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Blood Is Everywhere!
Important Poten�al and Emergent Causes of Bleeding In the Abdomen and Pelvis
EugeneHuo,MDLauraEisenmenger,MD
SpencerBehr,MD
UniversityofCalifornia,SanFranciscoAbstractCID:2622776
Disclosures:Dr.Behr:GEHealthcare–GrantandConsultant.Navidea–GrantandConsultant
Hemoperitoneum Manytraumaandatrauma�ccauses CTremainsthe“workhorse”ofevalua�on
Fastwithmul�ple�me-pointimaging
CTsignsofhemoperitoneum: “Sen�nelclot” Ac�vearterialextravasa�on Mesentericfluid
BloodhaséHUthanotherbodyfluids.However… Dependsonage,extent,andloca�on Unclo�edextravascularblood=~30–45HU <30HUif(a)êserumhematocritlevel,(b)an�coagula�on,or(c)hemorrhage>48hoursold
Loca�ngthesourceofintraperitonealhemorrhagecanhelpdirectmanagement
Trauma LeadingcauseofdeathintheUS<45yearsold Fourthhighestoverallcauseofdeath FASTscanultrasonography
Assessforhemopericardiumandhemoperitoneum Imagethehepatorenalrecess(Morison'spouch),perisplenicspace,pericardium,andpelvis
Mostcommonloca�onofbleed:liver,spleen Uniquecomplica�on:“Pagekidney” Traumagrading:AmericanAssocia�onfortheSurgeryofTrauma(AAST)
h�p://www.aast.org/Library/TraumaTools/InjuryScoringScales.aspx
Important CT findings of trauma Solidorganinjury
Sen�nelclot High-a�enua�onfluid
Nearoraroundtheinjuredorgan Inthecul-de-sacs,paracolicgu�ers,pelvis
Ac�veextravasa�on:1. Ac�vebleedingfromavesselonangiographicphase2. Serpiginousborderofhigh-a�enua�on3. Changesina�enua�on/morphologyonmul�phaseimaging
Mesentericorbowelinjury
Triangularhigh-a�enua�oninterloopmesentericfluidcollec�ons Bowelwallthickening Othersignsofac�veextravasa�oninmesenteryorbybowelloops
Case 1: Trauma HISTORY:53yostatuspostmotorvehiclecollision,unstablevitals IMAGING:
Post-contrastCT:Hypoa�entua�ngspleniclacera�ons(arrow)andac�veextravasa�onofcontrast Angiography:Splenicarteryaneurysmnearthehilumandac�veextravasa�on(arrow) Angiographypost-emboliza�onwithcoilsplacedinthesplenicaneurysm(orangearrow).Noflowdistaltothespleenandnofurtherextravasa�on
TREATMENT:Emboliza�on,solidorganremoval,orobserva�ondependingonpa�entstabilityandavailabletherapies
Axial
Angiography
Angiography–postemboliza�on
Case 2: Trauma, now hypertensive HISTORY:32yos/pmotorvehicleaccidentandwithsubsequenthypertension IMAGING:
Post-contrastCT(top):Subcapsularhypera�enua�ngfluid(arrow)compressingthele�renalparenchyma,findingsconsistentwithtrauma�cpagekidney
Pagekidney:Hypertensionsecondarytorenalcompressionusuallyassociatedwithaperinephricorsubcapsularhematoma
Fluoroscopy(bo�om)a�erdrainplacementwithinjectedcontrastinthesubcapsularspace
TREATMENT:Surgicalapproach(nephrectomyorhematomaevacua�on)andan�hypertensivetreatment
Fluoroscopy
Axial
Vascular Intraperitonealbleedingfromvascularlesionsislesscommonthanretroperitonealhemorrhage;however,morbidityandmortalitycanbehigh Acquiredvascularlesions:
Aneurysms Pseudoaneurysms Angiodysplasia
Congenitalvascularlesions: Arteriovenousmalforma�ons
Specialcase:Inyoungpa�ents,splanchnicarteryaneurysmsshouldincreasesearchforsystemicvasculardisease,mostnotablytypeIVEhlers-Danlossyndrome.Inpa�entswithEhlers-Danlossyndrome: Maypresentwithaspontaneousaneurysmrupture Angiographymaybecontraindicatedbecauseoftheriskofaneurysmforma�onatthesiteofpunctureandothervascularinjury/complica�ons
Aneurysm vs pseudoaneurysm Aneurysm:
Arterialdila�onwithintactvesselwalllayers Abdominalaor�caneurysm:
300millionpeopleglobally Elec�verepaircommonat5.5cm Withoutrepair,rupturediso�enfatal
