What is the management approach for Haemoperitoneum?

Management of Haemoperitoneum

Patients with haemoperitoneum and haemodynamic instability should undergo immediate assessment with FAST (Focused Assessment with Sonography for Trauma) followed by urgent surgical intervention if positive, while stable patients should undergo CT scanning for definitive diagnosis and treatment planning. 1

Initial Assessment and Resuscitation

Haemodynamic Stabilization

• Rapid restoration of intravascular volume to promote physiological stability 1
• For patients with septic shock, resuscitation should begin immediately when hypotension is identified 1
• Target mean arterial pressure of 65-70 mmHg in most patients 1
• For patients with traumatic brain injury (GCS <8), maintain mean arterial pressure ≥80 mmHg 1

Diagnostic Approach

1. FAST examination - rapid, non-invasive detection of free intraperitoneal fluid at bedside 1, 2

   • High specificity (97-100%) and accuracy (92-99%) but lower sensitivity (56-71%) 1
   • Particularly accurate in hypotensive patients (sensitivity and specificity close to 100%) 1

2. CT scan with IV contrast - gold standard for stable patients 1, 2

   • Provides detailed information about solid organ injuries and free fluid
   • Can detect active bleeding (contrast extravasation)
   • Helps identify source of bleeding (sentinel clot) 3

3. Diagnostic peritoneal lavage (DPL) - largely replaced by FAST and CT scanning 2

   • Consider only when FAST is unavailable or results are equivocal 2
   • Associated with complications including bleeding, infection, and visceral perforation 2

Management Algorithm

Haemodynamically Unstable Patients

1. Immediate resuscitation with fluid therapy and blood products 1

   • Initial coagulation resuscitation should comprise either:
     • Fibrinogen concentrate/cryoprecipitate and packed RBCs, OR
     • FFP or pathogen-inactivated FFP in a FFP:pRBC ratio of at least 1:2 1

2. FAST examination to detect free fluid 1

   • If positive with significant free fluid → urgent surgical intervention 1

3. Source control procedures 1

   • Damage control surgery for patients with:

     • Deep haemorrhagic shock
     • Signs of ongoing bleeding
     • Coagulopathy
     • Hypothermia
     • Acidosis 1

   • For pelvic fractures:

     • Early pelvic ring closure and stabilization 1
     • Temporary extra-peritoneal packing when bleeding is ongoing 1
     • Consider angioembolization for arterial bleeding 1
     • REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) may be considered as a bridge to definitive hemorrhage control 1

   • For abdominal bleeding:

     • Packing, direct surgical bleeding control, and local haemostatic procedures 1
     • In exsanguinating patients, aortic cross-clamping may be employed as an adjunct 1

Haemodynamically Stable Patients

1. CT scan for detailed assessment 1, 2

   • Identifies source of bleeding
   • Determines extent of injury
   • Guides treatment approach

2. Treatment options based on CT findings:

   • Solid organ injury (liver, spleen):

     • Non-operative management for selected cases 4
     • Angioembolization for active extravasation 5
     • Surgery for failed non-operative management or worsening status 1

   • Vascular injury:

     • Angioembolization for accessible arterial bleeding 1
     • Surgical repair for major vessel injuries 1

   • Gynecological causes (ruptured ovarian cysts, ectopic pregnancy):

     • Laparoscopic management when feasible 6
     • Laparotomy for unstable patients or extensive bleeding 6

Special Considerations

Non-traumatic Haemoperitoneum

• Common causes: ruptured hepatic tumors, ruptured ovarian cysts, ectopic pregnancy, anticoagulation therapy 3, 5
• Management principles similar to traumatic causes but focused on underlying etiology 5

Pharmacological Management

• Tranexamic acid: administer as soon as possible in bleeding trauma patients 1
  • Loading dose: 1g over 10 minutes
  • Followed by infusion of 1g over 8 hours
  • Most effective when given within 3 hours of injury 1

Monitoring and Follow-up

• Serial clinical examinations and hemoglobin measurements for patients managed non-operatively 4
• Repeat imaging (ultrasound or CT) for patients with equivocal findings or clinical deterioration 2
• Monitor for abdominal compartment syndrome in patients with significant haemoperitoneum 1

Pitfalls to Avoid

• Delaying surgical intervention in unstable patients with positive FAST examination 1
• Relying solely on FAST examination to exclude intra-abdominal bleeding (given its lower sensitivity) 1, 2
• Performing unnecessary laparotomy in stable patients who can be managed non-operatively 4
• Failing to consider gynecological causes in women of reproductive age 6