Spontaneous intraperitoneal haemorrhage of the gastric vessels
- Benjamin A Wagner ,
- Dwight D Harris ,
- Matthew R Shalvoy and
- Julie C Bulman
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Correspondence to Dr Benjamin A Wagner; bwagner7591@gmail.com
Abstract
A male in his 70s presented to the emergency department with sudden-onset abdominal pain and syncope. While in the emergency department, he developed worsening hypotension and anaemia. A CT angiogram was suggestive of abdominal apoplexy (spontaneous intraperitoneal haemorrhage), which was treated successfully with embolisation of the bleeding vessels. Spontaneous bleeding was thought to be related to his initiation of apixaban 1 week previously. The patient made an excellent recovery and was transitioned back to oral anticoagulation.
Background
Abdominal apoplexy, or spontaneous intraperitoneal haemorrhage (SIH), refers to non-traumatic intra-abdominal bleeding. A poorly understood phenomenon, SIH is typically seen in elderly patients with hypertension, atherosclerosis, vascular disorders, or anticoagulant use. Presenting features include abdominal pain, nausea, vomiting, and haemodynamic instability. Prompt recognition, imaging, and intervention is essential for preventing the considerable mortality associated with this condition.
Case presentation
A male in his 70s presented from a rehabilitation facility to the emergency department of a tertiary care hospital with progressive abdominal pain and syncope.
He had been straining to have a bowel movement for several days, and around midnight on the day of presentation, developed sharp, progressive abdominal pain. The following morning, he got up from his bed to urinate and began to feel as though he might pass out. He then collapsed and lost consciousness for a few seconds. With a nurse’s assistance, he tried to stand but again felt as if he may pass out, prompting transfer to the emergency department.
His medical history was notable for atrial fibrillation, coronary artery disease with previous percutaneous coronary intervention, hypertension, and a large inguinal hernia. Less than 1 week previously, he had transitioned from warfarin (which he had taken for years with stable dosage and therapeutic international normalised ratios (INRs)) to apixaban for convenience. A review of systems was negative for fevers, chills, nausea, vomiting, headache, vision change, chest pain, palpitations, abdominal trauma, history of significant bleeding, or history of thromboembolism.
In the emergency department, his vital signs included a temperature of 36.8°C, blood pressure 100/62 mm Hg, pulse 60 beats/min, and oxygen saturation 100% on ambient air. Orthostatic vital signs were positive. Physical examination was notable for left lower quadrant tenderness without rebound or guarding and a large reducible left inguinal hernia. Rectal examination showed haemoccult-negative brown stool.
Investigations
Laboratory findings were notable for haemoglobin 7.3 g/dL, creatinine 1.6 mg/dL, INR 2.6, and total bilirubin 1.8 mg/dL; 5 hours later, a repeat haemoglobin was 5.9 g/dL. While in the emergency department, his systolic blood pressure fell to 79 mm Hg. Bedside ultrasound showed fluid in the abdomen. Given the patient’s hypotension, known anticoagulation, and ultrasound findings, an immediate CT angiogram of the abdomen and pelvis was ordered. This revealed a large mesenteric haematoma within the lesser sac with active bleeding from a branch of the coeliac artery (presumably a branch from the left gastric artery), with moderate volume haemoperitoneum in the upper abdomen extending into the left inguinal hernia (figure 1). In the absence of trauma, solid organ injury, or free intraluminal air to suggest perforated viscus, this constellation of findings was suggestive of abdominal apoplexy.
Images from CT angiogram. (A) Axial image demonstrates a large mesenteric haematoma centred within the lesser sac, with a significant focus of active arterial extravasation seen arising from a branch of the coeliac artery, presumably a branch from the left gastric artery (white arrow). This finding is also well-visualised on the sagittal reformatted image (B), as demarcated by the solid white arrow. There is notable mass effect from the haematoma which displaces the stomach anteriorly and multiple bowel loops inferiorly. The sagittal image also partially demonstrates a known massive inguinal hernia containing complex fluid, likely due to extension of the haemoperitoneum seen in the upper abdomen. (C) An additional axial image was notable for a separate focus of active bleeding in the inferior aspect of the haematoma (white arrow), presumably arising from an omental branch of the right gastroepiploic artery.
Treatment
Before the CT scan, the patient developed haemorrhagic shock requiring norepinephrine and a massive transfusion with eight units of packed red blood cells, two units of fresh frozen plasma, and one unit of platelets. Anticoagulation was reversed with prothrombin complex concentrate. After the CT, the patient was taken from the emergency department to interventional radiology where he underwent Gelfoam embolisation of the left gastric artery branches and distal right gastroepiploic branches (figures 2 and 3).
Images from selective left gastric arteriography and Gelfoam embolisation of left gastric arterial branches. (A) Initial digital subtraction angiography (DSA) performed from a microcatheter in the left gastric artery shows opacification of numerous left gastric artery branches coursing superiorly towards the gastric cardia and fundus, as well as numerous branches extending inferiorly towards the gastric body and antrum. (B) Super-selective DSA performed from a microcatheter in a distal inferior branch of the left gastric artery, with a few areas of persistent contrast pooling (arrows) seen on delayed imaging (C), likely representing sites of active bleeding. (D) Final post-embolisation DSA performed from a microcatheter in the left gastric artery, with the previously seen inferior branches and sites of bleeding no longer visualised following embolisation with Gelfoam (the dotted oval marks the area of the embolised vessels). Notably, the superiorly coursing left gastric arterial branches remain intact and well-opacified.
