Visceral artery aneurysmal lesion of the omentum - a rare cause of spontaneous fatal intra-abdominal hemorrhage.

We report unexpected death of a 72-year-old man due to a hemoperitoneum (1.9 L of blood in the abdominal cavity). Postmortem examination revealed that the cause of the hemorrhage was an arterial aneurysmal lesion in the greater omentum. The lesion measured 4 × 4 × 6 cm with a generally smooth wall, but with a focal area of rupture within a hemorrhagic region measuring 1 × 2 cm. There was a substantial feeding artery. Histological examination revealed features in keeping with a pseudoaneurysm, but also with some features of a true aneurysm. There was no history of trauma and the rupture of the aneurysmal lesion that had caused the hematoperitoneum was considered to be spontaneous. Prior to his death the deceased had attended hospital for epigastric pain, which was attributed to dyspepsia, but otherwise he had not had symptoms prior to his death.

Hemoperitoneum Secondary to Liver Lobe Torsion in a Cat.

A 5 yr old male British blue shorthair cat was presented collapsed with hypotension, hypothermia, and cranial abdominal pain. Abdominal ultrasound and abdominocentesis revealed hemoperitoneum and a suspected hepatic mass. Cytology of fine-needle aspirates of the mass was inconclusive, so exploratory celiotomy was performed for diagnostic and therapeutic purposes. An enlarged, hemorrhagic papillary process of the caudate lobe was identified, with twisting of the vasculature at the hilus, so a complete lobectomy was performed using a thoracoabdominal stapler. Histopathology was consistent with liver lobe torsion with no evidence of hepatocellular neoplasia identified. This report describes the first case of hemoperitoneum secondary to liver lobe torsion without evidence of hepatocellular neoplasia in a cat and demonstrates a successful outcome following surgical management with liver lobectomy.

Lethal mesenteric perforation by osteophytes after blunt abdominal trauma.

A 50 year-old homeless man was found dead the day after he had sustained blunt abdominal trauma during a physical assault. Autopsy revealed no apparent injury to the abdominal wall, but showed a massive hemoperitoneum resulting from a large (8 cm) tear of the mesenteric root. It also revealed prominent and diffuse spinal osteophytes predominating in the lumbar region, where they were fused and formed a large anterior ossified excrescence. The diagnosis of diffuse idiopathic skeletal hyperostosis was established in the presence of continuous ossification along the anterior aspect of five contiguous vertebral bodies, without any additional features of degenerative disease on imaging. Death was attributed to intra-abdominal hemorrhage due to mesenteric perforation caused by blunt abdominal trauma in the context of diffuse idiopathic skeletal hyperostosis. This pre-existing condition was considered an aggravating factor, as anterior lumbar osteophytosis had made the mesentery more vulnerable to blunt trauma by reducing both the space separating the abdominal wall from the spine and the surface of interaction between the spine and the mesentery. Only a few cases of osteophyte-related visceral injury have been described in the literature. To our knowledge, this is the first reported case of lethal abdominal injury caused by osteophytes after blunt trauma.

Hemoperitoneum as a precursor of deep pelvic endometriosis: prospective cohort study.

OBJECTIVE: To determine whether significant hemoperitoneum could be a precursor of deep pelvic endometriosis in non-pregnant premenopausal women presenting with severe acute lower abdominal pain. METHODS: This was a prospective observational cohort study carried out at a dedicated gynecological diagnostic unit over a period of 18 months. We included consecutive non-pregnant, premenopausal women who attended with severe acute lower abdominal pain and underwent a pelvic ultrasound examination. Women were triaged for surgical or conservative management depending on the cause of pain and severity of their symptoms. Those who were selected for conservative management were invited for follow-up ultrasound scans. The main outcome measure was evidence of newly developed deep endometriosis at follow-up examination. RESULTS: Of 118 non-pregnant women who attended our unit with severe acute lower abdominal pain, 20 underwent emergency surgery and 17 had a history of endometriosis, or evidence of endometriosis on the initial scan, and were excluded from the study. Therefore, conservative management was employed in 81 women, eight of whom had evidence of significant hemoperitoneum at presentation. A total of 35 women attended for all follow-up ultrasound scans. At the completion of follow-up, four of six (67% (95% CI, 22-96%)) women who presented initially with significant intra-abdominal bleeding had developed new evidence of deep endometriosis, compared with one of 29 (3% (95% CI, 0-18%)) of those without hemoperitoneum (relative risk, 19.3 (95% CI, 3-144); P < 0.001). CONCLUSION: In some women, the presence of significant hemoperitoneum that is managed conservatively precedes the development of deep endometriosis. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Spontaneous hemoperitoneum in a pregnancy with endometriosis.