Splenicarteryaneurysm: Mostcommonvisceralaneurysm(60%) Spontaneousruptureoccursin3%–10%ofsplenicarteryaneurysms Dangerofruptureiflarge,inpregnantpa�ent,orinpa�entwithadvancedliverdisease
Pseudoaneurysm: Injurytoall3layersofthearterialwall Containedrupturewithperfusedsacthatcommunicateswithartery Pseudoaneurysmsofthehepa�c,splenic,andgastroduodenalarteriescanbecomplica�onsofpancrea��s Riskfactorsformajorvascularcomplica�onsofpancrea��sinclude:necro�zingpancrea��s,mul�-organfailure,sepsis,andpancrea�cfluid-collec�onssuchasabscesses,pseudocystsorwalled-offnecrosis
Case 3: Abdominal pain and syncope HISTORY:93yomalepresen�ngwithprogressiveabdominalpainfor24hours IMAGING:
Pre-contrastCTwithfreeabdominalfluidmeasuring38HU. Arterialphase(axialandsagi�al)CT:Enlargedabdominalaortawithac�veextravasa�onofcontrast(arrows)andsignificantperiaor�cfatstranding/hemorrhageindica�nganabdominalaor�caneurysmrupture. Sagi�alCT:Aor�cwalldefect(orangearrow) Delayedimagesdemonstra�ngextravasatedcontrastspreadingthroughouttheperitonealcavity Pa�entdiedwithin1hourofCT
TREATMENT:Stabilizepa�entandemergentsurgicalorendovascularaor�crepair
Pre-contrast
Arterial
Delayed
Sagi�al
Case 4: Recent pancrea��s HISTORY:58yoMwithepisodeofacutepancrea��s,nowwithnewonsetupperabdominalpain IMAGING:
Post-contrastCTaxialandcoronalimageswithasplenicarterypseudoaneurysm(arrowhead)withinapancrea�cpseudocyst(arrow)andsurroundingfatstranding Angiographydemonstra�ngthesplenicarterypsuedoaneurysm(arrowhead)withac�veextravasa�on(arrow)
TREATMENT:Stabiliza�onifbleedingac�vely.Emboliza�onduetocurrentbleedingortopreventfuturebleedingbecauseofthehighrisk
Angiography
Gastrointes�nal bleed Thoughnottypicallyacauseofhemoperitoneum,gastrointes�nal(GI)bleedscanbelifethreatening GIbleed
CanoccuranywherealongtheGItractandpassthroughthebowel E�ologies:mass,angiodysplasia,inflamma�on
CTAremainsanimportantdiagnos�ctoolfornonvaricealupperGIbleedsbutislessusefulinlowerGIbleeds ACRAppropriatenessCriteriaforlowerGIbleedsstateCTAuseisusuallyappropriateasthenextprocedure/interven�onfor: Ac�vebleedingwithhematocheziaormelenainahemodynamicallystablepa�ent Intermi�entorobscurenon-localizedrecurrentbleeding
CTAusemaybeappropriatewhen: Ac�vebleedinginahemodynamicallyunstablepa�entorapa�entwhohasrequiredmorethan5unitsofblood
However,transcatheterarteriography/interven�on(TAI)isusuallyrecommendedinthiscircumstance
CTAisusuallyNOTrecommendeda�erlowerGIbleedingsourceisalreadyiden�fied
Case 5: Melena HISTORY:71yowithmelena IMAGING:
AxialandcoronalCTAimagesdemonstra�ngac�veextravasa�onintotheascendingcolonnearthehepa�cflexure(arrows),consistentwithalowerGIbleed Angiographyimagesfromaselec�veinjec�ondemonstra�ngbriskpassageofcontrast(arrows)intothecoloniclumen
TREATMENT:Stabiliza�onofthepa�ent.Endoscopictreatmentorendovascularemboliza�on.Ifunavailable,opensurgerymaybenecessary
Axial Coronal
Angiography-early Angiography-later
Gynecologic Reproduc�vetractisthemostcommonsourceofspontaneoushemoperitoneuminwomenofchildbearingage PrimaryimagingmodalityusedisUS;
CTusediftheclinicalfindingsarenonspecific
Mostcommon:ectopicpregnancyandrupturedovariancyst Lesscommon:endometriosis,uterinerupture,andHELLPsyndrome(subcapsularhematomaorhepa�crupture)
Case 6: Abdominal pain, vaginal bleeding HISTORY:31yopresen�ngwithacuteonsetabdominalpain
IMAGING: Post-contrastCT:A�entua�ngbloodproductsrangingfrom35-50HUinthepelvis,consistentwithhemoperitoneum Peripherallyenhancingcys�cmassintherightadnexa,consistentwithahemorrhagiccyst(arrow) Transvaginalultrasound2dayslater:Smallamountofresidualfluid.Pa�entsymptomsresolvedbythis�me.