Images from gastroduodenal artery (GDA) and right gastroepiploic arteriography. (A) Digital subtraction angiography (DSA) performed from a microcatheter in the GDA is notable for the low position of the right gastroepiploic artery and its omental branches, which project over the lower abdomen/upper pelvis due to the downward displacement caused by the patient’s known massive inguinal hernia. (B) Super-selective DSA performed from a microcatheter in the right gastroepiploic artery again demonstrates the low position of multiple omental branches coursing upwards toward the mid-abdomen, with a few areas of probable contrast pooling (arrows) seen on delayed imaging (C), suggesting additional sites of active bleeding. Gelfoam embolisation was subsequently performed from this position.
Outcome and follow-up
Post-procedurally, the patient’s haemoglobin remained stable. He was transitioned back to warfarin before discharge.
Discussion
Abdominal apoplexy, also known as SIH, is defined as intra-abdominal bleeding in the absence of trauma. Most cases occur in males (2–3:1), present in middle age, and are thought to be due to aneurysms related to arteriosclerosis and essential hypertension leading to weakening of the tunica media. Other identifiable causes include portal hypertension,1 pregnancy,2 anticoagulation, fibromuscular dysplasia, connective tissue disorders (Ehlers-Danlos, Marfan syndrome), and inflammatory processes (polyarteritis nodosa, rheumatoid arthritis).3 The most common sites are the splenic artery (60%), hepatic artery (20%), superior mesenteric artery (5.5%), coeliac artery, gastrointestinal/epiploic arteries (4%), intestinal artery (3%), and duodenal/pancreatic arteries (1.5%).4
Presenting features of SIH include sudden-onset severe abdominal pain, vomiting, diarrhoea, melena, abdominal mass, peritoneal signs, shock, and anaemia. As these signs are non-specific, diagnosis requires a high index of suspicion. A focused assessment by sonography in trauma (FAST) exam has been proposed as a useful bedside screening test, demonstrating a hypoechoic or heterogeneous collection. Definitive diagnosis can be made with CT angiography, with one case series reporting a sensitivity of 80%.5 Though not commonly performed, diagnostic peritoneal lavage is a highly sensitive alternative where ultrasound or CT is unavailable.6 In cases of extreme haemodynamic instability, diagnosis is made on laparotomy. Bleeding is almost universally fatal without prompt intervention, which may be surgical (open or laparoscopic resection of aneurysms, ligation of feeding vessels, or arterial reconstruction) or endovascular (transcatheter embolisation of the feeding vessel). Endovascular management has become the standard of care at most centres, as it avoids an open surgical approach and further blood loss, with a reported success rate as high as 100%7 (although this is likely inflated by publication bias). Mortality after non-therapeutic exploratory laparotomy varies from 40–66%, while surgical ligation reduces mortality to 8.6%.8 Following ligation, there are no reports of recurrence.9 Select patients may benefit from diagnostic laparoscopy and washout of the haemoperitoneum to provide diagnostic clarity and/or relieve symptoms such as refractory pain or severe ileus.
Our patient’s history of atherosclerosis and hypertension would seem to pose potential risks of aneurysm formation, but his atherosclerotic risk was mitigated with aspirin and statin therapy and his blood pressure was well-controlled without medication. Moreover, there was no evidence on CT or conventional angiography of aneurysm formation. Incarcerated hernias have been reported to cause spontaneous mesenteric haemorrhage,10 but not non-incarcerated hernias, as was the case for our patient. In theory, straining could cause the abdominal contents to shift into the hernia sac generating stress on the vessels, but our patient’s acute onset of pain, which likely coincided with vessel rupture, occurred while at rest. The timing of our patient’s spontaneous haemorrhage within 1 week of initiating apixaban, a direct factor Xa inhibitor, after years without major bleeding on warfarin, suggests that apixaban may have been implicated in this event. There are reports of SIH associated with warfarin11 and rivaroxaban12 use; to our knowledge, this is the first case report of SIH associated with apixaban. One limitation of this patient’s life-saving endovascular management is the absence of a specimen for pathological review, which may have identified an underlying aetiology.
Patient’s perspective
A lot of it is fuzzy. The whole thing was a traumatic experience. That night I had the one good nurse at the rehab—he stayed past his shift to take care of me. The rest would have left me in bed to die. They told the ambulance to take me to the closest hospital, but the driver asked me ‘where do you usually get your care?’ and when I told him he said, ‘then we’re going to BI [Beth Israel]’. That really made all the difference.
It was a frightening experience in the ED [emergency department]. There were eight doctors in the room, all talking, and I thought I must be in serious trouble. They tipped me upside down and gave me blood—I didn’t realise how much at the time. The whole time I was in terrific pain. And then the radiologist rushed into the room and said ‘we’re going to do the best we can to save your life’.
I was surprised when I woke up. It was scary—I couldn’t breathe because of the tube in my mouth—but I was still alive, and the excruciating pain was gone. Someone must have been looking out for me that day—maybe my wife, maybe my brother. I think I caught a lucky break.
Learning points
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Spontaneous intraperitoneal haemorrhage (SIH), or abdominal apoplexy, describes the rare and highly morbid phenomenon of non-traumatic intra-abdominal bleeding.
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Risk factors for SIH include atherosclerosis, connective tissue disorders, and inflammatory disorders; in rare cases, SIH has been associated with oral anticoagulants.
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Signs of SIH include abdominal pain, shock, and anaemia in the absence of trauma.
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SIH can be promptly identified with bedside ultrasonography followed by CT angiography.
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Preferred treatment of SIH is endovascular; laparotomy is reserved for severe, uncertain, or refractory cases.
Ethics statements
Patient consent for publication
Footnotes
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Contributors BAW conceived of, coordinated, and drafted the manuscript. DDH provided input on surgical management. MRS and JCB contributed edits, images, and image captions. All authors read and approved the final manuscript.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
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Competing interests None declared.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.
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