The protective effect of pregnancy on endometriosis is well known, but complications related to the pregnant state, such as hemoperitoneum, uroperitoneum and bowel perforation may occur.

Fibrinolysis in trauma patients: wide variability demonstrated by the Lysis Timer.

Hyperfibrinolysis contributes to the pathophysiology of trauma-induced coagulopathy. At present, systematic administration of tranexamic acid (TXA) is recommended in all patients in the early phase of trauma. However, there is some debate regarding whether TXA is beneficial in all trauma patients. A rapid and accurate tool to diagnose hyperfibrinolysis may be useful for tailoring TXA treatment. We conducted a proof-of-concept study of consecutive adult trauma patients. A first blood sample was obtained at the time of pre-hospital care (T1). Patients received 1 g of TXA after T1. A second sample was obtained on arrival at the emergency unit (T2). We examined coagulation, fibrin and fibrinogen formation and degradation. Fibrinolysis was assessed by determining tissue plasminogen activator (t-PA) antigen and plasminogen activator inhibitor 1 (PAI-1) activity and global fibrinolysis capacity assay using a device developed by Hyphen BioMed: the Lysis Timer (GFC/LT). The study population consisted of 20 patients (42 ± 21 years, index of severity score 32 ± 21). Both coagulation and fibrinolysis were altered at T1. GFC/LT values exhibited hyperfibrinolysis only in five patients. Principal component analysis carried out at T1 showed two main axes of alteration. The major axis was related to coagulation, altered in all patients, while the second axis was related to fibrinolysis. GFC/LT was mainly influenced by PAI-1 activity while fibrin monomers were related to the severity of trauma. At T2, GFC/LT exhibited the marked effect of TXA on clot lysis time. In conclusion, GFC/LT demonstrated huge variation in the fibrinolytic response to trauma.

Rupture of perivascular epithelioid cell neoplasm at 34 weeks' gestation: A nonendometriosis case of spontaneous hemoperitoneum in pregnancy.

Spontaneous hemoperitoneum in pregnancy (SHiP) has mainly been discussed in the context of endometriosis. With hormonal changes and enlargement of the uterus during pregnancy, tumors can also increase the chance of rupture and consequent SHiP. We report a case of a 30-year-old primiparous woman presented with sudden-onset intraabdominal hemorrhage at 34 weeks' gestation. The source of bleeding was rupture of a perivascular epithelioid cell neoplasm on the left round ligament of the uterus. The pregnancy ended with an uncomplicated, full-term, vaginal delivery. We performed an additional post-partum surgery to resect the left round ligament and transposition of the right ovary. In cases of SHiP, the possibility of a nonendometriosis origin should be considered. Preoperative imaging and histologic examinations of bleeding lesions are crucial for managing SHiP.

Idiopathic bladder rupture.

Deaths due to hemoperitoneum are not rare and can result from a variety of underlying pathologic processes, including natural disease as well as trauma. Whenever hemoperitoneum is identified at autopsy, it is incumbent upon the pathologist to identify the source of the hemorrhage. The authors present a case of probable traumatic rupture of the urinary bladder that resulted in lethal intra-abdominal hemorrhage, occurring in a young man who was found dead the morning after drinking heavily.

[COMPLICATION AFTER UNRECOGNIZED ECTOPIC PREGNANCY--A CASE REPORT].

