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BACKGROUND: Ectopic pregnancy (EP) is a serious obstetric condition that can be life-threatening, with various risk factors contributing to its development. In particular, in vitro fertilization (IVF) techniques may lead to an increased rate EP. Additionally, also endometriosis seems to be related to this particular obstetrical condition. CASE REPORT: We report a rare case of ectopic pregnancy on the uterosacral ligament (USL) along with a suspected coexisting tubal ectopic pregnancy following IVF. The patient is a 48-year-old woman in menopause, with a history of pelvic endometriosis, who experienced sudden abdominal pain and vomiting at eight weeks of amenorrhea after undergoing a double heterologous frozen embryo transfer. Thorough examination and pelvic ultrasound, we diagnosed a hemoperitoneum due to a suspected heterotopic EP on the left USL and contralateral tube. Due to the sudden worsening of the patient's condition, we opted for a surgical procedure. An urgent laparotomy revealed a severe hemoperitoneum caused by an EP implanted on the left USL and a malacic, bleeding contralateral tube, both of which were removed, and hemostasis was then guaranteed. The histopathologic exam confirmed the EP on the left USL and an edematous tube without product of conception (POC). CONCLUSIONS: Comparing our case with others reported in the current literature, it appears that the etiopathogenetic mechanisms leading to this urgent obstetrical condition are various and not fully understood. Despite those circumstances, the present case highlights the importance of considering non-tubal ectopic pregnancies in the context of risk factors, including IVF techniques, endometriosis, and advanced age, in cases of abdominal pain and hemoperitoneum after a single or double embryo transfer. The treatment, which involves different professional figures, should be executed as soon as possible, with the aim of preserving the patient's life and any future desire for pregnancies. [ABSTRACT FROM AUTHOR]

Introduction: Patients with liver cirrhosis develop thrombocytopenia and an increased risk of bleeding events after invasive procedures. Lusutrombopag, a thrombopoietin receptor agonist, can increase the platelet count. This study assessed whether lusutrombopag reduces the risk of hemoperitoneum following percutaneous radiofrequency ablation for hepatocellular carcinoma, compared with platelet transfusion. Methods: Participants in the present study comprised patients with severe thrombocytopenia (platelet count <50,000/μL) enrolled between November 2012 and March 2020, excluding patients with idiopathic thrombocytopenia or anticoagulant use. Hemoperitoneum rate, hemostasis rate, hemoglobin reduction rate, rate of achieving a platelet count ≥50,000/μL, and increases in platelet count and factors contributing to hemoperitoneum were retrospectively analyzed. Results: This study enrolled 41 patients, comprising 18 patients administered lusutrombopag and 23 patients who received platelet transfusion. The major hemoperitoneum rate after RFA was tend to be lower in the lusutrombopag group (0%) than in the platelet transfusion group (21.7%). All of the major hemoperitoneum was observed in the platelet transfusion group. Hemoglobin reduction rate was lower in the lusutrombopag group (−0.17%) than in the platelet transfusion group (6.79%, p = 0.013). Hemostasis rate was lower in the lusutrombopag group (0%) than in the platelet transfusion group (21.7%, p = 0.045). The rate of achievement of platelet counts ≥50,000/μL the day after RFA was higher in the lusutrombopag group (100%) than in the platelet transfusion group (60.9%, p = 0.005). Conclusion: Lusutrombopag may be able to perform RFA more safely with respect to the hemoperitoneum caused by percutaneous radiofrequency ablation compared with platelet transfusion. [ABSTRACT FROM AUTHOR]

The diagnosis of intra-abdominal exsanguination in hemodynamically unstable blunt trauma patients is almost universally determined by Focused Assessment with Sonography in Trauma (FAST). However, FAST has been reported to have poor sensitivity and is therefore associated with false-negative examinations. Our institutional practice includes diagnostic peritoneal aspirate (DPA) following two negative FASTs to address the poor sensitivity. We hypothesized that serial FAST alone would be able to exclude clinically significant abdominal bleeding in an unstable blunt trauma patient. A retrospective cohort study was conducted between 2018 and 2020 at a major tertiary trauma referral hospital, including all blunt trauma patients who were hemodynamically unstable. Two groups were analyzed: 1. "FAST+": those who had a positive FAST scan and proceeded to a trauma laparotomy, and 2. "DPA": those who had serial negative FAST scans and proceeded to DPA. Of the 12 patients in the FAST+ group, 92% correctly identified the abdomen as the source of instability. Of the seventeen patients in the DPA group, only two (12%) had positive DPA. Both patients underwent laparotomies, but neither identified an abdominal source of hemodynamic instability. The most common cause of hemodynamic instability in the DPA group was pelvic bleeding from major pelvic ring disruption. The sensitivity and specificity of the serial FAST exam for clinically significant abdominal bleeding were 100% and 94%, respectively. These data suggests that two sequential negative FAST scans are adequate for excluding intra-abdominal bleeding as the source of instability, with further investigation with DPA not identifying any clinically significant sources of intra-abdominal bleeding. [ABSTRACT FROM AUTHOR]

Aneurysms of the splenic artery are relatively rare, being found in patients with portal hypertension, multiparous, atherosclerosis, or in young people with various genetic diseases. In the uncomplicated forms, splenic artery aneurysms are often difficult to diagnose either because of the asymptomatic evolution, or because of the non-specific symptoms. In cases of trauma or large sizes, aneurysms can be complicated by rupture, which can cause hemoperitoneum with the risk of death if specific treatment is not initiated as soon as possible. Depending on the location of the splenic aneurysm, comorbidities, the patient's general condition or lifethreatening complications, laparotomy, laparoscopy, endovascular techniques or combined procedures can be performed. The case of a 33-year-old female patient who presented to the emergency room with abdominal pain, nausea, vomiting and later syncope is presented. The patient was referred to the radiology department, and computed tomography revealed a ruptured splenic artery aneurysm with hemoperitoneum. The splenic artery aneurysm and the spleen were excised by emergency surgery, with a favorable postoperative outcome. The young age of diagnosis and treatment probably implies a genetic component, so that she was referred for additional investigations after discharge.

