/radiology.173.1.2781000. PMID 2781000.
  4. ↑ Donohue JH, Crass RA, Trunkey DD (December 1985). "The management of duodenal and other small intestinal trauma". World J Surg. 9 (6): 904–13. doi:10.1007/BF01655395. PMID 4082612.
  5. ↑ McCort JJ (December 1976). "Intraperitoneal and retroperitoneal hemorrhage". Radiol Clin North Am. 14 (3): 391–405. PMID 12535.
  6. ↑ "Anticoagulants and Abdominal Pain: The Role of Computed Tomography | JAMA | JAMA Network".
  7. ↑ Kanematsu M, Imaeda T, Yamawaki Y, Seki M, Goto H, Sone Y, Iinuma G, Mochizuki R, Doi H (June 1992). "Rupture of hepatocellular carcinoma: predictive value of CT findings". AJR Am J Roentgenol. 158 (6): 1247–50. doi:10.2214/ajr.158.6.1317090. PMID 1317090.
  8. ↑ Molina E, Hernandez A (April 2003). "Clinical manifestations of primary hepatic angiosarcoma". Dig Dis Sci. 48 (4): 677–82. doi:10.1023/a:1022868221670. PMID 12741455.
  9. ↑ Hertzberg BS, Kliewer MA, Paulson EK (1999). "Ovarian cyst rupture causing hemoperitoneum: imaging features and the potential for misdiagnosis". Abdom Imaging. 24 (3): 304–8. doi:10.1007/s002619900502. PMID 10227900.
  10. ↑ "Redirecting".
  11. ↑ "Spontaneous Hemoperitoneum in Endometriosis: A Case Report | Journal of Gynecologic Surgery".
  12. ↑ "Hemoperitoneum studied by computed tomography. | Radiology".
  13. ↑ "Evaluation of abdominal trauma by computed tomography. | Radiology".
  14. ↑ "CT of blunt abdominal trauma in adults. | Radiology".
  15. ↑ "Blunt upper abdominal trauma: evaluation by CT. : American Journal of Roentgenology : Vol. 158, No. 3 (AJR)".
  16. ↑ Katz MJ, Peters MN, Wysocki JD, Chakraborti C (April 2013). "Diagnosis and management of delayed hemoperitoneum following therapeutic paracentesis". Proc (Bayl Univ Med Cent). 26 (2): 185–6. doi:10.1080/08998280.2013.11928956. PMC 3603744. PMID 23543985.
  17. ↑ Mortele KJ, Cantisani V, Brown DL, Ros PR (November 2003). "Spontaneous intraperitoneal hemorrhage: imaging features". Radiol Clin North Am. 41 (6): 1183–201. doi:10.1016/s0033-8389(03)00118-0. PMID 14661665.
  18. ↑ Shackford SR, Rogers FB, Osler TM, Trabulsy ME, Clauss DW, Vane DW (April 1999). "Focused abdominal sonogram for trauma: the learning curve of nonradiologist clinicians in detecting hemoperitoneum". J Trauma. 46 (4): 553–62, discussion 562–4. doi:10.1097/00005373-199904000-00003. PMID 10217217.
  19. ↑ "Blood in the Belly: CT Findings of Hemoperitoneum | RadioGraphics".
  20. ↑ Di Martino G (1993). "[The emergency surgical treatment of hemoperitoneum due to the spontaneous rupture of a hepatocarcinoma in a cirrhotic liver]". Ann Ital Chir (in Italian). 64 (1): 83–5, discussion 86. PMID 8392305.
  21. ↑ [+https://doi.org/10.1371/journal.pone.0091171 "Successful Conservative Management of Ruptured Ovarian Cysts with Hemoperitoneum in Healthy Women"] Check |url= value (help).

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