The authors present a clinical case of performing an abortion at patient with unrecognized ectopic pregnancy and subsequent complication- perforation of the uterus and the colon and life-threatening haemoperitoneum.

Hemoperitoneum from corpus luteum rupture in patients with aplastic anemia.

BACKGROUND: Aplastic anemia is a rare hematopoietic stem-cell disorder that results in pancytopenia and hypocellular bone marrow. Women with aplastic anemia usually are at increased risk of corpus luteum rupture due to thrombocytopenia and infection. METHODS: Here we report two cases had hemoperitoneum from corpus luteum rupture in patients with aplastic anemia in our center. RESULTS: Case 1 involved two episodes of hemoperitoneum resulting from rupture of the corpus luteum in a 23-year-old unmarried female with severe aplastic anemia. This patient was managed conservatively with platelet and packed red cell transfusion. Case 2 involved two episodes of hemoperitoneum resulting from rupture of the corpus luteum in a 33-year-old married patient with aplastic anemia. Emergency laparoscopy revealed massive hemoperitoneum. Bilateral salpingo-oophorectomy were performed successively with platelet and packed red cell transfusion. CONCLUSIONS: Hemoperitoneum resulting from a ruptured corpus luteum is a life-threatening condition in patients with aplastic anemia. Prompt and appropriate evaluation of corpus luteum rupture and emergent therapy are needed.

An Autopsy Case of a Pregnant Woman With Severe Placental and Fetal Damage From Domestic Violence.

We present an autopsy case of a pregnant woman who was a victim of domestic violence. The deceased showed injuries mainly to her head and abdomen. Postmortem examination revealed 1400 mL of abdominal hemorrhage, ablation of the perimetrium, placental avulsion, and intracranial hematoma. The cause of death was diagnosed as hemorrhagic shock. The uterus contained a fetus of 7 months' gestational age. Fetal autopsy revealed laceration of the lungs, laceration and avulsion of the liver, and 15 mL of hemoperitoneum. Both placental and fetal injuries suggested repeated severe attacks to the abdomen, such as those expected to result from kicking or hitting.

Delayed Fatal Hemorrhage Due to Small Bowel Mesenteric Laceration.

Injuries of small bowel and its mesentery due to blunt trauma are uncommon. Of deaths due to delayed intra-abdominal hemorrhage, mesenteric laceration is a rare cause of hemoperitoneum.A case of a 33-year-old man, who was hospitalized with chest and retroperitoneal trauma after a forklift rollover, is presented. He died 10 days after the incident. At autopsy, he had a massive hemoperitoneum due to a small bowel mesenteric laceration, which was not diagnosed during his clinical course. Microscopic examination of the hematoma around the laceration revealed healing and ruptured pseudoaneurysms in the distal branches of the superior mesenteric artery.

Postmortem Computed Tomography Findings in Ruptured Splenic Artery Aneurysm: Value of the Clinical "Sentinel Clot" Sign in Identification of Bleeding Location.

Postmortem computed tomography (PMCT) scanning is a routine examination in the medicolegal death investigation of all deceased persons admitted to our institution. Postmortem computed tomography images deliver important information to the medicolegal death investigation process, may alleviate the need for conventional autopsy examination, or provide findings that can guide the performance of a subsequent postmortem examination. We present a case of hemoperitoneum arising from a ruptured splenic artery aneurysm. The case demonstrates how PMCT can strongly suggest the region of bleeding in the abdomen, may provide a provisional diagnosis, and guide the forensic pathologist before the formal autopsy examination, given the particular circumstances of a case, indicates a reasonable cause of death.

[Haemoabdomen and haemothorax in a cow with metastatic granulosa cell tumor]. / Hämoabdomen und Hämothorax bei einem Rind mit metastasierendem Granulosazelltumor.

