Introduction
Hemoperitoneum refers to the pathological accumulation of blood within the peritoneal cavity. It represents a surgical and medical emergency because ongoing intra-abdominal bleeding can rapidly progress to hypovolemic shock and death if not promptly diagnosed and managed. This condition can occur secondary to trauma, ruptured intra-abdominal structures, gynecological emergencies, vascular lesions, or iatrogenic causes. The clinical spectrum of hemoperitoneum ranges from vague abdominal pain to severe hemodynamic instability, necessitating rapid recognition and appropriate intervention.
This review explores the causes, pathophysiology, clinical features, diagnostic modalities, and management strategies for hemoperitoneum while highlighting key preventive measures and outcomes.
Etiology
The causes of hemoperitoneum are broadly divided into traumatic and non-traumatic origins.
1. Traumatic Causes
- Blunt trauma: Common in road traffic accidents or falls, leading to splenic rupture, hepatic lacerations, or mesenteric tears.
- Penetrating trauma: Stab wounds, gunshot injuries, or sharp-object assaults can directly damage intra-abdominal organs or blood vessels.
- Iatrogenic injuries: Accidental damage during abdominal or laparoscopic surgery, paracentesis, or organ biopsy.
2. Non-traumatic Causes
- Gynecological causes: Ruptured ectopic pregnancy, hemorrhagic ovarian cyst, or endometriotic cyst rupture.
- Vascular causes: Ruptured abdominal aortic aneurysm or splenic artery aneurysm.
- Neoplastic causes: Spontaneous rupture of hepatocellular carcinoma, hepatic hemangioma, or gastrointestinal stromal tumors.
- Hematological disorders: Coagulopathies, anticoagulant overdose, or platelet dysfunction leading to spontaneous bleeding.
- Spontaneous causes: Rarely, hemoperitoneum may occur without identifiable trauma or disease, often in patients with vascular fragility.
Pathophysiology
The peritoneal cavity has the capacity to accommodate significant volumes of blood before overt symptoms occur. Blood accumulation causes irritation of the peritoneum, leading to pain and guarding. Continuous bleeding reduces intravascular volume, decreasing venous return and cardiac output, ultimately leading to hypovolemic shock. The clinical severity depends on the rate of bleeding and the total blood volume lost.
Clinical Features
The clinical presentation varies with the etiology and extent of bleeding.
Symptoms
- Acute abdominal pain, generalized or localized, often radiating to the shoulder (Kehr’s sign) due to diaphragmatic irritation.
- Nausea, vomiting, and dizziness in moderate cases.
- Syncope, restlessness, and altered consciousness in severe blood loss.
- Amenorrhea or missed periods in women with ruptured ectopic pregnancy.
Signs
- Pallor, tachycardia, hypotension — features of hypovolemia and shock.
- Abdominal distension and tenderness due to blood accumulation.
- Rebound tenderness and guarding on palpation.
- Reduced bowel sounds, indicating paralytic ileus.
- Signs of anemia if bleeding is subacute or chronic.
Diagnosis
Early diagnosis is crucial for improving survival. A combination of clinical evaluation, laboratory workup, and imaging is usually required.
Clinical Assessment
- Detailed history of trauma, gynecological problems, or anticoagulant therapy.
- Focus on hemodynamic stability and abdominal signs.
Laboratory Investigations
- Complete blood count (CBC): Hemoglobin and hematocrit levels may fall.
- Coagulation profile: To identify bleeding diathesis.
- β-hCG test: Essential for ruling out ectopic pregnancy in women of reproductive age.
- Cross-matching: Preparing for possible blood transfusion.
Imaging Modalities
- Focused Assessment with Sonography for Trauma (FAST): Bedside ultrasound to detect free intraperitoneal fluid in emergency settings.
- Computed Tomography (CT) scan: Gold standard in stable patients; identifies source, extent, and site of bleeding.
- Magnetic Resonance Imaging (MRI): Rarely used, but may aid in non-traumatic causes.
- Diagnostic peritoneal aspiration or lavage: Historically important, now less commonly used.
Management
The management of hemoperitoneum depends on the cause, severity, and hemodynamic status.
Initial Resuscitation
- Airway, breathing, circulation (ABC) stabilization.
- Intravenous access and fluid resuscitation with crystalloids.
- Blood transfusion as required.
- Monitoring: Vital signs, urine output, and central venous pressure.
Definitive Management
- Surgical approaches:
- Laparotomy for unstable patients with ongoing bleeding.
- Splenectomy or splenorrhaphy for splenic rupture.
- Hepatic repair, resection, or packing for liver lacerations.
- Salpingectomy or salpingostomy for ruptured ectopic pregnancy.
- Minimally invasive approaches:
- Laparoscopy for diagnosis and treatment in stable patients.
- Angiographic embolization to control bleeding from arterial sources.
- Conservative management:
- Suitable in stable patients with minor bleeding (e.g., small liver lacerations or ovarian cyst rupture).
- Requires close monitoring, repeated imaging, and supportive care.
Supportive Measures
- Correction of coagulopathy using vitamin K, plasma, or prothrombin complex concentrate.
- Prophylactic antibiotics in surgical patients.
- Pain management and supportive monitoring.
Prognosis
The prognosis depends on the etiology, volume of blood lost, and promptness of treatment. Rapidly fatal causes include ruptured ectopic pregnancy and splenic rupture if untreated. Advancements in imaging and minimally invasive therapies have improved survival. However, mortality remains significant in delayed or misdiagnosed cases.
Prevention
- Road safety measures to minimize traumatic cases.
- Regular antenatal care for early detection of ectopic pregnancy.
- Screening of aneurysms in high-risk populations.
- Monitoring anticoagulant therapy to prevent spontaneous bleeding.
- Safe surgical techniques to avoid iatrogenic injuries.
Conclusion
Hemoperitoneum is a life-threatening condition that requires a high index of suspicion, especially in trauma and gynecological emergencies. Early diagnosis using ultrasound and CT, prompt resuscitation, and appropriate surgical or minimally invasive intervention are essential for improving outcomes. Preventive strategies such as antenatal monitoring, aneurysm screening, and careful surgical practice also play a key role. With modern diagnostic and therapeutic advancements, the prognosis of hemoperitoneum has significantly improved, though it continues to pose serious risks in undiagnosed or untreated cases.
References
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- Katz, D. S., & Jeffrey, R. B. (2019). Hemoperitoneum: A review of causes with an emphasis on cross-sectional imaging findings. Emergency Radiology, 26(5), 527–536. https://doi.org/10.1007/s10140-019-01690-0
- McKenney, M. G., & McKenney, K. L. (2020). Focused assessment with sonography for trauma (FAST): Clinical applications. Journal of Trauma and Acute Care Surgery, 88(1), 154–161.
- O’Connor, O. J., & Maher, M. M. (2018). Imaging of abdominal trauma. Radiology Clinics of North America, 56(4), 741–757. https://doi.org/10.1016/j.rcl.2018.03.008
- Tulandi, T., & Al-Fozan, H. (2022). Ruptured ectopic pregnancy. New England Journal of Medicine, 387(3), 278–286. https://doi.org/10.1056/NEJMra2200945
- Zago, T., Costa, G., & Di Saverio, S. (2018). Current trends in the management of hemoperitoneum: From open surgery to nonoperative and minimally invasive approaches. International Journal of Surgery, 54, 120–125. https://doi.org/10.1016/j.ijsu.2018.04.003
