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.

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 after transperineal prostate biopsy.

Bleeding is the most common complication after a prostate biopsy, commonly self-limited. We describe a case of a patient who developed a hemoperitoneum after a transperineal prostate biopsy. A 65-year-old man with a history of prostate cancer diagnosed in 2016 by transurethral resection, with no further urologic control until 2020 when a rise in the serum prostate-specific antigen was diagnosed: 4.49 ng/ml. Prostate digital rectal examination had no pathologic findings. Magnetic resonance imaging informed anequivocal lesion. A target transperineal fusion biopsy was performed, guided by ultrasound (US). Pre-surgical blood tests, including coagulogram, were normal. No immediate postoperative complications were recorded, and the patient was discharged. Hours later, he returned after a head concussion due to orthostatic hypotension and diffuse abdominal pain. Blood test showed a drop in hematocrit and hemoglobin values. Abdominal US and abdominopelvic computed tomography scan showed free intraperitoneal fluid and intraperitoneal hematic collection on top of the bladder of 104 × 86 mm with no active bleeding. The patient was admitted to intensive care unit due to persistent hypotension despite fluid restoration. He received a single-unit blood transfusion and had a good response to vasopressors. Abdominal pain decreased. He was finally discharged with stable hematocrit 48hours after admission. Clinical management with no surgery or radiologic angio-embolization was required. We found no clear origin of the intraperitoneal bleeding, but we hypothesize that maybe the previous transurethral resection of the prostate made anatomical changes that facilitated blood passage to the abdominal cavity after puncture of branches from the inferior vesical artery.

La complicación más frecuente tras una biopsia prostática es el sangrado, generalmente autolimitado. Aquí describimos un caso de hemoperitoneo secundario a dicho procedimiento. Hombre de 65 años con antecedentes de cáncer de próstata diagnosticado en 2016 por una resección transuretral de próstata, sin seguimiento urológico, consultó en 2020 por aumento del antígeno prostático específico: 4.49 ng/ml, asociado a tacto rectal normal y una resonancia multiparamétrica de próstata mostró una lesión indeterminada. Se realizó una biopsia prostática transperineal por fusión guiado por ecografía. Los análisis preoperatorios, incluido coagulograma, eran normales. No se registraron complicaciones intraquirúrgicas y se indicó el alta. Horas más tarde, consultó al hospital por hipotensión ortostática y dolor abdominal difuso. Los análisis demostraron caída del hematocrito y hemoglobina. Una ecografía y posterior tomografía computada evidenciaron una colección supravesical de 104 × 86mm sin signos de sangrado activo. Se indicó internación en sala de cuidados intensivos debido a hipotensión refractaria a expansiones con requerimiento de vasopresores. Recibió una transfusión de glóbulos rojos. Por favorable evolución, 48 horas después del ingreso recibió el alta. En este caso, fue posible un manejo conservador, sin requerimiento de cirugía o embolización. Si bien no se encontró sitio exacto del sangrado, creemos que la resección transuretral previa podría haber generado cambios anatómicos que facilitaran el pasaje de sangre, posiblemente proveniente de ramas de la arteria vesical inferior a cavidad abdominal luego de la punción.

The predicting factors for indication of surgery in patients with hemoperitoneum caused by corpus luteum cyst rupture.

The aim of the study was to determine the risk factors for surgery in patients with hemoperitoneum caused by corpus luteum cyst rupture. A retrospective review of medical records of 155 patients diagnosed with hemoperitoneum caused by corpus luteum cyst rupture was conducted between January 2010 and March 2015. The patients were divided into two groups: surgical and conservative management. The differences in characteristics between the two groups were compared. The indicators that determine the need of a surgery at the initial visit were also compared between the two groups. Initial hemoglobin level was lower (11.3 ± 1.4 g/dL vs. 12.2 ± 1.2 g/dL; p = 0.007) in the surgery group. There were significant differences in posterior cul-de-sac (PCDS) fluid collection depth (6.2 ± 2.5 cm vs. 4.5 ± 1.6 cm, p = 0.000), total fluid collection depth (8.4 ± 1.8 cm vs. 6.5 ± 2.1 cm, p = 0.000), single deepest pocket depth (6.7 ± 2.2 cm vs. 5.1 ± 1.5 cm, p = 0.006), liver-dome fluid (78.9% vs. 35.6%; p = 0.002), and estimated intrapelvic bleeding amount (325 ± 250 cc vs. 206 ± 146.5 cc, p = 0.002). The extravasation over grade 2 was more often in surgery group (68.4% vs. 30.1%; p = 0.001). PCDS fluid collection depth, the presence of liver-dome fluid, and the severity of contrast extravasation through ultrasonography and computed tomography are good indicators for determining the management of hemoperitoneum resulting from corpus luteum cyst rupture in healthy women.

Fatal hemoperitoneum due to rupture of mesenteric artery in remission state of microscopic polyangiitis, concomitant with severe hypertension and posterior reversible encephalopathy syndrome: an autopsy case report.

