What is the management approach for an adult patient with hemoperitoneum, likely due to abdominal trauma or underlying medical conditions?

Management of Hemoperitoneum

Patients with hemoperitoneum and hemodynamic instability require immediate surgical bleeding control unless initial resuscitation is successful, while hemodynamically stable patients should undergo CT imaging to guide definitive management. 1, 2

Immediate Assessment and Resuscitation

Hemodynamic status is the single most critical determinant of management strategy. 2

• Establish large-bore IV access and initiate resuscitation with blood products targeting hemoglobin 7-9 g/dL while pursuing definitive hemorrhage control 3
• Apply permissive hypotension (systolic BP 80-100 mmHg) until bleeding is definitively controlled, as aggressive crystalloid resuscitation worsens hemorrhage through clot dislodgement and dilutional coagulopathy 3
• Minimize time between injury and intervention—mortality increases approximately 1% every 3 minutes of delay in unstable patients 3, 4
• Administer tranexamic acid 10-15 mg/kg followed by 1-5 mg/kg/h infusion to prevent fibrinolysis 3, 4

Diagnostic Algorithm Based on Hemodynamic Status

For Hemodynamically Unstable Patients:

Perform E-FAST immediately to differentiate between intra-abdominal injury requiring laparotomy versus pelvic arterial bleeding requiring angioembolization. 2, 3, 4

• E-FAST has 100% sensitivity and specificity for detecting hemoperitoneum in hypotensive patients 1
• If E-FAST shows abundant hemoperitoneum (≥3 positive sites), proceed directly to emergency laparotomy—this indicates 61% probability of intra-abdominal injury requiring surgical control 2, 3
• If E-FAST is negative or shows minimal free fluid, the bleeding source is likely pelvic arterial hemorrhage requiring angiographic embolization (73-97% success rate) 3, 4
• Obtain chest X-ray and pelvic X-ray simultaneously to identify extra-pelvic bleeding sources 2, 3

For Hemodynamically Stable Patients:

Obtain thoraco-abdomino-pelvic CT scan with intravenous contrast to identify bleeding source and guide management. 1, 2

• CT has 93.9% sensitivity and 77.8% specificity for detecting active bleeding compared to angiography 2, 4
• Contrast extravasation within the peritoneal cavity indicates active massive bleeding and predicts rapid hemodynamic deterioration requiring emergent surgery 1
• Intra-parenchymal contrast pooling with intact organ capsule often indicates self-limited hemorrhage amenable to non-operative management 1

Definitive Management Pathways

Immediate Surgical Control (Grade 1B):

Indicated for patients with hemorrhagic shock and identified bleeding source who fail initial resuscitation. 1

• Penetrating injuries with hemodynamic instability require immediate operative bleeding control 1
• Blunt trauma with abundant hemoperitoneum on E-FAST requires emergency laparotomy 2, 3
• Do NOT perform laparotomy for isolated pelvic bleeding—this cannot control pelvic arterial hemorrhage and dramatically increases mortality 3, 4

Angiographic Embolization:

The definitive treatment for arterial pelvic bleeding with 73-97% success rate. 3, 4

• Indicated when E-FAST rules out significant intra-abdominal injury but patient remains hypotensive despite pelvic stabilization 3, 4
• Proceed directly to angiography without additional imaging in persistently hypotensive patients 3, 4
• Ensure pelvic binder remains in place during angiography to control venous and cancellous bone bleeding 3, 4

Non-Operative Management:

• Consider for hemodynamically stable patients with solid organ injuries and minimal hemoperitoneum on CT 1
• Large volume hemoperitoneum (≥500 mL) is a risk factor for non-operative management failure but not an absolute contraindication 2

Critical Pitfalls to Avoid

• E-FAST cannot detect hemoperitoneum until at least 500 mL is present—a negative exam does not exclude early or slowly bleeding injuries 2
• E-FAST has lower sensitivity (69%) for bowel and mesenteric injuries compared to solid organ injuries 1
• Do not delay angiography for additional imaging in unstable patients—every 3 minutes of delay increases mortality by 1% 3, 4
• Do not remove pelvic binders prematurely, as mechanical stabilization must be maintained until definitive hemorrhage control is achieved 3, 4
• Diagnostic peritoneal lavage has high sensitivity (98%) but false-positive rates of 13-54% leading to non-therapeutic laparotomies with 20% complication rates 1
• Blood clots form rapidly in the peritoneum and may have sonographic qualities similar to soft tissue, potentially being overlooked on ultrasound 2

Non-Traumatic Hemoperitoneum Considerations

When trauma is excluded, search for alternative causes including: 5, 6, 7

• Hepatic causes: hepatocellular carcinoma, hepatic adenoma rupture, HELLP syndrome
• Gynecologic causes: ruptured ovarian cyst, ectopic pregnancy
• Vascular causes: visceral artery aneurysm rupture, Ehlers-Danlos syndrome
• Coagulopathy: anticoagulation therapy, hemophilia, polycythemia vera
• Iatrogenic: post-procedural complications