Objective: Our aim is to demonstrate a rare cause of hemoperitoneum without vaginal bleeding resulting from the rupture of a uterine artery pseudoaneurysm after uncomplicated vaginal delivery. Case report: A 39-year-old woman who had experienced a normal vaginal delivery 8 days previously to being seen in our hospital, was presented to the emergency room with hypovolemic shock. Computed tomography angiography (CTA) showed massive internal bleeding and a ruptured pseudoaneurysm arising from the left uterine artery. The patient was successfully treated through transcatheter arterial embolization (TAE). Conclusion: A pseudoaneurysm is a rare disease which can occur during an uncomplicated vaginal delivery. The clinical presentation can vary from asymptomatic, vaginal bleeding or hemoperitoneum. The diagnosis can be made by using Doppler sonography, CTA or Magnetic Resonance Imaging. The use of TAE is now the most common treatment option and possesses a high success rate.

The diagnosis of intra-abdominal exsanguination in hemodynamically unstable blunt trauma patients is almost universally determined by Focused Assessment with Sonography in Trauma (FAST). However, FAST has been reported to have poor sensitivity and is therefore associated with false-negative examinations. Our institutional practice includes diagnostic peritoneal aspirate (DPA) following two negative FASTs to address the poor sensitivity. We hypothesized that serial FAST alone would be able to exclude clinically significant abdominal bleeding in an unstable blunt trauma patient. A retrospective cohort study was conducted between 2018 and 2020 at a major tertiary trauma referral hospital, including all blunt trauma patients who were hemodynamically unstable. Two groups were analyzed: 1. “FAST+”: those who had a positive FAST scan and proceeded to a trauma laparotomy, and 2. “DPA”: those who had serial negative FAST scans and proceeded to DPA. Of the 12 patients in the FAST+ group, 92% correctly identified the abdomen as the source of instability. Of the seventeen patients in the DPA group, only two (12%) had positive DPA. Both patients underwent laparotomies, but neither identified an abdominal source of hemodynamic instability. The most common cause of hemodynamic instability in the DPA group was pelvic bleeding from major pelvic ring disruption. The sensitivity and specificity of the serial FAST exam for clinically significant abdominal bleeding were 100% and 94%, respectively. These data suggests that two sequential negative FAST scans are adequate for excluding intra-abdominal bleeding as the source of instability, with further investigation with DPA not identifying any clinically significant sources of intra-abdominal bleeding.

Objective. To identify specific features of the clinical course of Congo-Crimean hemorrhagic fever (CCHF) in children in order to optimize early and differential diagnosis, management tactics and treatment of pediatric patients Materials and Methods. A retrospective analysis of 159 probable and confirmed cases of Congo-Crimean hemorrhagic fever was carried out in patients admitted to the infectious diseases departments of Shymkent, district hospitals of Turkestan region for the period 2013–2022, of which 39 (24.5%) were children aged 1 to 18 years. Results. Of the 39 cases of CCHF in children, 9 (23.07%) were reported as confirmed, 5 (12.8%) as probable and 25 (64.1%) as suspected cases. In the epidemiological history, tick bite was noted in 25 (64.1%) cases. The incubation period in children and adolescents ranged from 1 to 14 days, on average – 9–8 days. Two children developed a severe complication of CCHF – hemoperitoneum. Conclusions. The probability of CCHF infection in children increases during the season of tick vector activity. The clinical picture of CCHF in children may be similar to manifestations of this infection in adults. Among the rare severe forms of CCHF, children may develop hemoperitoneum.

Introduction and importance: Spontaneous hemoperitoneum (SH) is a rare, life-threatening condition characterized by nontraumatic and non-iatrogenic intraperitoneal bleeding. This article explores three unique cases of SH, shedding light on unusual causes and emphasizing the critical role of diagnostic imaging and exploratory laparotomy in management. Methods: The study was a retrospective single-center non-consecutive case series. Results: We report three distinct cases of SH, each originating from uncommon sources: rupture of greater omentum arterio-venous malformation, a branch of the left gastric artery, and pathological splenic rupture. Clinical evaluation, diagnostic imaging, and surgical interventions are detailed for each case. Conclusion: These rare cases underscore the diverse etiologies of SH, including idiopathic omental bleeding, gastric intramural hematoma, and atraumatic splenic rupture. Enhanced CT imaging plays a crucial role in diagnosis, enabling the characterization of underlying pathologies. Exploratory laparotomy proves to be an essential treatment option for unstable patients with suspected or confirmed diagnoses of SH. [ABSTRACT FROM AUTHOR]

