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Introduction: Tranexamic acid (TXA) is an antifibrinolytic drug used for the prophylaxis and treatment of haemorrhage of various origin. This retrospective study investigated the effect of TXA on ongoing bleeding in dogs with nonsurgically treated haemoabdomen. The study population consisted of 48 dogs treated in the period 2009-2020 at the Small Animal Clinic of the Vetsuisse Faculty of Zurich. Twenty-eight of 48 dogs were treated with 20 mg/kg TXA IV within 3h of diagnosis of haemoabdomen. Dogs treated with and without TXA were monitored over 48 hours for signs of ongoing haemorrhage. Ongoing haemorrhage was defined as an increase in abdominal fluid accumulation, a decrease in haematocrit of >5% over time or need for surgical exploration after at least 12 hours of medical treatment. Transfusion requirements, cumulative amount of fluid therapy, heart rate, respiratory rate, temperature, systolic and mean arterial pressure, estimate of abdominal fluid identified by FAST analysis, venous haematocrit, abdominal haematocrit, serum albumin, serum lactate and thrombocyte count were extracted from patient records at 6, 12, 24 and 48 hours after diagnosis of haemoabdomen. Groups were comparable at presentation, however dogs of the TXA group showed a significantly lower abdominal haematocrit at presentation (37 vs 45%, P=0,034) and a higher fluid accumulation (P=0,019), both persisting over time. None of the outcome parameters for ongoing haemorrhage was significantly different between groups. Transfusion requirement was low and similar in both groups. Of interest, none of the 16 dogs undergoing thromboelastometry showed hyperfibrinolysis at presentation. We conclude that other mechanisms than antifibrinolytic therapy was responsible for cessation of bleeding in the majority of patients.

Objective: To evaluate the effects of 6% hydroxyethyl starch 130/0.4 (HES) and a polyionic isotonic crystalloid (CRYS) on standard coagulation tests and rotational thromboelastometry (ROTEM) in dogs with spontaneous hemoperitoneum (SHP)., Design: Prospective randomized open-label clinical study., Setting: University teaching hospital., Animals: Forty-two client-owned dogs presented with SHP., Interventions: Dogs diagnosed with SHP and hypovolemic shock were randomly allocated to receive HES (10 mL/kg, n = 22) or CRYS (30 mL/kg, n = 20) intravenously over 20 minutes for hemodynamic stabilization., Measurements and Main Results: Parameters measured before (T 0 ) and after (T 1 ) treatment were HCT, platelet counts, prothrombin time, activated partial thromboplastin time, fibrinogen concentrations, and extrinsic activated (EXTEM), intrinsic activated (INTEM), and extrinsic activated with platelet inhibition ROTEM assays. Data were analyzed as absolute values and as the percentage change from T 0 to T 1 . No significant differences between groups were detected in any variable at T 0 , and for HCT, platelet counts, prothrombin time, activated thromboplastin time, and fibrinogen concentrations at T 1 . Clot formation time in EXTEM was significantly prolonged (P = 0.037), and maximum clot firmness was significantly decreased (P = 0.038) in the HES group compared to the CRYS group at T 1 . The percentage change in EXTEM clotting time (P = 0.012) and INTEM clot formation time (P = 0.031) was greater after HES than CRYS. Lysis indices remained at 100% for all ROTEM assays in both groups., Conclusion: Compared to a 3-fold volume of CRYS, administration of HES was associated with impairment in ROTEM parameters in dogs with SHP, but no evidence of hyperfibrinolysis was detected., (© Veterinary Emergency and Critical Care Society 2020.)

