What is the management of hemoperitoneum?

Management of Hemoperitoneum

Immediate Assessment: Hemodynamic Status Determines Everything

The management of hemoperitoneum hinges entirely on hemodynamic stability—unstable patients require immediate surgical bleeding control or angioembolization after rapid source identification, while stable patients undergo CT imaging followed by selective intervention. 1

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Hemodynamically Unstable Patients

Immediate Resuscitation

• Establish IV access, initiate fluid resuscitation, and administer blood products immediately 1, 2
• Minimize time between injury and definitive intervention—delays increase mortality 1, 2
• Patients in hemorrhagic shock with identified bleeding source require immediate surgical control unless initial resuscitation succeeds 1, 2

Rapid Diagnostic Sequence

• Perform E-FAST immediately at the bedside during ongoing resuscitation 1, 3
• E-FAST has 100% sensitivity and specificity for detecting hemoperitoneum in hypotensive patients 4, 1
• Obtain chest X-ray and pelvic X-ray simultaneously to identify bleeding sources 1, 3
• When E-FAST and chest X-ray combined are used, they enable appropriate urgent intervention decisions with 98% accuracy 3

Decision Algorithm Based on E-FAST Findings

• Abundant hemoperitoneum (3 positive E-FAST sites): Proceed directly to emergency laparotomy—this correlates with 61% appropriate laparotomies 1, 3
• Moderate hemoperitoneum (2 positive E-FAST sites): Consider laparotomy—correlates with 26% appropriate laparotomies 3
• If E-FAST and chest X-ray rule out extra-pelvic hemorrhage: Proceed to angiography/embolization for pelvic bleeding 1, 3

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Hemodynamically Stable Patients

Comprehensive Imaging

• Obtain thoraco-abdomino-pelvic CT scan with IV contrast as the primary diagnostic modality 1, 3
• CT has 93.9% sensitivity and 77.8% specificity for detecting active bleeding 1
• Skip pelvic X-ray in stable patients—proceed directly to CT 2

Intervention Based on CT Findings

• Active contrast extravasation on CT: Consider angioembolization 1
• Solid organ injury without active bleeding: Consider non-operative management with close monitoring 1
• Hollow viscus injury: Surgical exploration required 4

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Diagnostic Modality Performance Characteristics

E-FAST Strengths and Limitations

• Sensitivity for hemoperitoneum: 68-91% overall, 100% in hypotensive patients 4, 1, 3
• Specificity: 98-99.7% 4, 1
• Positive predictive value of 97% for intra-abdominal bleeding in pelvic trauma 3
• Critical limitation: Cannot detect hemoperitoneum until at least 500 mL is present 1
• Poor sensitivity (58%) for bowel and mesenteric injuries 4

CT Scan Performance

• Sensitivity 98%, specificity 99% for intra-abdominal injury overall 4
• Effectively identifies hemoperitoneum, retroperitoneal trauma, and solid organ injuries 4
• Less effective for diaphragmatic, pancreatic, and hollow viscus injuries 4

Diagnostic Peritoneal Lavage (DPL)

• Sensitivity >99% for hemoperitoneum but largely obsolete given E-FAST and CT availability 1
• Complication rate 0.8-2.3% 1
• Neither specific nor reliable for retroperitoneal injuries 1

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Critical Pitfalls to Avoid

E-FAST False Positives and Negatives

• Blood clots form rapidly and appear similar to soft tissue—can be overlooked 1
• Perinephric fat may be mistaken for hemoperitoneum 1
• Hemoretroperitoneum or intraperitoneal bladder rupture can create false positives 1, 3
• Negative E-FAST does not exclude early or slowly bleeding injuries 1

Management Errors

• Never delay intervention in unstable patients for additional imaging 1, 2
• Don't rely solely on E-FAST to exclude all intra-abdominal injuries—it misses bowel injuries 1
• Avoid using oral contrast in acute trauma—it delays diagnosis without improving accuracy and carries aspiration risk 4

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Special Clinical Scenarios

Pelvic Trauma with Hemoperitoneum

• This combination creates a difficult decision algorithm requiring assessment of all potential bleeding sources 1
• If extra-pelvic causes are excluded, proceed to angiography/embolization 1, 3
• Apply external pelvic compression with binders around the greater trochanters immediately 2

Non-Traumatic Hemoperitoneum

• Consider ruptured hepatocellular carcinoma, hepatic adenoma, or vascular metastases 5, 6
• Gynecologic causes: ruptured ovarian cyst, ectopic pregnancy, HELLP syndrome 5, 7
• Vascular lesions: visceral artery aneurysms in Ehlers-Danlos syndrome or pancreatitis 5, 6
• Iatrogenic causes: anticoagulation therapy, post-procedural complications 5

Pregnancy-Related Hemoperitoneum

• Determine pregnancy status with β-hCG immediately 2
• Perform pelvic ultrasound to evaluate for ectopic pregnancy (13% prevalence in symptomatic ED patients) 2
• Consider ruptured uterine varix in advanced pregnancy 8
• Emergency cesarean section may be required for maternal hemodynamic stability 8