VA ICU Report Pearls: Spontaneous Hemoperitoneum!

This morning Will, Emma, and Dr. Monto taught us to divide up the causes of hemoperitoneum into traumatic and spontaneous then organ-related and vascular causes, keeping in mind that spontaneously bleeding HCC (sometimes assoc w minimal trauma) and ruptured intra-abdominal varices can be causes of spontaneous hemoperitoneum in patients with cirrhosis.

Delving a little deeper…

Divide up causes into:

Hepatic Causes – still rare, but the most often reported etiology

-Malignant Masses:

Hepatocellular Carcinoma is the most common (in one case series of 70 cases of spont hepatic rupture HCC accounted for 60/70 cases. Most frequently reported in pts w cirrhosis. Proximity of masses to the surface appears to predispose.

— Rupture of a primary angiosarcoma has also been reported to be a cause of hemoperitoneum.

Metastatic disease is an unusual cause.

-Benign Masses:

Hepatic adenoma (most common – more frequent in females) can be a cause. There is increased risk with OCPs and pregnancy.

Giant hemangiomata and focal nodular hyperplasia (both extremely rare).

Other Hepatic Causes:

Spontaneous Hepatic Rupture – associated with HELLP (most commonly causes subcapsular hematoma).

Infiltrative Disease – there are reports of spontaneous rupture in amyloidosis.

Splenic Causes –When it does occur it can have to do with infection including CMV, malaria, and EBV as well as Bartonella henselae. Only very associated with parenchymal masses. Can also occur with infiltrative disease such as amyloidosis and Gaucher’s disease. Hamartoma can cause it and it has been reported with lymphoma, leukemia, and angiosarcoma.

Gynecologic Causes – Most commonly assoc with rupture of an ovarian cyst but always consider ectopic pregnancy (w/ or without tubal rupture), hemorrhagic corpus luteum cyst torsion, and leiomyosarcoma.

Vascular Causes – Can be divided up into arterial and venous but usually happens because of abnormal vessels as in aneurysm, pseudo-aneurysm, and mycotic aneurysm (often assoc with the splenic or renal arteries but can be anywhere). In terms of venous causes the most common cause would be rupture of abdominal varices in the setting of portal htn. Vascular bleeding can also happen because of erosion from an adjacent tumor or endometrioma.

Altered Coagulation Status – spontaneous bleeding either from a blood dyscrasia or from anticoagulation therapy.

From Lucey, Varghese, Soto. Spontaneous hemoperitoneum: causes and significance. Curr Probl Diagn Radiol. 2005 Sep-Oct;34(5):182-95.

Have a great weekend and see you at Hardly Strictly Bluegrass!!

Manny and Dan

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