Hyperfibrinolysis contributes to the pathophysiology of trauma-induced coagulopathy. At present, systematic administration of tranexamic acid (TXA) is recommended in all patients in the early phase of trauma. However, there is some debate regarding whether TXA is beneficial in all trauma patients. A rapid and accurate tool to diagnose hyperfibrinolysis may be useful for tailoring TXA treatment. We conducted a proof-of-concept study of consecutive adult trauma patients. A first blood sample was obtained at the time of pre-hospital care (T1). Patients received 1 g of TXA after T1. A second sample was obtained on arrival at the emergency unit (T2). We examined coagulation, fibrin and fibrinogen formation and degradation. Fibrinolysis was assessed by determining tissue plasminogen activator (t-PA) antigen and plasminogen activator inhibitor 1 (PAI-1) activity and global fibrinolysis capacity assay using a device developed by Hyphen BioMed: the Lysis Timer (GFC/LT). The study population consisted of 20 patients (42 ± 21 years, index of severity score 32 ± 21). Both coagulation and fibrinolysis were altered at T1. GFC/LT values exhibited hyperfibrinolysis only in five patients. Principal component analysis carried out at T1 showed two main axes of alteration. The major axis was related to coagulation, altered in all patients, while the second axis was related to fibrinolysis. GFC/LT was mainly influenced by PAI-1 activity while fibrin monomers were related to the severity of trauma. At T2, GFC/LT exhibited the marked effect of TXA on clot lysis time. In conclusion, GFC/LT demonstrated huge variation in the fibrinolytic response to trauma.

Introduction: Tranexamic acid (TXA) is an antifibrinolytic drug that is used for uncontrolled bleeding of various origin. This retrospective study investigated the effect of tranexamic acid administration on bleeding tendency in dogs with surgically managed hemoperitoneum. Thirty dogs were treated with (TXA group) and 25 dogs without (CTR group) tranexamic acid prior to surgery. Various parameters (decrease in haematocrit, number of transfusions, shock index and changes in abdominal fluid accumulation) were used for characterization of bleeding tendency and compared between groups. Groups were similar at presentation and prior to surgery. None of the dogs undergoing rotational thromboelastography analysis showed hyperfibrinolysis prior to surgery. Overall transfusion and erythrocyte transfusion requirements as well as bleeding tendency, hospitalisation time and hospital discharge rate were similar between groups. Dogs of the TXA group received significantly more intraoperative plasma transfusions (P=0.013) and showed a higher systolic and mean arterial blood pressure (P=0.002 and 0.050) and lower shock index (P=0.028) with less dogs being in shock (P=0.012) at 24h. In summary, in this study population of dogs with surgically managed spontaneous hemoperitoneum dogs treated with tranexamic acid received more plasma transfusions intraoperatively and showed a lower shock index 24h after presentation. In dogs with surgically treated hemoabdomen tranexamic acid administration prior to surgery does not reduce red blood cell transfusion requirements or postoperative bleeding tendency.

Haemorrhagic rupture is a life-threatening complication of a hepatic simple cyst. A 63-year-old man presented with severe acute abdominal pain and a massive haemoperitoneum resulting from haemorrhagic rupture of a large hepatic cyst. The haemorrhagic rupture was aggravated by an overdose of vitamin K-antagonist treatment. CT scans revealed a large hepatic simple cyst. The patient was successfully treated conservatively with resuscitation, transfusion therapy and administration of coagulation agents. To date, there is no clear evidence regarding optimal treatment of haemorrhagic hepatic cyst rupture. The risk of recurrent bleeding from the haemorrhagic hepatic simple cyst, and the need for final treatment to avoid rebleeding either by percutaneous sclerotherapy, endovascular embolisation, surgical cyst resection, or surgical deroofing, is discussed., (2015 BMJ Publishing Group Ltd.)

Severe hemophilia patients are more likely to be complicated by intra-articular hemorrhage, subcutaneous hemorrhage, and intra-mascular hemorrhage. Spontaneous intra-abdominal hemorrhage is a rare fatal disease, which is an arterial bleeding of uncertain causes from vessel feeding arteries. In case the spontaneous intra-abdominal hemorrhage is complicated to severe hemophilia patients, the mortality rate increases considerably. We experienced a patient with severe hemophilia A, who made a full recovery from spontaneous intra-abdominal hemorrhagic shock by replacement therapy of coagulation factor VII, a noninvasive procedure.