Spontaneous splenic rupture (SSR) is a relatively rare but potentially lethal complication of infectious mononucleosis (IM). While SSR is extremely rare in patients with proven IM, it is the most lethal complication of the infection (9% mortality rate) and can present completely asymptomatically or with abdominal pain and hemodynamic instability. As adolescents and young adults are the most affected population group, with this case report, we intend to raise the vigilance of any doctor treating those patients in the emergency department. We present the case of a 16-year-old patient with an atraumatic splenic rupture and hemoperitoneum secondary to an Epstein–Barr virus (EBV) infection. The patient underwent an exploratory laparotomy, and a splenectomy was performed. This case demonstrates that, even if SSR in patients with IM is extremely rare, it should always be considered in a patient with a relevant clinical presentation. [ABSTRACT FROM AUTHOR]

Introduction: A rare case of atraumatic liver laceration associated with hemoperitoneum is presented in a patient with amyloidosis who came to the hospital for abdominal pain. Case Presentation: The imaging findings reveal significant hepatomegaly with finely heterogeneous hepatic density and subcapsular hypo-dense streaks in segments VI and VII, likely representing lesions. Post-contrast enhancement shows a punctiform contrast medium extravasation within the subhepatic fluid collection, visible from the arterial phase and intensifying in subsequent study phases. Discussion: These imaging findings suggest an atraumatic hepatic laceration, a diagnosis confirmed by the presence of hemoperitoneum distributed bilaterally under the diaphragm, in the paracolic gutters, along the mesentery root, and predominantly in the peri-hepatic region. Conclusion: The detailed imaging analysis provided critical insights into the diagnosis and management of this rare clinical presentation. [ABSTRACT FROM AUTHOR]

Background Injuries involving substantial bleeding, frequently encountered in victims of road traffic accidents, pose a significant risk to mortality. For abdominal trauma cases, accurately assessing internal bleeding and hematomas becomes crucial. Detecting hemoperitoneum, which indicates both blood loss and organ damage in the abdominal cavity, requires precise evaluation. Timely diagnosis and quantification of hemoperitoneum following road accidents are crucial during the critical golden hour, enabling prioritized medical intervention and potentially saving lives while enhancing overall patient care. However, achieving precise hemoperitoneum quantification in abdominal trauma faces challenges due to the intricate nature of overlapping Hounsfield unit (HU) regions.

Background Injuries involving substantial bleeding, frequently encountered in victims of road traffic accidents, pose a significant risk to mortality. For abdominal trauma cases, accurately assessing internal bleeding and hematomas becomes crucial. Detecting hemoperitoneum, which indicates both blood loss and organ damage in the abdominal cavity, requires precise evaluation. Timely diagnosis and quantification of hemoperitoneum following road accidents are crucial during the critical golden hour, enabling prioritized medical intervention and potentially saving lives while enhancing overall patient care. However, achieving precise hemoperitoneum quantification in abdominal trauma faces challenges due to the intricate nature of overlapping Hounsfield unit (HU) regions. Methods In this feasibility study, we sought to assess the efficacy of the novel HUVAO (Hounsfield Unit-based Volume quantification of Asymmetrical Objects) segmentation algorithm for quantifying hemoperitoneum in thoracoabdominal non-contrast computed tomography (CT) images. Using 28 retrospective non-contrast CT scans of thoracoabdominal regions from trauma patients, we analyzed crucial imaging data without necessitating additional scans or contrast-enhanced procedures. The study aimed to compare HUVAO against classical algorithms and visual estimations by trained radiologists for hemoperitoneum segmentation in thoracoabdominal non-contrast CT images. Results Our findings revealed that although the technical feasibility of employing HUVAO and other segmentation algorithms for hemoperitoneum quantification is evident, the outcomes derived from these algorithms display notable discrepancies. Conclusion In assessing technical feasibility, we introduced the HUVAO segmentation algorithm for hemoperitoneum quantification, comparing its performance against classical segmentation algorithms and visual estimations from trained radiologists. While our results affirm the technical feasibility of HUVAO for this purpose, the observed variations underscore the task's inherent complexity. This emphasizes the limitations of relying solely on HU-based detection, advocating for integration with clinical data. This insight urges exploration of advanced techniques to boost accuracy and elevate patient care standards. [ABSTRACT FROM AUTHOR]

Key Clinical Message: We highlight the risk of lenvatinib drug toxicity when high‐risk anatomic regions are affected by angiosarcoma. [ABSTRACT FROM AUTHOR]

Copyright of Revista de Gastroenterología del Perú is the property of Sociedad de Gastroenterologia del Peru and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Magyar Radiológia Online is the property of Society of Hungarian Radiologists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Chest compressions are the mainstay of cardiopulmonary resuscitation. Secondary injuries are frequently reported, most frequently to the thorax and less frequently to the abdomen. Review of existing literature highlights liver lacerations as the most common abdominal injury following cardiopulmonary resuscitation; however, an isolated hepatic caudate lobe injury due to CPR has not yet been reported. We discuss existing literature regarding resuscitation‐related injuries, report a case of an isolated hepatic caudate lobe injury due to cardiopulmonary resuscitation, and discuss possible mechanisms of injury. [ABSTRACT FROM AUTHOR]