Microscopic polyangiitis (MPA) is a type of necrotizing vasculitis associated with high levels of myeloperoxidase-specific antineutrophil cytoplasmic antibody (MPO-ANCA). While generally associated with renal dysfunction, MPA can also cause intraabdominal hemorrhage in rare cases. A 66-year-old man was admitted to our hospital for renal dysfunction, numbness, and weight loss for 3 months. He had no significant medical history. Renal biopsy revealed crescentic glomerulonephritis with necrotizing vasculitis, which was associated with a high serum titer of MPO-ANCA, leading to a diagnosis of MPA. Remission-induction treatment with glucocorticoids and rituximab was initiated, which improved the patient's general condition and renal failure. His blood pressure was elevated and was controlled by amlodipine treatment. Two months after discharge, he visited the emergency department because of chest pain. A diagnosis of acute cardiovascular syndrome was suggested; however, his cardiac artery was not stenotic. The patient's blood pressure was high despite antihypertensive therapy, and he developed posterior reversible encephalopathy syndrome (PRES). Despite intensive treatment, the patient died 3 days later. An autopsy revealed that the cause of death was hypovolemic shock due to massive intra-abdominal hemorrhage from the ruptured mesenteric artery involved in vasculitis. In cases of MPA with sudden-onset chest or abdominal pain, a ruptured intra-abdominal artery should be considered. Secondary hypertension associated with vasculitis should be carefully managed to prevent hemorrhagic complications and PRES.

Cirsoid aneurysm rupture of the splenic artery as a rare cause of fatal hemoperitoneum.

Cirsoid aneurysms are rare arteriovenous malformations without any capillaries interposed and almost always observed in the scalp region. These types of aneurysms are so-called "cirsoid" because of their serpiginous appearance. In this report, the authors present the first case of a lethal spontaneous rupture of a cirsoid aneurysm of the splenic artery, which could be diagnosed only by post-mortem histologic examination. The victim was a 70-year-old man who was suddenly found dead in bed while he was hospitalized and waiting for a scheduled cardiac surgery. A forensic autopsy was ordered due to the suspicion that the man's death could have been related to medical malpractice. An accurate autopsy and a complete forensic histologic examination could clarify the cause of death, which was identified in the spontaneous rupture of a cirsoid aneurysm of the splenic artery. The case is intended to be used as source data for similar forensic cases, where the cause of a massive hemoperitoneum is difficult to be identified.

Sudden and unexpected death in childhood due to an undiagnosed hepatoblastoma: Case report and review of literature.

The sudden and unexpected death of an infant or child due to cancer is a particularly rare event. Most of the cases concern primary growths located in vital organs such as the heart or the brain. Only in an extremely small number of cases does it occur in infants or children affected by liver cancer. Herein we report the sudden and unexpected death of a 3-and-a-half-year-old infant, who due to an undiagnosed tumor of the liver, namely hepatoblastoma, suffered a major intra-abdominal (hemoperitoneum) bleed, leading to a fatal hemorrhagic trauma. In cases like these, it is of utmost importance to carry out both an autopsy as well as complete histological tests in order to determine if the hepatic tumor is the real cause of death or if it was a mere chance finding. In the case of sudden and unexplained deaths in infancy and childhood, the forensic pathologist should always consider that other complications, for example, those correlated with hepatoblastoma could, in fact, cause sudden death given that this particular tumor is often scarcely symptomatic and can remain undiscovered for a long period of time.

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.

Pancreatic microcystic serous cystadenoma: a lethal disease? Rare case of a life-threatening haemorrhage.

Serous pancreatic cystadenomas are benign tumours and most cases are detected incidentally. Complications are unusual. A patient with a history of a large pancreatic serous cystadenoma (SCA) presented to the emergency department with abdominal pain and haemodynamic shock. After haemodynamic stabilisation, an urgent abdominal CT scan revealed a large hemoperitoneum but the origin of the bleeding was not found. The patient was submitted to an angiography that revealed a bleeding hypervascular pancreatic mass and an embolisation was done successfully. After 3 weeks, the patient underwent a laparotomic left pancreatectomy with en bloc splenectomy. The anatomopathological results were consistent with a microcystic SCA of the pancreas. Despite the high vascularity of pancreatic SCA, haemorrhage is a very rare but life-threatening complication.

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.

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.

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.

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.

Spontaneous rupture of uterine smooth muscle tumour presenting acute abdominal pain and haemoperitoneum.

Uterine smooth muscle tumours are histologically categorised into benign leiomyoma, malignant leiomyosarcoma or smooth muscle tumours of uncertain malignant potentials (STUMPs).1 Common symptoms of uterine tumours are hypermenorrhea, dysmenorrhea, lumbago or irregular genital bleeding. We experienced a case of uterine tumour with atypical clinical behaviour. A 40-year-old woman who had been diagnosed with leiomyoma presented with severe abdominal pain and intraperitoneal haemorrhage. By emergent surgery, we found that the uterine tumour had ruptured spontaneously. The pathological diagnosis was STUMPs. 14 months later, she underwent a second surgery for a tumour recurrence. Pathological diagnosis was leiomyosarcoma. 20 months later, she underwent a third surgery for a re-recurrent tumour. After the third surgery, massive fluid containing haemorrhage accumulated inside the tumour. Percutaneous drainage of intratumour fluid was successfully performed. Chemotherapy was also taken, but it ended without significant efficacy. 3 years after the first surgery, she died because of intestinal perforation and peritonitis.