TREATMENT:Ifstable,observa�on.Inunstablepa�ents,bloodtranfusionorsurgicalinterven�onmayberequired
Transvaginal
Axial
Case 7: Posi�ve β-HCG, abdominal pain HISTORY:36yowithaposi�veβ-HCGandacuteonsetle�lowerquadrantabdominalpain
IMAGING: TransvaginalUS:Thickenedendometriallining(arrowheads)withnointrauterinegesta�onalsac M-modetransvaginalUS:Le�adnexawithdetectablefetalheartrate,consistentwithaliveectopicpregnancy(arrow)
TREATMENT:Emergentsurgicalinterven�on
M-mode
Ectopic pregnancy 1%ofpregnancies
97%ofoccurrenceslocatedineithertheampullary(mostcommon)ortheisthmicpor�onofthefallopiantube
Riskfactors: Previousectopicpregnancy Pelvicinflammatorydisease Invitrofer�liza�on Intrauterinedevice Tubalsurgery
Signsofectopicpregnancy: Posi�vehumanchorionicgonadotropinlevelofmorethan2000IU/Landnointrauterinepregnancy Extraovarianmass
Case 8: Pregnant pa�ent with RUQ pain HISTORY:30yopregnantfemalepresen�ngwithsevererightupperquadrantpain,hypertension,andelevatedliverenzymes.Emergencyc-sec�onwasperformedfollowedbyCT IMAGING:
Non-contrastCT:Largehighdensitysubcapsularhematoma(arrow)withadjacenthepa�cedema.Dependenthigherdensityfluidcorrespondingtobloodintheparacolicgu�er(arrowhead)
HELLPsyndrome Peripartumtriad:hemolysis,elevatedliverenzymes,andlowplateletcount
Disseminatedintravascularcoagula�onin20%-40%ofpa�ents
Othercomplica�ons:hepa�cinfarc�on,hematoma,hepa�crupture,andplacentalabrup�on
TREATMENT:Stabilizepa�entanddeliveryofthepregnancy
Iatrogenic bleeds Anysurgicalproceduremaycausehemoperitoneum
Evenminimallyinvasivepercutaneousorendovascularproceduresoccasionallyleadtointraperitonealhemorrhage
Causes: Directvascularinjury
Examples:endovascularinjury,percutaneousoropensurgicalinjury(eg.inferiorepigastricarteryduringparacentesis)
Biopsyorsurgeryinvolvingasolidorganormass Examples:liver,spleen,renalcellcarcinoma,hepatocellularcarcinoma
Case 9: Percutaneous liver biopsy HISTORY:45yowithsevererightupperquadrantpains/ppercutaneousliverbiopsy
IMAGING: Post-contrastaxialCT:Hemoperitoneumandac�veextravasa�on(arrows)fromtheliverbiopsysiteconsistentwithbiopsy-relatedhemorrhage
TREATMENT:Conserva�vemanagementwithstabiliza�on.Considerreversingan�coagula�on.Endovascularemboliza�onifpa�entdemonstrateshemodynamicinstabilityorcon�nuedhemorrhage
Arterial
PortalVenous
Case 10: Severe RUQ pain a�er TACE HISTORY:64yowithabdominalpaina�erTACEviarightfemoralarteryaccess IMAGING:
Post-contrastCT:Noac�veextravasa�on.Higherdensityfluidwithintherightabdomenconcerningforhemoperitoneum Metallicclosuredevice(arrowhead)superficialtotheexpectedloca�onofthefemoralarterywithinterposedhematoma Angiographyshowingaccesssite.Hemorrhagefromacombina�onofhighfemoralaccessandfailedclosuredevice
TREATMENT:Monitorforstability,ifac�vehemorrhagethenmayrequireendovascularsten�ngoropenrepair
Spontaneous bleeds “Spontaneousbleeds”arelargelyamisnomer Usuallyan�coagula�onrelated,withriskofbleedingpropor�onaltotothedegreeofan�coagula�on An�coagula�onmostcommonlycauseshemorrhageintotheretroperitoneum/psoasorrectusmuscles,butoccasionallyresultsinhemoperitoneum
Trulyspontaneoushemoperitoneumisrare Mustexcluderuptureofoccultneoplasm
Pa�entwithportalveinthrombosis(arrowhead)treatedwithTIPS/declotandan�coagula�onwhopresentswithsuddenRUQpain,noreportedtrauma.Largehematoma(arrow)withruptureintotheperihepa�cspace.