We report a case of hemoperitoneum after percutaneous radiofrequency ablation in a patient with hepatocellular carcinoma. A 60-year-old female was hospitalized for the treatment of thrombasthenia and cirrhosis caused by chronic Hepatitis C, and computed tomography revealed hepatocellular carcinoma, which was treated by percutaneous radiofrequency ablation. After the ablation, hemoperitoneum was suspected because of the low hemoglobin level with abdominal pain. Approximately 6 h after the ablation treatment, the patient suddenly fell into a shock state and died. In this case, medical treatment-related death including malpractice was suspected, and forensic autopsy was performed. The abdominal cavity contained 910 mL of dark red fluid blood and 210 g of soft hemocoagula. Moreover, several puncture marks were observed on the liver surface and diaphragm, and there was no clear damage to the main arteries and veins. Considering the macroscopic and microscopic findings, the cause of death was assumed as hemorrhagic shock due to the hemoperitoneum caused by the damage to the liver by radiofrequency ablation. It is important to consider all the indications and adverse effects of radiofrequency ablation. [ABSTRACT FROM AUTHOR]

A 2‐year‐old spayed female Siberian Husky was presented with a history of acute onset lethargy, collapse, haematochezia and vomiting. The patient was severely tachycardic and hypotensive. Point‐of‐care ultrasound revealed gallbladder wall thickening and peritoneal effusion consistent with haemorrhage on subsequent abdominocentesis. Despite attempted medical stabilization over the course of several hours, including blood products and multiple autotransfusions, the patient progressed to cardiopulmonary arrest. The dog was successfully resuscitated but was subsequently euthanized. Necropsy revealed a severe, acute hemoperitoneum secondary to rupture of the left lateral liver lobe. A tear in the hepatic capsule was identified along with a large hematoma. A single adult nematode, consistent with Dirofilaria immitis, was found in a pulmonary vessel in the right caudal lung lobe. The remaining necropsy findings were supportive of the clinical diagnosis of anaphylaxis. This report details a case, with necropsy findings, supporting a diagnosis of anaphylaxis and severe, refractory hemoperitoneum resulting from hepatic rupture. Acute hepatic rupture should be considered in cases of anaphylaxis‐related hemoperitoneum. [ABSTRACT FROM AUTHOR]

Management of hemoperitoneum due to ruptured ovarian cyst in patients on anticoagulation is a dilemma. Low threshold of surgery intervention may increase the risk of some events operatively. There is a trend for less invasive treatment in highly selected patients. We present two cases of massive hemoperitoneum due to ruptured ovarian cyst that were on anticoagulation. Successful conservative management was done in both of them and one patient, due to refractory abdominal pain, required interventional radiologic drainage, instead of surgery approach with good outcome. Ovulation suppression was started in both of them with regular uneventful follow up heretofore. Less invasive management is preferred in carefully selected patients of hemoperitoneum in women on anticoagulation. Ovulation suppression to avoid recurrence must be emphasized. [ABSTRACT FROM AUTHOR]

Factor V is a major part of the coagulation system and maintains a balance in pro-coagulant and anticoagulant pathways. Any deficiency or mutation can lead to disequilibrium in coagulation. Factor V deficiency can be congenital or acquired. Congenital factor V deficiency (parahemophilia or Owren’s disease) is a rare autosomal recessive condition. We present a case of an adolescent unmarried girl presenting with an acute abdomen and deranged coagulation parameters. It was confirmed that the bilateral haemorrhagic ovarian cysts and hemoperitoneum were due to factor V deficiency. In her case, the bleeding was likely due to a ruptured corpus luteum during ovulation. She was successfully managed conservatively with red cells and fresh frozen plasma transfusions, tranexamic acid and combined oral contraceptive pills (COCP) with instructions to continue the use of COCP to prevent such bleeding manifestations.

Uterine myomas, fibroids or leiomyomas are benign neoplasms that can present as abnormal uterine bleeding and pressure symptoms. Significant complications are infrequent, but they can be life-threatening. This is a case of a ruptured fibroid where excessive intra-abdominal bleeding resulted in hemoperitoneum. In this clinical scenario, timely recognition and intervention were essential to prevent morbidity and mortality.This article discusses the diagnostic challenges and surgical management of a case of hemoperitoneum resulting from spontaneous haemorrhage from a ruptured vessel on the surface of a subserosal leiomyoma.A 42-year-old patient with a known multi-fibroid uterus awaiting elective surgery presented with acute-onset abdominal pain to the emergency department. She had a distended, tender abdomen. Laboratory tests and contrast computerised tomography revealed haemorrhage with no clear source of bleeding. Emergency midline laparotomy revealed active bleeding from the surface of a posterior subserosal leiomyoma with 1950 mL hemoperitoneum. A total abdominal hysterectomy was performed, and the patient had an uncomplicated recovery.The pre-operative haemoglobin level was 80 g/L, which normalized after several blood transfusions. Histopathological examination confirmed multiple leiomyomas and haemorrhage associated with ischaemic changes.Hemoperitoneum from a bleeding degenerating leiomyoma is an exceedingly uncommon complication. The atypical presentation of abdominal pain and the presence of a multi-fibroid uterus posed diagnostic challenges. This case underscores the importance of considering leiomyomas as a potential cause of acute abdominal pain and bleeding. Timely surgical intervention, supported by a multidisciplinary approach, is essential for optimal patient outcome.