Hepatosplenic schistosomiasis is due to chronic parasitic trematode infections with various Schistosoma sp. The Schistosoma life cycle requires contamination of surface water by infected human or animal excreta, specific freshwater snail intermediate hosts and human skin contact with water. The disease is prevalent in many developing tropical areas, particularly in sub-Saharan Africa as well as in Southeast Asia. Deposition of Schistosoma eggs in the hepatic portal system leads to periportal fibrosis, cirrhosis and portal hypertension but little hepatocellular damage. Portal hypertension of any etiology may cause gastrointestinal varices. Rarely, ectopic varices may rupture into the peritoneal cavity and result in a hemoperitoneum. The authors describe a case of a Filipino immigrant who presented with a hemoperitoneum associated with previously unrecognized hepatosplenic schistosomiasis due to Schistosoma japonicum.

Anticoagulation has long complicated the care of hemorrhage in the emergency department and other acute care settings. With the advent of novel anticoagulants such as direct thrombin inhibitors and direct factor Xa inhibitors, the absence of any direct antidote for these medications presents new and difficult challenges in the management of hemorrhagic complications in these patients. We present 2 cases of patients with hemorrhagic complications taking novel oral anticoagulants, their management, and outcomes.

Abdominal pregnancy is a rare condition that accounts for only 1% of all ectopic pregnancies but results in high maternal morbidity and mortality. We present a case of abdominal pregnancy with massive peritoneal bleeding successfully treated using systemic methotrexate (MTX). A 34-year-old woman with amenorrhea for 8 weeks and a positive pregnancy test was referred for evaluation of ectopic pregnancy. Transvaginal ultrasonographic scan showed a gestational sac measuring 25 mm in diameter containing a viable embryo in the cul-de-sac and a considerable amount of free fluid in the patient's lower abdomen and pelvis. Laboratory parameters showed that her hemoglobin concentration was 5.8 g/dl and serum human chorionic gonadotropin concentration was 13,195 mIU/ml. Emergency surgery revealed an abdominal pregnancy in the cul-de-sac and a massive intra-abdominal hemorrhage. After a hemostasis procedure, the patient was successfully treated using systemic MTX. We also present the review of abdominal pregnancy cases treated using systemic MTX at our institution over 10 years. Systemic MTX treatment for abdominal pregnancy is safe and effective and makes it possible to avoid the risk of excessive bleeding by surgical resection of the implantation site., (Copyright © 2013 S. Karger AG, Basel.)

We report the case of a 62-year-old woman who presented to the emergency department with abdominal pain and distension. She was diagnosed with haemoperitoneum and a large tumour that occupied the entire left hypochondrium and attached to the posterior surface of the fundus of the stomach at the level of the greater curvature. Anatomical pathology examination identified the tumour as a gastrointestinal stromal tumour with highly malignant characteristics and the haemoperitoneum was considered to contribute to a worse prognosis because of its ability to produce a peritoneal seeding. Considering these adverse characteristics, imatinib was initiated as an adjuvant treatment, with no evidence of relapse in the follow-up.

Objective: To report a case of ruptured hepatocellular carcinoma with massive hemoperitoneum which was successfully controlled with isoamyl 2-cyanoacrylate., Clinical Presentation and Intervention: A 46-year-old Bangladeshi gentleman presented to our casualty complaining of acute abdominal pain and distension, associated with jaundice. Bedside abdominal ultrasound showed multiple focal lesions in the liver with fluid in the abdomen. The patient was vitally unstable, so he was resuscitated and underwent emergency laparotomy for massive hemoperitoneum due to a ruptured tumor nodule. Isoamyl 2-cyanoacrylate was applied to the ruptured nodule which stopped bleeding within 1-2 min., Conclusion: This case shows the effectiveness of isoamyl 2-cyanoacrylate in controlling bleeding in ruptured liver tumors., (Copyright © 2011 S. Karger AG, Basel.)

Introduction: Pregnancy in a rudimentary horn is although rare, but is associated with the risk of rupture and life threatening hemorrhage. With the use of ultrasound the diagnosis can be made before symptoms occur. Management usually consists of excision of the rudimentary horn along with the pregnancy and the ipsilateral tube, traditionally by laparotomy., Materials and Methods: We present a case of a 16-week ruptured rudimentary horn pregnancy diagnosed intraoperatively and managed laparoscopically in the presence of massive haemoperitoneum, which is first of its kind along with literature review., Conclusion: This case demonstrates that laparoscopy is a feasible approach and can provide rapid diagnosis and control of bleeding in such cases provided there is availability of efficient multi-disciplinary teamwork, optimal anesthesia, advanced cardiovascular monitoring, laparoscopic expertise and ability to convert rapidly to laparotomy if required.

