Hemoperitoneum is an intra–abdominal bleeding that leads to the outpouring of free blood into the abdominal cavity. It is clinically manifested by signs of hemorrhagic shock: fainting (or motor excitement), pallor of the skin and mucous membranes, dizziness, cold sweat, darkening of the eyes, tachycardia, arterial hypotension, as well as local symptoms – sharp abdominal pain. Diagnosis is based on anamnesis, clinical picture, hemoglobin and hematocrit studies, ultrasound and CT of the abdominal cavity, peritoneal lavage, diagnostic laparoscopy. Emergency laparotomy, revision of the abdominal cavity and stopping bleeding are indicated.
ICD 10
K66.1 Hemoperitoneum
Meaning
Hemoperitoneum (laparohemorrhagia, bleeding into the abdominal cavity, intraabdominal bleeding) is a common condition in abdominal surgery, gastroenterology, gynecology, traumatology, disaster medicine. With hemoperitoneum, there is an outpouring and accumulation of free fluid (blood) between the visceral and parietal leaves of the peritoneum. Suspicion of this pathology requires urgent hospitalization and provision of surgical aid. The death of patients with intraabdominal internal bleeding most often occurs from traumatic shock and acute blood loss.
Causes of hemoperitoneum
Hemoperitoneum can complicate a wide range of conditions: closed abdominal injuries, thoracoabdominal injuries, pathological processes in the abdominal cavity and retroperitoneal space, surgical interventions, gynecological diseases, etc. Hemoperitoneum develops due to a violation of the integrity of the vessels of the abdominal cavity and may have a traumatic and non-traumatic origin.
Traumatic hemoperitoneum occurs with blunt blunt abdominal injuries (blows, falls, accidents, compression), penetrating (gunshot, knife) abdominal wounds, intraoperative trauma. At the same time, parenchymal organs are most often damaged – the liver, spleen, pancreas, as well as vessels passing through the ligaments, folds of the peritoneum, mesentery of the intestines, omentum. Damage to internal organs by bone fragments can be observed with a fracture of the lower ribs.
Non-traumatic hemoperitoneum occurs in ectopic pregnancy, ovarian apoplexy, rupture of an aortic aneurysm, liver hemangioma, diseases leading to a decrease in blood clotting (mechanical jaundice, malaria, blood diseases, hemorrhagic diathesis), long-term therapy with fibrinolytics and anticoagulants.
In surgical practice, pathology can develop as a result of organ damage during invasive diagnostics (angiography, puncture biopsy), eruption or slipping of surgical ligatures after gastric resection, appendectomy, herniation, hemicolectomy, cholecystectomy, supravaginal amputation of the uterus, nephrectomy, splenectomy, liver resection, etc.
Symptoms of hemoperitoneum
Clinical manifestations are determined by the nature of the injury, the intensity of intra-abdominal bleeding and the amount of blood loss. A sudden hemoperitoneum is accompanied by signs of hemorrhagic shock and local symptoms. Acute blood loss is manifested by dizziness, darkening of the eyes, pallor of the skin and visible mucous membranes, cold sweat, thirst, adynamia, fainting, sometimes – motor excitement. Tachycardia is objectively determined (120-140 beats. in min.) with a pulse of weak filling, arterial hypotension.
Acute sharp pain in the abdominal cavity can be local or diffuse, diffuse in nature; when irritated by blood, the diaphragmatic peritoneum radiates into the upper arm and shoulder blade. An increasing or massive hemoperitoneum may be accompanied by an increase in the volume of the abdomen; sometimes (usually in children) – cyanosis of the navel, through which blood shines through. There is a so-called “roly-poly” symptom when the patient tends to take a sitting position that reduces abdominal pain.
Diagnostics
When examining the patient, the abdominal surgeon pays attention to signs of injury – abrasions, hematomas in the anterior abdominal wall. During superficial palpation, a soft, moderately painful abdomen is determined, which is limited in the act of breathing, a positive peritoneal symptom of Shchetkin-Blumberg, stretching of the anterior abdominal wall and rigidity of its muscles.Deep palpation allows you to identify sharp soreness in the area of injury or damaged organ. With percussion of the abdomen, there is a dulling of the percussion sound, soreness, with auscultation – a weakening or absence of intestinal noises.
Finger rectal examination allows you to determine the overhang of the anterior wall of the rectum. Gynecological examination data are characterized by the identification of flattening of the vaginal arches, their soreness, overhanging of the posterior arch. In ectopic pregnancy, puncture of the posterior vaginal arch (culdocentesis) becomes of great diagnostic importance. Laboratory blood tests reveal signs of bleeding – a decrease in the level of hematocrit, an increasing decrease in the number of red blood cells and hemoglobin.
With the help of ultrasound of the pelvic organs, ultrasound of the abdominal cavity and retroperitoneal space, the presence of anechoic fluid or organized hematomas in the abdominal cavity is diagnosed. An overview radiography of the abdominal cavity also allows you to identify the presence of free fluid, to carry out differential diagnosis of hemoperitoneum with hematoma of the anterior abdominal wall, retroperitoneal hematoma and perforated stomach ulcer. The final diagnosis is made by puncture of the abdominal cavity and the introduction of a “fumbling” catheter or laparoscopy.
Hemoperitoneum treatment
If this pathology is suspected, an emergency hospitalization of the patient to the abdominal surgery department is indicated. At the stage of pre-medical care, the introduction of painkillers, including narcotic drugs, is strictly prohibited. In case of massive bleeding, intensive therapy is carried out to combat hypovolemic shock, including the introduction of analeptics, transfusion of solutions and blood substitutes, resuscitation measures. With recent intra-abdominal bleeding, reinfusion of blood that has poured into the abdominal cavity of blood can be performed.
In a surgical hospital, patients with hemoperitoneum are shown laparotomy to identify the source of bleeding and stop it. In case of traumatic damage to internal organs, liver resection, splenectomy, vascular ligation, and other interventions can be performed. In case of ectopic pregnancy or ovarian apoplexy, tubectomy, removal of appendages is performed. In the postoperative period, hemostatic, antibacterial therapy is carried out; blood parameters, blood pressure, pulse are monitored; dynamic ultrasound, CT of the abdominal cavity and retroperitoneal space is performed.
Prognosis and prevention
The prognosis for hemoperitoneum is always serious. Mortality rates vary depending on the age of patients, the cause of bleeding, the presence of concomitant somatic pathologies, the volume of blood loss, and the timeliness of delivery to a medical institution. The greatest number of deaths is observed in ruptured aortic aneurysms in elderly patients (almost 30%). Prevention includes injury prevention, compliance with the technique of operations and manipulations, timely detection and treatment of diseases that can cause hemoperitoneum.