Introduction: A rare case of atraumatic liver laceration associated with hemoperitoneum is presented in a patient with amyloidosis who came to the hospital for abdominal pain. Case Presentation: The imaging findings reveal significant hepatomegaly with finely heterogeneous hepatic density and subcapsular hypo-dense streaks in segments VI and VII, likely representing lesions. Post-contrast enhancement shows a punctiform contrast medium extravasation within the subhepatic fluid collection, visible from the arterial phase and intensifying in subsequent study phases. Discussion: These imaging findings suggest an atraumatic hepatic laceration, a diagnosis confirmed by the presence of hemoperitoneum distributed bilaterally under the diaphragm, in the paracolic gutters, along the mesentery root, and predominantly in the peri-hepatic region. Conclusion: The detailed imaging analysis provided critical insights into the diagnosis and management of this rare clinical presentation.

Splenic injury is an extremely rare complication of endoscopic retrograde cholangiopancreatography (ERCP). There are only 34 cases reported in the literature up to now. Based on a case of a 72-year-old man, who after ERCP due to choledocholithiasis developed a large perisplenic and subcapsular hematoma, we carried out an extensive review of all cases of ERCP-induced splenic injury found in the literature. We searched PubMed/Medline and Google Scholar till 15 April 2023, for published case reports and series using the following terms: splenic injury after ERCP, ERCP-induced splenic injury, and post-ERCP splenic trauma. The case reports included were in English, Spanish, and German literature. We attempt to discuss the possible clinical image, the available diagnostic methods, the potential treatment alternatives, and predisposing factors related to this entity. Furthermore, a theory of a possible mechanism of this injury is discussed and supported schematically. The ERCP-induced splenic injury is rare and a high index of suspicion is needed for diagnosis. Therefore, we present two diagnostic algorithms, which according to our opinion may assist the evaluation of this complication and lead to early accurate diagnosis and appropriate management. Collectively, our findings support that although ERCP-induced splenic injury is an unexpected/unusual complication of ERCP, following the proper steps can be timely diagnosed and treated. [ABSTRACT FROM AUTHOR]

Copyright of Revista Médica de Risaralda is the property of Universidad Tecnologica de Pereira and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Granulosa cell tumors (GCTs) are the most common ovarian tumors in mares. The classical presentation of a GCT is a unilaterally enlarged ovary appearing as a multi cystic honeycomb mass. In rare cases, GCTs cause hemoperitoneum as a result of the rapid growth of the tumor. The clinical diagnosis of GCT is usually based on history, rectal examination, ultrasonographic examination, and serum hormone analysis, and surgical removal of the affected ovary is the treatment of choice. The different surgical approaches are based on the dimension of the GCT. Case Description: A 7-year-old mare was referred to the department for horses due to suspicion of a large colon impaction. The mare presented with clinical signs of colic, fever, and signs of hypovolemic shock. Rectal and ultra sonographic examination showed hemoperitoneum and a honey-comb mass within the abdomen, and a GCT as the cause of an acute hemoperitoneum was diagnosed based on the serum level of anti-Müllerian hormone. After stabilization of the mare, the GCT was removed through a ventral midline incision. Because of the enormous dimensions of the GCT, intra-abdominal partial resection of the tumor using a tenotomy knife was necessary to exteriorize the ovarian pedicle. At 3 months follow-up, the mare was ridden for her intended use. Conclusion: This report provides an approach to an uncommon case of a very large and heavy GCT. [ABSTRACT FROM AUTHOR]

Key Clinical Message We highlight the risk of lenvatinib drug toxicity when high‐risk anatomic regions are affected by angiosarcoma.

Abstract A 2‐year‐old spayed female Siberian Husky was presented with a history of acute onset lethargy, collapse, haematochezia and vomiting. The patient was severely tachycardic and hypotensive. Point‐of‐care ultrasound revealed gallbladder wall thickening and peritoneal effusion consistent with haemorrhage on subsequent abdominocentesis. Despite attempted medical stabilization over the course of several hours, including blood products and multiple autotransfusions, the patient progressed to cardiopulmonary arrest. The dog was successfully resuscitated but was subsequently euthanized. Necropsy revealed a severe, acute hemoperitoneum secondary to rupture of the left lateral liver lobe. A tear in the hepatic capsule was identified along with a large hematoma. A single adult nematode, consistent with Dirofilaria immitis, was found in a pulmonary vessel in the right caudal lung lobe. The remaining necropsy findings were supportive of the clinical diagnosis of anaphylaxis. This report details a case, with necropsy findings, supporting a diagnosis of anaphylaxis and severe, refractory hemoperitoneum resulting from hepatic rupture. Acute hepatic rupture should be considered in cases of anaphylaxis‐related hemoperitoneum.

A perimenopausal woman with a known history of fibroid uterus presented to the emergency department with the chief complaint of three weeks of intermittent abdominal pain with acute worsening for two days. The pain was described as 10/10 “tearing” peri-umbilical pain with radiation to the rectum associated with nausea. Vital signs, laboratory results, and physical examination were largely unremarkable at presentation, aside from diffuse tenderness with rebound. Computed tomography revealed a markedly enlarged uterus and large-volume hemoperitoneum and sentinel clot sign, suggesting fibroid as the source of bleeding. Upon re-examination, the patient was found to be hypotensive and tachycardic with worsening hemoglobin, worsening abdominal distension, and a positive focused assessment with sonography in trauma (FAST) exam. Although the source of bleeding was non-specific, a decision was made by the gynecology and general surgery teams to perform an emergency exploratory laparotomy. A midline vertical incision was made and four liters of blood were evacuated from the peritoneal cavity. The gynecology and general surgery teams thoroughly inspected the abdomen. A myomectomy was performed and good hemostasis was confirmed. The patient was transferred to the surgical intensive care unit, where she had an uncomplicated post-operative course. She was discharged home on postoperative day 4. Uterine fibroid rupture should be on the differential for hemoperitoneum in a patient with known fibroids and should be addressed with a timely multi-specialty approach.

