Hemoperitoneum in cirrhotic patients in the absence of abdominal trauma

ABSTRACT

Introduction: Hemoperitoneum can be a life-threating condition in cirrhotic patients who have a limited compensatory reserve during hemorrhagic shock. We aim to review the literature on the different etiologies associated with non-traumatic hemoperitoneum (NTH), summarizing the most relevant conditions associated with spontaneous and iatrogenic peritoneal and retroperitoneal bleeding that may occur in cirrhotic patients and to illustrate the most relevant diagnostic strategies and optimal management.

Area covered: This review encompasses the current literature in hemoperitoneum in cirrhotic patients in the absence of abdominal trauma. Established diagnostic procedures, therapeutic interventions and potential novel targets are reported and discussed.

Expert opinion: To ensure the optimal management regardless of the underlying etiology of NTH, the first goal for the clinician is to obtain immediate hemodynamic stabilization with supportive measures and to control the source of bleeding. The latter can be achieved with angiographic embolization, which is usually the first choice, or with open surgery. Other therapeutic options according to specific etiologies include transjugular intrahepatic portosystemic shunt (TIPS), balloon-occluded retrograde transvenous obliteration (BRTO), balloon-occluded anterograde transvenous obliteration (BATO) or intra operative radio frequency (RF).

KEYWORDS:

• Cirrhosis
• non-traumatic hemoperitoneum
• spontaneous hemoperitoneum
• ectopic varices
• splenic artery aneurism
• ruptured Hepatocellular Carcinoma (HCC)
• retroperitoneal bleeding
• trans arterial embolization (TAE)
• emergency TIPS

Article highlights

• Ruptured hepatocellular carcinoma (HCC) is one of the most common causes of NTH. HCC can bleed into the peritoneal cavity with a frequency ranging from 3 to 15% and is associated with a mortality of up to 30%.

• Venous varices are usually found in the esophageal wall, but they can develop in all digestive or extra-digestive venous beds of the splanchnic and retroperitoneal area. Rupture of ectopic varices is a catastrophic event and may represent a diagnostic challenge.

• Splenic artery aneurysms (SAA), are very rare in the general populations, but some conditions associated with cirrhosis like hyperestrogenism and hyperdynamic state are considered important risk factors for their development. Given the rarity of these conditions, a high index of suspicion is required for a correct diagnosis and a prompt treatment.

• In cirrhotic patients, hemoperitoneum can also be secondary to some procedures such as paracentesis, liver biopsy and trans-arterial chemoembolization (TACE).

• Patients with NTH usually present with abdominal pain and signs of hypoperfusion and shock. Point of care ultrasound is usually the first test to detect free fluid in the abdominal cavity, but contrast-enhanced CT scan is mandatory in stable patients to locate the source of bleeding and to plan an appropriate treatment.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.