We report a case of brodifacoum (superwarfarin) intoxication of unknown etiology presenting as hemoperitoneum after fluconazole administration for one week before the onset of symptoms. The initial prothrombin time (PT) and partial thromboplastin time (PTT) were markedly prolonged, although a mixing study with normal plasma showed that the corrected PT and PTT were in the normal range. Vitamin K-dependent coagulation factors (Factors II (5%), VII (8%), IX (4%), and X (6%)), and Protein C (16%) and Protein S (19%) activities were reduced. Although the patient denied ingesting rodenticides or medications other than an antifungal drug, fluconazole, superwarfarin toxicity was suspected; subsequently, his serum brodifacoum level was found to be positive. After administration of fresh frozen plasma (FFP) and oral vitamin K(1) for five days and following drainage of the hemoperitoneum, the patient's bleeding tendency stopped, with slow decreases in PT and PTT. Compared to previous reports of superwarfarin intoxication of unknown exposure, this case is distinct in that the severe bleeding tendency needed surgical management and involved a suspected drug interaction with fluconazole. Therefore, superwarfarin intoxication should be suspected in subjects with markedly prolonged PT and PTT of unknown etiology, since a drug interaction could amplify the toxicity from a small exposure to superwarfarin.

We experienced unusual repeated ante-partum intra-abdominal bleedings in a woman with placenta percreta invading into the left broad ligament, in whom recombinant factor VIIa was effective for controlling severe retro-peritoneal bleeding. A 34-year-old multiparaous woman with two prior cesarean sections presented acute abdominal pain at 16 weeks of gestation. She also represented with abdominal pain at 22 weeks of gestation, and a diagnostic laparoscopy revealed hemoperitoneum, although we could not identify the exact source of bleeding. She also represented with abdominal pain without vaginal bleeding at 27 weeks of gestation, and an MRI revealed a hematoma in the lower abdomino-pelvic region and placenta percreta invading into the left broad ligament. A classical cesarean section followed by hysterectomy with partial cystectomy was performed at 32 weeks of gestation. Since the bleeding from the retro-peritoneum could not be controlled by the use of fresh frozen plasma, recombinant factor VIIa was administered, resulting in successful hemostasis.

Effects ofverapamil, a slow calcium channel blocker, on the production of anti-inflammatory cytokines (TNF-alpha and IL-beta) by peritoneal mononuclears were studied using a rat model of aseptic intra-abdominal inflammation. Autohemoperitoneum was simulated by intraperitoneal administration of autoblood (group 1). The similarly treated animals of group 2 were additionally given verapamil. A statistically significant rise in the TNF-alpha and IL-beta levels was documented in the former case. In group 2, verapamil substantially modified functional activity of peritoneal macrophages in that TNF-alpha content in peritoneal exudate was twice lower than in group 1 while the IL-beta level remained unaltered. These findings suggest that slow calcium channels are involved in regulation of cytokine-producing function of mononuclear cells during intra-abdominal inflammation.

A 66-year-old man with a metallic valve and under treatment with acenocoumarol developed hypovolemic shock after rupture of a splenic artery pseudoaneurysm. We managed to reverse anticoagulation within 60 minutes by administering 20 mg of vitamin K and 4.8 mg of activated recombinant factor VII. No thromboembolic adverse events were observed. We discuss the pharmacologic effects of coumarin derivatives and their antagonists, as well as the use of activated factor VII in the reversal of anticoagulation by these drugs.