BackgroundEndometriomas are a type of ovarian cyst composed of degenerated blood products from hemorrhage of ectopic endometrial tissue. Endometriomas can rupture, causing hemoperitoneum, and present with signs and symptoms similar to other, more common abdominal emergencies. Therefore, they are not often diagnosed preoperatively. Ultrasound and cross-sectional imaging can assist in diagnosis of endometriomas. We present a case of ruptured endometrioma causing massive hemoperitoneum that was initially suspected to represent malignancy with carcinomatosis.Case presentationA 32-year-old Hispanic woman presented with sharp abdominal pain and 15-pound unintentional weight loss over 6 months. Laboratory work was significant for a negative pregnancy test and elevated cancer antigen-125. Computed tomography of the abdomen and pelvis demonstrated a 13-cm complex cystic mass in the left adnexa with moderate hyperdense ascites and omental nodularity. Ultrasound demonstrated a large left adnexal complex cystic structure with internal echoes, and chest computed tomography showed no signs of intrathoracic neoplastic or infectious processes. Her presentation was concerning for malignancy with carcinomatosis. Fluid from a paracentesis was sent for culture and cytology. Diagnostic laparoscopy revealed that the left ovary had been completely replaced by an endometrioma, which had a small ruptured area superiorly. Brown deposits of endometriosis were present on the cyst, omentum, and various peritoneal linings. Tissue samples of the endometrium, myometrium, cervix, ovaries, fallopian tubes, peritoneum, omentum, and paracolic spaces were taken and showed no hyperplastic, dysplastic, or malignant cells on pathology.ConclusionsRuptured endometrioma and ruptured hemorrhagic cyst should be included in the differential diagnosis when a premenopausal female presents with hemoperitoneum in combination with complex adnexal cystic masses in the absence of trauma. Cancer antigen-125 and cancer antigen 19-9 can be falsely elevated in the setting of ruptured endometrioma.

Since its advent, the transjugular intrahepatic portosystemic shunt (TIPS) procedure has been accepted as an effective option to treat patients with complications of portal hypertension. While generally considered a safe procedure, TIPs can be associated with certain complications, including inadvertent puncture of the liver capsule with the needle/catheter combination during needle passes. In addition, the accompanying post-TIPS intraperitoneal hemorrhage has not been well reported and guidelines behind its management are not well described. We present a case of a 33-year-old male with refractory ascites who underwent TIPS, during which the hepatic capsule was inadvertently punctured, leading to the development of hemoperitoneum in the patient due to a bleeding diathesis.

We report a case of a 53-year-old male with decompensated liver cirrhosis secondary to alcohol abuse and hepatitis C infection who was admitted for hemorrhagic shock secondary to upper GI bleed. He underwent a therapeutic paracentesis 17 days after admission with the removal of 6 L of ascitic fluid. The patient became hemodynamically unstable after paracentesis and an acute drop in his hemoglobin was noted. On imaging, he was found to have massive hemoperitoneum secondary to a bleeding mesenteric varix. This is a very rare complication of paracentesis in patients with advanced cirrhosis and should be recognized early in the post-procedure period to initiate prompt life-saving measures to minimize morbidity and mortality.

Meckel's diverticula are one of the most common gastrointestinal anomalies, yet mesodiverticular bands are rare. The treatment of these bands commonly requires surgery. A healthy patient in his 20s presented to the emergency department with a 1 day history of acute onset abdominal pain. Computed tomography imaging was consistent with volvulus of the large intestine. In the operating room, the patient was noted to have a band between the ileal mesentery and tip of a Meckel's diverticulum, consistent with a mesodivertiular band, through which cecum had volvulized. The patient underwent resection. The patient recovered without major complications. Mesodiverticular bands are rare, but may present as hemoperitoneum, small bowel obstruction, or volvulus. Pre-operative diagnosis of a mesodiverticular band is often difficult and they are most commonly diagnosed intraoperatively. Treatment should include surgery and may include simple lysis of the band, bowel resection, or more extensive resection if other pathology is present. [ABSTRACT FROM AUTHOR]

We present a case of spontaneous abdominal hemoperitoneum secondary to ruptured splenosis in a 35-year-old patient with a history of splenectomy secondary to trauma 23 years prior. Computed tomography imaging demonstrated a large amorphous mass-like structure in the mesentery of the left hemiabdomen with active extravasation and hemoperitoneum. The patient also had a separate focus of hyper-enhancing mass adjacent to the bladder representing a mass versus splenule. The patient's radiographic and clinical presentation prompted management with exploratory laparotomy, hematoma evacuation, and resection of two splenules. With only a few cases of spontaneous abdominal hemoperitoneum from splenosis reported, this case describes successful management with surgical intervention. [ABSTRACT FROM AUTHOR]

