From the Guidelines
The treatment for hemoperitoneum should prioritize urgent surgical intervention, such as laparotomy, to identify and control the source of bleeding, especially in cases of severe pelvic trauma associated with hemoperitoneum, as suggested by the study of Rucholtz et al. 1.
Initial Management
Initial management includes fluid resuscitation with crystalloids, such as normal saline or lactated Ringer's, and blood products as needed, typically starting with 1-2 liters of crystalloids followed by packed red blood cells if hemodynamic instability persists.
- The focus is on the control of bleeding, and a definite diagnosis of the source of bleeding must be established as rapidly as possible in conditions of ongoing resuscitation that do not allow performing a CT-scan.
- In haemodynamically unstable patients, pelvic X-ray, as well as chest X-ray (CXR) and Extended Focused Assessment with Sonography for Trauma (E-FAST), are the only imaging workups compatible with both ongoing resuscitation and the imperative to decide upon different bleeding control options, either surgical or radiological.
Surgical Intervention
Urgent surgical intervention is often necessary to identify and control the source of bleeding, which may involve laparotomy or, in selected cases, laparoscopy.
- In trauma cases, damage control surgery may be performed to quickly address life-threatening hemorrhage before definitive repair.
- For patients with coagulopathy, correction with fresh frozen plasma, platelets, and cryoprecipitate may be required.
Alternative Management
In some cases of minor bleeding or when the source has been identified and is self-limiting, non-operative management with close monitoring may be appropriate.
- Interventional radiology with embolization can be an alternative to surgery in select cases, particularly for bleeding from solid organs like the liver or spleen, as suggested by the study of Fitzpatrick et al. 1.
- Throughout treatment, continuous hemodynamic monitoring, serial hemoglobin measurements, and abdominal examinations are essential to assess response to therapy and detect ongoing bleeding.
From the Research
Treatment for Hemoperitoneum
The treatment for hemoperitoneum depends on the underlying cause and severity of the condition.
- For traumatic hemoperitoneum, management may involve surgical intervention or angioembolization to control bleeding, as noted in 2.
- In cases of nontraumatic hemoperitoneum, such as spontaneous rupture of the liver or spleen, treatment may also involve angioembolization or surgical intervention 2.
- For patients with hemoperitoneum due to other causes, such as anticoagulation therapy or blood dyscrasias, treatment may involve reversal of anticoagulation or management of the underlying condition.
- In some cases, hemoperitoneum may be managed conservatively with close monitoring and supportive care, as seen in 3, where point of care ultrasound (POCUS) was used to diagnose and monitor hemoperitoneum.
- It is essential to note that hemoperitoneum can be associated with active bleeding in the peritoneum in only about 50% of hypotensive blunt trauma patients, and extraperitoneal bleeding sources should also be considered, as highlighted in 4.
- The presence of hemoperitoneum may not always indicate active bleeding in the peritoneum, and a thorough evaluation is necessary to determine the source of bleeding and guide treatment, as discussed in 4.
- In complex cases, such as anaphylaxis to prophylactic antibiotics during cesarean delivery, management may involve a multidisciplinary approach to address disseminated intravascular coagulation, hemoperitoneum, and other complications, as reported in 5.