We describe the case of a 48-year-old woman who underwent emergent diagnostic and therapeutic laparoscopy after sustaining two self-inflicted abdominal stab wounds. After evacuation of approximately 1.5 L hemoperitoneum, a through-and-through liver injury with active bleeding was locally packed with hemostatic agents (Surgicel and Avitene) to achieve successful hemostasis. The patient also underwent systematic exploration of the abdominal cavity, which was free of associated injury. She had an uneventful recovery. This case adds to the growing evidence supporting the role of therapeutic laparoscopy in the safe management of carefully selected stable patients with penetrating abdominal trauma.

Haemoperitoneum secondary to ruptured corpus luteum is a rare complication for women on anticoagulants and with certain congenital bleeding disorders. A surgical approach is often taken, leading to oophorectomy in many cases. We describe three patients presenting with haemoperitoneum in association with factor VII deficiency, factor X deficiency and sitosterolaemia. In two of the patients, recurrent episodes occurred prior to introduction of the oral contraceptive pill. Conservative management with blood product and factor concentrate support was successful in avoiding surgery in three of the five episodes of bleeding. These cases demonstrate that preservation of ovarian function is possible with a conservative approach and recurrent episodes may be prevented by suppression of ovulation.

The authors describe an 11-year-old boy with hemophilia A and high titer inhibitor who developed a life-threatening mediastinal-retroperitoneal hemorrhage. Chest CT showed a large hematoma beginning in the retrotracheal area, filling the mediastinum, compressing the carina, and extending retroperitoneally up to the kidneys. As the surgical approach has a high mortality rate, the authors chose a more conservative approach initially and obtained excellent bleeding control with recombinant activated factor VII without the need for surgical intervention. As reported in other patients, the authors also showed a decrease in the factor III inhibitor while this patient was successfully treated with bypassing agents.

We report a case of a 50-year-old woman, taking antivitamin K for double mitro-aortic valvular replacement, having presented a clinical picture of acute cholecystitis with marked hypotension. The radiological and biologic exams showed a deep hypocoagulability, vesicular gallstones, a haemoperitoneum and retroperitoneal haematoma. After correction of biological anomalies, the patient was operated. The gallbladder was distended containing large clots and four stones without any evidence of perforation. One of the gallstones led to cystic duct obstruction. Haemocholecyst is a rare complication of anticoagulant therapy, which may occur in the setting of gallbladder stones. The usual complication was the vesicular perforation. In spite of its rarity, haemocholecyst should be suspected when an anticoagulant treated patient presents symptoms of acute cholecystis with or without haemorrhagic shock.

We describe the first case of spontaneous splenic rupture associated with tinzaparin in a cancer patient. This low-molecular-weight heparin was administrated for deep venous thrombosis and pulmonary embolism. No underlying splenic pathology predisposing to this condition was found.

Two patients (a 17-year-old male and a 19-year-old female) sustained single gunshot wounds to the abdomen. Given the nature of their wounds and presumed peritoneal penetration they were taken urgently to the operating room for exploratory laparotomy. Both patients sustained multiple intra-abdominal injuries including gastric and small and large bowel perforations. Given the extensive nature of these injuries both patients required bowel resections. Upon further exploration they were both noted to have significant bleeding from the bony aspect of their sacrum. A surgical hemostat (CoStasis; Cohesion Technologies, Inc., Palo Alto, CA) (4.5-9.0 cm3) was directly applied to the injured area of the sacrum in both cases after standard surgical hemostatic techniques were unsuccessful. After application no further attempts of hemostatic control by standard methods were attempted. In both cases the sacral bleeding ceased without any further surgical intervention. Postoperatively neither patient rebled from the sacral injuries. Penetrating injuries to the sacrum can be life threatening and difficult to control with standard surgical hemostatic techniques. CoStasis, a new surgical hemostat, was effective in obtaining immediate and definitive hemostatic control. Future prospective trials on the use of CoStasis in trauma patients are warranted.

In female patients affected by congenital coagulation disorders haemorrhagic corpus luteum must be considered for the differential diagnosis of acute abdomen. We report the complication in a 22-year-old woman with type 3 von Willebrand's disease who presented with abdominal pain and haemorrhagic shock. Along with adequate factor VIII replacement therapy oral contraceptive treatment is the key for the management of this potentially life-threatening complication and the long-term prevention of future bleeding episodes of this origin.