Angiomatoid fibrous histiocytoma (AFH) is a rare soft tissue tumor with low-grade malignant potency that has typically occurred in the extremities of young adults over the last 30 decades. A 77-year-old female presented to the emergency department with a sudden onset of severe abdominal pain. Contrastenhanced computed tomography demonstrated a 2.5 cm cystic tumor in the upper abdomen that appeared ruptured with hemorrhage. The tumor that arose from the peritoneum was successfully resected and proven to be a ruptured AFH. The patient remained recurrence-free at the 1-year follow-up. [ABSTRACT FROM AUTHOR]

Although hemoperitoneum is a benign and common complication of chronic peritoneal dialysis the apperance of the effluent will be devastating for the patients. In women of reproductive age group gynecological causes are the common etiological factors. A 17 years old girl who had been on automated peritoneal dialysis for six months was admitted because of bloody effluent lasting for two days. At admission she described mild abdominal pain; physical examination was unremarkable and bleeding time and coagulation profile was normal. Abdominal ultrasound revealed hemorrhagic cysts on left ovary. Peritoneal effluent was cleared by using rapid exchanges with room temperature dialysate. Hemoperitoneum is a well recognized complication of peritoneal dialysis in women of reproductive age.Abdominal ultrasound is the first, easily applicable and reliable diagnostic modality in order to detect underlying causes of hemoperitoneum. Performing rapid exchanges with cold-room temperature dialysate is the mainstay of treatment. [ABSTRACT FROM AUTHOR]

Spontaneous splenic rupture (SSR) is a relatively rare but potentially lethal complication of infectious mononucleosis (IM). While SSR is extremely rare in patients with proven IM, it is the most lethal complication of the infection (9% mortality rate) and can present completely asymptomatically or with abdominal pain and hemodynamic instability. As adolescents and young adults are the most affected population group, with this case report, we intend to raise the vigilance of any doctor treating those patients in the emergency department. We present the case of a 16-year-old patient with an atraumatic splenic rupture and hemoperitoneum secondary to an Epstein–Barr virus (EBV) infection. The patient underwent an exploratory laparotomy, and a splenectomy was performed. This case demonstrates that, even if SSR in patients with IM is extremely rare, it should always be considered in a patient with a relevant clinical presentation.

Background: Abdominal trauma is one of the leading causes of morbidity and mortality in both developing and developed countries. Management of blunt trauma abdomen (BTA) relies on most importantly, the clinical presentation of the patient. Aims and Objectives: This study aims at determining the accuracy of the clinical abdominal scoring system (CASS) in predicting the need for operative management of blunt abdominal trauma patients and also comparing the CASS score with the American association for the surgery of trauma – computed tomography (AAST CT) score. Materials and Methods: A total of 50 patients with BTA presenting to the Government tertiary care center Mysore were evaluated for age, sex, type of trauma, systolic blood pressure, Glasgow coma scale, pulse rate, time of presentation after trauma, abdominal clinical findings, respiratory rate, and hemoglobin concentration. Radiological investigations were done as indicated. CASS score was calculated and a comparison of the same with CT findings, in determining the need for laparotomy, was studied. Patients with co-existing head injuries and comorbidities were excluded from the study. Results: Among 50 cases, 44 were male accounting for 88% of the study population and 6 were female. The majority belonged to 18–30 years of age, accounting for 46%. In 42% of cases, a road traffic accident was the mode of injury, followed by a fall from height in 4%. Latent period 52% of cases presented to the hospital between 0 and 6 h of the incident. 10% associated chest injuries. 42% showed splenic injury, thereby making it the most commonly injured organ. 28% had the liver injury. 28% had hemoperitoneum with source of bleed being unknown. Conclusion: CASS is a reliable and promising scoring system with sensitivity comparable to AAST CT grading in determining the need for surgical intervention in BTA patients. CASS provides an effective means of saving time and resources and gives the added advantage of avoiding expenses to underprivileged patients in our country.

Copyright of Ginecología y Obstetricia de México is the property of Federacion Mexicana de Ginecologia y Obstetricia and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Ginecología y Obstetricia de México is the property of Federacion Mexicana de Ginecologia y Obstetricia and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Introduction: Ectopic pregnancy accounts for approximately 2% of all pregnancies and is the most common cause of pregnancy-related mortality in the first trimester. Our aim was to study the preoperative clinical factors affecting the choice of laparoscopic approach to tubal ectopic pregnancy. Materials and methods: This was a retrospective cross-sectional study of tubal ectopic pregnancy cases that were managed by laparoscopy at an academic university hospital in the period January 2010 to December 2018. Cases that were managed medically or conservatively and laparoscopic cases that were converted to laparotomy were excluded. Cases where the surgical approach of laparoscopy or laparotomy were determined by the patients’ choice were also excluded. Results: The laparoscopy rate was 49.4%. The mean age was 32.04 years. Compared with laparotomy, laparoscopy was significantly associated with low parity (less than 3) (p=0.008), a low level of initial beta-human chorionic gonadotrophin (p=0.032), fewer cases of adnexal mass (p=0.000451), hemoperitoneum (p=0.000072), ruptured ectopic (p=0.000261), and more cases of bowel adhesions (p=0.0095). There was no significant difference between laparoscopy and laparotomy regarding the risk factors of ectopic pregnancy. Salpingectomy and salpingostomy were not significantly different between the two surgical approaches (p=0.643). Twenty-eight laparoscopic cases were converted to laparotomy. Conclusion: The laparoscopic approach to ectopic pregnancy was affected by parity, presenting symptoms of pain and vomiting, mean initial beta-human chorionic gonadotrophin, the presence of adnexal mass, the presence of hemoperitoneum, and the rupture of the ectopic. Bowel adhesions were seen more frequently in laparoscopy than laparotomy. Salpingectomy and salpingostomy were no different between laparoscopy and laparotomy. [ABSTRACT FROM AUTHOR]