This case report describes the clinical, ultrasonographic, pathological and histological findings in a two-year-old Swiss Braunvieh cow with granulosa cell tumor and metastases in the abdomen and thorax. The cow was ill and had tachycardia, coughing, increased breath sounds, positive reticular foreign body tests and a tense abdominal wall. Ultrasonography revealed a massive accumulation of hypoechoic fluid in the thorax and abdomen, and abdomino- and thoracocentesis yielded red fluid indicative of abdominal and thoracic haemorrhage. Because of a poor prognosis, the cow was euthanized and examined postmortem. Multiple nodular lesions were seen in the omentum, liver, spleen and lungs. The left ovary was grossly enlarged and nodular in appearance. Histological examination of the lesions revealed granulosa cell tumour of the left ovary and metastases in the omentum, liver, spleen and lungs.

[Spleen trauma in children].

UNLABELLED: The aim was to determine blood loss degree in case of spleen trauma in children and to justify safety of victims treatment without surgery. MATERIALS AND METHODS: It was performed retrospective cohort study of 105 autopsies of children who died of combined trauma. 33 of them had spleen injury. Prospective cohort study was performed in 75 children with spleen injury, 69 (92%) from whom were treated without surgery. RESULTS: It was established that thanatogenetic feature of spleen injury in children is moderate blood loss (89.6% of victims), incidence of large and massive blood loss was 6.8% and 3.4% respectively. In unoperated children blood loss did not exceed 15% of blood volume. In group of operated children (n=6; 8%) incidence of large blood loss was 4% (n=3) and did not exceed 28% of blood volume. Prevalence of moderate blood loss in case of spleen trauma due to anatomic and physiological features and mechanisms of spleen injury is theoretically justified.

Rare Presentation of Chorioadenoma Destruens as Acute Haemoperitoneum Mimicking Ruptured Ectopic Pregnancy.

Gestational trophoblastic neoplasms (GTN) are proliferative degenerative disorders of placental elements and include complete or partial mole (90%), invasivemole (5-8%), choriocarcinoma (1-2%) and placental site tumor (1-2%). Chorioadenoma destruens is a trophoblastic tumor, characterized by myometrial invasion through direct extension or via venous channels. We present a case of invasive mole eroding uterus and uterine vasculature, causing sudden rupture of uterus with massive haemoperitoneum mimicking ectopic pregnancy. A 20 year old G1P0 at 6 weeks gestation presented in Casualty of Kasturba Hospital complaining of severe acute onset lower abdominal pain for one hour. Clinical examination revealed shock. Sonography suggested ectopic pregnancy and immediate exploratory laparotomy was decided. On laparotomy, 2000cc of haemoperitoneum was noted. Grape like vesicles protruding through fundal perforation with profuse active bleeding was seen. Bleeding persisted despite evacuation. Step wise uterine devascularisation failed to achieve haemostasis. Total abdominal hysterectomy was performed as a life saving measure.

Peliosis of the spleen as an unusual cause of splenic rupture: A case report and a review of literature.

Isolated splenic peliosis is an extremely rare condition characterized by the presence of multiple blood-filled cavities, occasionally resulting in non-traumatic splenic rupture with fatal bleeding. In our case, a 64-year-old man was brought by ambulance due to weakness and abdominal pain without nausea or febrility. On clinical examination, the patient was sensitive to palpation with significant tenderness over the abdomen but no associated features of peritonitis. He collapsed during the imaging examination and became unconscious and asystolic. Cardiopulmonary resuscitation was not successful. The patient died approximately within 2 hours of admission to the hospital. Postmortal examination showed 2800 ml of intraperitoneal blood with clots and a laceration of the lower pole of the spleen. Macroscopic examination of the spleen revealed huge nodular splenomegaly, measuring 21 cm x 19 cm x 5 cm, weighing 755 g. On the cut surfaces, multiple randomly distributed blood-filled cavities ranging from 0,5 to 2 cm in diameter were seen. At microscopic examination, the specimens showed multiple irregular haemorrhagic cyst-like lesions that were not lined by any epithelium or sinusoidal endothelium, consistent with the diagnosis of peliosis lienis. Although the condition is often clinically silent, the forensic pathological significance arises from the differential diagnosis of resultant intraperitoneal haemorrhage and sudden death, mimicking a violent death.