Spontaneous Haemoperitoneum

Spontaneous haemoperitoneum is bleeding into the peritoneal cavity without trauma or recent surgery, producing abdominal pain, shock and a falling haemoglobin. It is a surgical and radiological emergency, and the cause is often found only on imaging or at operation.

Epidemiology. It is rare overall. The main causes are gynaecological (ruptured ectopic pregnancy, haemorrhagic ovarian cyst), hepatic (ruptured hepatocellular carcinoma or adenoma, hepatic haemangioma, HELLP syndrome), splenic (rupture in infection, haematological malignancy, anticoagulation), and vascular (visceral artery aneurysm).

Causes and associations.

• Gynaecological: ectopic pregnancy, ruptured corpus luteum or ovarian cyst (particularly with anticoagulation), endometriosis, ovarian hyperstimulation.
• Hepatobiliary: hepatocellular carcinoma (up to 10% rupture), hepatic adenoma (risk rises over 5 cm and in pregnancy and oral contraceptive use), metastases, haemangioma, liver rupture in pre-eclampsia and HELLP syndrome.
• Splenic: infectious mononucleosis, malaria, lymphoma and leukaemia, splenic artery aneurysm (including pregnancy), anticoagulants.
• Vascular: ruptured splenic, hepatic, gastroduodenal or other visceral artery aneurysm, segmental arterial mediolysis, vasculitis (polyarteritis nodosa), and rupture of the mesenteric veins in portal hypertension.
• Coagulopathy: anticoagulant or antiplatelet therapy, thrombolysis, liver disease and thrombocytopenia.

Pathophysiology. Bleeding fills the peritoneal cavity, with initial pain from irritation, then hypovolaemia. Anticoagulation and coagulopathy make bleeding difficult to control.

Presentation is sudden abdominal pain, abdominal distension, dizziness, syncope, shoulder tip pain, tachycardia and hypotension, peritonism, and a fall in haemoglobin. In women of reproductive age, amenorrhoea and vaginal bleeding suggest ectopic pregnancy. Anticoagulated patients may show only mild pain.

Red flags.

• Hypotension with abdominal pain in a woman of reproductive age (until ectopic pregnancy is excluded).
• Anticoagulation, known liver mass or aneurysm.
• Pre-eclampsia or HELLP syndrome with upper abdominal pain.

Bedside ultrasound (free intraperitoneal fluid, uterus, adnexa, liver, spleen). Pregnancy test (urine or serum beta human chorionic gonadotrophin) in every woman of reproductive age. Full blood count, coagulation, fibrinogen, liver tests, creatinine, lactate and crossmatch. CT with arterial and portal phases when stable shows the source (contrast blush). Diagnostic paracentesis is rarely needed.

Differential diagnosis. Perforated viscus, ruptured aortic aneurysm, mesenteric ischaemia, pancreatitis, ovarian torsion, haemorrhagic ascites in cirrhosis and trauma not disclosed.

Resuscitation. Two large bore cannulae, balanced blood products (1 red cell unit to 1 plasma to 1 platelet pool), permissive hypotension (systolic 80 to 90 mmHg), warming, calcium (calcium gluconate 10% 20 mL for each 4 units) and early group O RhD-negative blood for women of reproductive age.

Reverse coagulopathy and anticoagulants.

• Warfarin: prothrombin complex concentrate 25 to 50 units/kg with vitamin K 10 mg IV.
• Unfractionated heparin: protamine 1 mg for each 100 units given in the last 2 to 3 hours (maximum 50 mg).
• Dabigatran: idarucizumab 5 g IV. Factor Xa inhibitors: prothrombin complex concentrate 50 units/kg (maximum 5000 units), or the specific reversal agent.
• Tranexamic acid 1 g IV over 10 minutes then 1 g over 8 hours for severe bleeding.

Source control by cause.

• Ruptured ectopic pregnancy: immediate laparoscopic or open salpingectomy. Give anti-D immunoglobulin 250 IU IM to RhD-negative women.
• Ruptured hepatic tumour or adenoma, and visceral artery aneurysm: transarterial embolisation as first choice in stable patients, with surgery for instability or failure.
• Splenic rupture: embolisation or splenectomy (vaccinate and give antibiotic prophylaxis afterwards).
• HELLP syndrome liver rupture: hepatic packing, embolisation, delivery and magnesium sulphate 4 g IV loading then 1 g/h.
• Ovarian cyst haemorrhage: conservative if stable, otherwise surgery.
• Unexplained: damage control laparotomy.

Antibiotic prophylaxis. Cefazolin 2 g IV (3 g if weight is over 120 kg) at surgery.

Monitoring. Vital signs, haemoglobin every 4 to 6 hours, lactate, coagulation, urine output, abdominal girth and bladder pressure.

Referral and escalation. Surgical, gynaecological or interventional radiology teams at once, with anaesthesia and blood bank.

Special groups. In pregnancy, involve obstetrics immediately, and prefer delivery and embolisation or surgery as directed by foetal and maternal stability. In anticoagulated patients, restart anticoagulation only after bleeding is controlled and the thrombotic risk is weighed.