Acute abdomen in women of child-bearing age remains a diagnostic dilemma. Etiology of acute abdominal pain may be due to obstetric, gynecological, gastrointestinal, or genitourinary causes. Early diagnosis and decision on conservative management versus emergency laparotomy/laparoscopy should be made in cases with acute abdomen as a lifesaving approach. We report a rare case of acute abdomen with hemoperitoneum due to rupture of hydrosalpinx.

Background: An Ectopic pregnancy occurs when fertilized ovum is implanted outside the uterine cavity. Typically, the site of this ectopic pregnancy is the Fallopian tube in about 93-97% of ectopic pregnancies. Only 50% of patients present with the classic clinical triad of ectopic pregnancy i.e., pain, amenorrhea, and vaginal bleeding. It is extremely important to diagnose a case of ectopic pregnancy to prevent rupture and internal bleeding Case Report: A 35-year-old Female, was brought to a hospital, gasping, complaining of pain abdomen, and abdominal distension. Pulses could not be felt, GCS was 3/15, blood pressure was not recordable. She was shifted to the Intensive Care Unit and intubated. Fluid correction was attempted and ionotopes were started. USG abdomen showed a hemoperitoneum, pelvic hematoma, and ruptured right adnexa. The patient was taken up for an emergency laprotomy and had a cardiac arrest on table, but could not be resuscitated. Following an Medicolegal case the body was subjected for postmortem examination, the relevant findings at autopsy will be discussed.

Mesenteric aneurysms and their complications can be a life-threatening presentation of acute abdomen to the emergency department. The majority of mesenteric artery aneurysms are incidentally detected on imaging investigations and are asymptomatic. Symptomatic mesenteric aneurysms manifest as hemoperitoneum or abdominal pain. In addition, treatment of symptomatic aneurysms is delayed due to the infrequent consideration of the diagnosis in patients presenting with abdominal pain. Timely and accurate diagnosis is of paramount importance as any delay in definitive surgical management can lead to increased patient's mortality and morbidity with up to 25% of mesenteric aneurysms may be complicated by rupture. [ABSTRACT FROM AUTHOR]

Primary segmental omental torsion (PSOT) is a very rare cause of acute abdominal pain, and it may often imitate the clinical picture of acute appendicitis. In instances of acute abdominal pain without anorexia, nausea, and vomiting, omental torsion should be included in the differential diagnosis. Any misdiagnosis may lead to major complications such as intraabdominal abscesses and adhesions. A 63-year-old overweight man with a body mass index (BMI) of 41 Kg/m² presented to the emergency department on a remote island with acute abdominal pain. His medical history included type 2 diabetes mellitus managed with insulin, essential hypertension, osteoarthritis, and no previous abdominal operations. He reported a sharp pain originating in the epigastrium and the right hypochondrium that started five days prior. Physical examination revealed rebound tenderness and guarding across the abdomen with a positive McBurney sign. However, the patient did not report vomiting and was not nauseous. Vital signs were as follows: blood pressure 116/56 mmHg, heart rate 98 beats/min, respiratory rate 19 breaths/min, and a temperature of 38.2 °C. Laboratory results showed a white blood cell count of 10.6, neutrophils of 8.11, C-reactive protein (CRP) 74 mg/l, haemoglobin11.6 g/dl, and hematocrit 36.9%. Due to the absence of a radiographer at the hospital during that period, no imaging investigations were conducted. Diagnostic laparoscopy demonstrated diffused hemoperitoneum and necrotic mass at the site of the hepatic flexure. Initially suspected to be an advanced colon cancer, the decision was made to proceed with open surgery. The necrotic segment of the omentum was found at the right superior point of attachment of the omentum to the hepatic flexure. Consequently, the necrotic segment of the omentum was resected. A thorough investigation of the abdominal cavity did not detect any other abnormalities or pathologies. The patient recovered uneventfully and was transferred to the surgical ward. Torsion of the omentum is a very rare cause of acute abdominal pain. This case highlights the necessity of considering PSOT in the differential diagnosis of acute abdominal pain, especially in cases where symptoms are suggestive of appendicitis but diagnostic findings are negative. [ABSTRACT FROM AUTHOR]

Ectopic pregnancy is the implantation of the developing embryo outside the uterine cavity. It usually occurs in the fallopian tubes. One of the critical complications of ectopic pregnancy is rupture. The most common symptoms of ectopic pregnancy rupture are vaginal bleeding and abdominal pain. In atypical presentations, the diagnosis is based on suspicion. Herein, we presented a case of ruptured ectopic pregnancy with an atypical presentation. The diagnosis of ruptured ectopic pregnancy should be considered when women with childbearing potential apply to the emergency department. [ABSTRACT FROM AUTHOR]