Post-TIPSwithouthematoma
NewRUQpain10dayslater
Case 11: Pain and right abdominal bruising HISTORY:61yowithchronicabdominalpainanddiarrheaonlow-molecularweightheparinforatrialfibrilla�on.Acuteonsetabdominalpainandhypotension IMAGING:
Post-contrastCT:Rightrectushematomaextendingintotheanteriorpelvis(tople�)andasecondintrapelviccollec�onwithlayeringdependenthighdensity(bo�omle�) Angiographydemonstra�ngac�veextraperitonealhemorrhage(orangearrows)
TREATMENT:Conserva�vemanagementwithstabiliza�on.Considerreversingan�coagula�on.Angiographycanbeu�lizedfordiagnos�candtherapeu�cpurposes
Angiography
Bleeding masses Spontaneoushemoperitoneumintheabsenceoftrauma,instrumenta�on,oran�coagula�ontherapyisrare Insuchcases,arupturedneoplasmmustbeexcluded
Eitherprimaryormetasta�ctumorcanruptureandbleedintotheperitonealcavitybuthighlyvascularmassesmorecommonlybleed
Primarymasses: Mostcommonprimarylesionstocausehemoperitoneumareliverandrenal Rupturingsplenicmassesaremorerarethanhepa�correnal
E�ologies:Hemangiomatosis,angiosarcoma,leukemia,orlymphoma
Metasta�cmasses: Spontaneousruptureisrarebutcancausemassivehemoperitoneum Mostcommon:Lungcarcinoma,renalcellcarcinoma,andmelanoma
Renal masses Mostcommonspontaneouslyhemorrhagingmassisabenignormalignantneoplasm(61%) Mostcommon:Angiomyolipoma(29%) Secondmostcommon:Renalcellcarcinoma(26%)
Angiomyolipoma Associatedwithtuberoussclerosis <4cm:usuallywatch ≥4cm:prophylac�cemboliza�onduetoriskofhemorrhage
Case 12: Flank pain HISTORY:61yowithacuteonsetle�flankpain IMAGING:
Post-contrastCT:Fatcontaininglesionintheinferiorle�kidney(arrow) Surroundinghemorrhageintheperinephricspaceandlayeringinthele�paracolicgu�er(orangearrows),consistentwitharupturedangiomyolipoma(AML)
TREATMENT:Stabiliza�onofthepa�ent.Endovascularemboliza�onorresec�onisalsoapossibility,eitheremergentlyorifthelesionis≥4cm
Axial
Coronal
Hepa�c masses Hepatocellularcarcinoma(HCC)
Mostcommoncauseofatrauma�chemoperitoneuminmalepa�entsofallages; Nearly15%incidenceofrupture* Largeorperipherallylocatedtumorswithoutnormaloverlying�ssueareatahigherriskforrupture
Hepa�cadenoma Benignlivertumorassociatedwithincreasedestrogen Morecommoninfemalesandthoseonoralcontracep�ves Avidlyenhanceandcancontainfat
Cavernoushemangioma Fewcasesofhemorrhageandspontaneousruptureandhemorrhageoftheselesionsreported Gianthemangiomas>10cmmorelikelytorupture,par�cularlywithtraumaorduringpregnancy
*Kim,H.C.,Yang,D.M.,Jin,W.etal.AbdomImaging(2008)33:633.doi:10.1007/s00261-007-9353-7
Case 13: Acute RUQ pain HISTORY:55yowithhepa��sCandcirrhosis.Acuterightupperquadrantabdominalpain IMAGING:
Post-contrastCT:Enhancingexophyichepa�cmass(arrow)withfocalruptureoftheoverlyingcapsule,andsurroundingperihepa�chemorrhage,consistentwithrupturedhepatocellularcarcinoma
TREATMENT:Stabiliza�onofthepa�entandobserva�on.Endovascularemboliza�onorhepa�cresec�onifunstable.TreatmentoftheHCCa�erresolu�onofacutecondi�on
Axial
Coronal
Case 14: Acute RUQ pain HISTORY:31yoonoralcontracep�veswithacuterightupperquadrantabdominalpain
IMAGING: Post-contrastCT:Enhancinghepa�cmass(arrows)withcapsulerupture(orangearrow)andsurroundingperihepa�chemorrhage,consistentwithrupturedhepa�cadenomaandhemoperitoneum In-andout-of-phaseMRI:Mul�pleaddi�onallesionswithsignaldropout,consistentwithsmaller,fatcontaininghepa�cadenomas
TREATMENT:Ini�alstabiliza�onofthepa�ent.Endovascularemboliza�onorhepa�cresec�ontostopac�vebleeding.Defini�vetreatmentishepa�cresec�onduetohighriskoffuturebleeding.
CT
MRIin-phase
MRout-of-phase
Conclusions Abdominalandpelvichemorrhageareimportantcausesofmorbidityandmortalityinthese�ngofbothtrauma�candatrauma�ccases
Theradiologistshouldbeabletoconveyemergentfindingsandrecommendappropriateaddi�onalimaging
Accurateiden�fica�onofabdominalandpelvichemorrhageandconcisedescrip�onofassociatedinjurycanhelpguidepa�entcare
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