What is the management of hemoperitoneum?

Management of Hemoperitoneum

The management of hemoperitoneum requires rapid assessment of hemodynamic status, identification of bleeding source, and appropriate intervention based on patient stability, with immediate surgical control indicated for unstable patients despite resuscitation efforts. 1

Initial Assessment and Stabilization

• Hemodynamic stability is the key factor in determining management strategy 1
• For unstable patients, immediate resuscitation measures should include IV access, fluid resuscitation, and blood products if necessary 2
• The time between injury and intervention should be minimized for patients requiring urgent bleeding control 2
• Patients presenting with hemorrhagic shock and identified source of bleeding should undergo immediate surgical bleeding control unless initial resuscitation is successful 2

Diagnostic Approach

Hemodynamically Unstable Patients

• Extended Focused Assessment with Sonography for Trauma (E-FAST) should be performed to identify potential sources of bleeding 1, 2
• E-FAST has 68-91% sensitivity and excellent specificity for detecting hemoperitoneum, with 100% sensitivity and specificity in hypotensive patients 1
• Pelvic X-ray and chest X-ray should be obtained for patients who are hemodynamically unstable or require urgent intervention to stabilize vital signs 1, 2
• When E-FAST and chest X-ray rule out extra-pelvic causes of hemorrhagic shock, angiography should be considered to visualize active arterial bleeding 1
• The abundance of hemoperitoneum on E-FAST correlates with the need for laparotomy - 3 positive E-FAST sites (abundant hemoperitoneum) is associated with 61% appropriate laparotomies 1

Hemodynamically Stable Patients

• A thoraco-abdomino-pelvic CT scan with intravenous contrast should be performed when hemodynamic status allows 1, 2
• Pelvic X-ray is not necessary for stable patients; proceed directly to CT scan with contrast 1
• CT scan with contrast has high sensitivity (93.9%) and specificity (77.8%) for detecting active bleeding compared to angiography 1

Management Algorithm

For Hemodynamically Unstable Patients:

1. Immediate resuscitation (IV access, fluids, blood products) 2
2. E-FAST, chest X-ray, and pelvic X-ray to identify bleeding source 1
3. If extra-pelvic causes of hemorrhagic shock are ruled out:
   • For pelvic trauma with hemoperitoneum: Consider angiography/embolization 1
   • For abundant hemoperitoneum on E-FAST: Consider emergency laparotomy 1
4. If multiple potential bleeding sources exist, semiquantitative analysis of hemoperitoneum size can help guide decisions - large hemoperitoneum has 62% positive predictive value for active peritoneal hemorrhage requiring intervention 3

For Hemodynamically Stable Patients:

1. Thoraco-abdomino-pelvic CT scan with intravenous contrast 1, 2
2. Based on CT findings:
   • Identified solid organ injury (liver, spleen): Consider non-operative management or angioembolization 4, 5
   • Active extravasation of contrast: Consider angioembolization or surgical intervention 4
   • Sentinel clot: May indicate source of bleeding and help direct management 4

Special Considerations

• In patients with pelvic fractures, the presence of hemoperitoneum doesn't always indicate peritoneal injury requiring hemostatic procedure - semiquantitative analysis of hemoperitoneum size improves predictability 3
• For non-traumatic hemoperitoneum, consider causes such as ruptured hepatocellular carcinoma, hepatic adenoma, vascular metastases, gynecologic conditions, or vascular lesions 4, 5
• Diagnostic peritoneal lavage (DPL) has high sensitivity (>99%) for hemoperitoneum but is neither specific nor reliable for retroperitoneal injuries and is associated with 0.8-2.3% risk of complications 1
• When pelvic trauma is associated with hemoperitoneum, the decision algorithm becomes more difficult and requires careful assessment of all potential bleeding sources 1

Pitfalls to Avoid

• Don't rely solely on E-FAST to exclude all intra-abdominal injuries - it has lower sensitivity for bowel and mesenteric injuries 1
• Avoid unnecessary laparotomies based solely on the presence of hemoperitoneum in pelvic fracture patients without considering the size of hemoperitoneum and other clinical factors 3
• Remember that E-FAST performance may be diminished by false positives such as suffusion of a hemoretroperitoneum or intra-peritoneal bladder rupture 1
• Don't delay intervention in unstable patients - the time between injury and intervention should be minimized 2