Traditional Chinese Acupuncture Causing Acute Hemoperitoneum from Direct Liver Injury.

Traditional Chinese medicine is a popular form of complementary and/or alternative medicine in Southeast Asia, often incorporating acupuncture. Acupuncture involves the insertion of thin needles into varied anatomical points on the body for the relief of a range of symptoms, such as musculoskeletal aches and pains. We present the first reported case of percutaneous liver injury secondary to acupuncture. We aim to familiarize readers with this rare and as-yet unreported case of intra-abdominal injury related to acupuncture, which is commonly practiced in many countries in Eastern and Southeast Asia.

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.

Autotransfusão imediata em cão - relato de caso / Instant autotransfusion in dog - case report

As hemorragias podem levar à morte, em caso de não interrupção e recuperação da volemia. A substituição do sangue pode ser realizada por transfusão homóloga ou autóloga. Na transfusão homóloga, o sangue é obtido de um doador, na autotransfusão ou transfusão autóloga, o sangue é coletado do próprio paciente. Objetivou-se relatar a autotransfusão em um cão como um método simples, rápido e barato, e discutir esse procedimento como uma alternativa emergencial para clínicas e hospitais que não possuem bancos de sangue ou animais doadores. Foi atendido um cão Rottweiler fêmea, 42,8kg, 10 anos de idade, com queixa principal de tumor mamário e para realização de castração. Após o procedimento, a paciente apresentou hemoperitônio, sendo encaminhada para novo procedimento cirúrgico, durante o qual se observou grande quantidade de sangue livre na cavidade abdominal. Foi realizada a autotransfusão de emergência, pela técnica das duas seringas, devido à indi1111sponibilidade de sangue ou animal doador no momento do procedimento cirúrgico emergencial, demonstrando ser uma opção eficiente, econômica, de fácil acesso e segura, por ser uma transfusão normotérmica, apresentar diminuição do risco de sobrecarga circulatória e por ser o sangue compatível, devendo ser mais explorada, pois existem poucos dados descritos na literatura.(AU)

Hemorrhages can lead to death in case of non-interruption and recovery of blood volume. Blood replacement may be performed by homologous or autologous transfusion. In homologous transfusion, blood is obtained from a donor, in autotransfusion or autologous transfusion, blood is collected from the patient himself. We aimed to report autotransfusion in a dog as a simple, quick, and inexpensive method, and discuss it as an emergency alternative for clinics and hospitals that do not have blood banks or animal donors. A female Rottweiler dog, 42.8kg, 10 years of age, was treated with a primary complaint of mammary tumor and for castration. After the procedure the patient presented hemoperitoneum, being referred to a new surgical procedure, where a large amount of free blood was observed in the abdominal cavity. The emergency autotransfusion was performed by the two syringes technique, due to the unavailability of blood or donor animal at the time of the emergency surgical procedure, proving to be an efficient, economical, easily accessible and safe option because it is a normothermic transfusion, risk of circulatory overload and blood is compatible. It should be more exploited because there are few data described in the literature.(AU)

Twelve autologous blood transfusions in eight cats with haemoperitoneum.

OBJECTIVES: The objectives of this study were to describe the clinical use and outcome of autologous transfusions in cats with intracavitary haemorrhage. METHODS: A retrospective descriptive study was performed. Computerised medical records of a single referral centre were searched for cats receiving an autotransfusion. Medical records were evaluated for underlying disease process, autotransfusion technique, autotransfusion volume, time period over which the autotransfusion was given, packed cell volume (PCV) pre- and post-autotransfusion, percentage rise in PCV, use of other blood products and any complications of the procedure. Survival to discharge and survival at 2 months was documented. RESULTS: Between July 2012 and March 2018 a total of 12 autotransfusions were performed in eight cats. All patients were diagnosed with haemoperitoneum. Four of the eight cats were diagnosed with abdominal neoplasia, three had postoperative haemorrhage and one had a traumatic haemoperitoneum. Three cats received more than one autotransfusion. Blood was collected using a 23 G butterfly catheter and 20 ml syringe in 7/12 collections, a 23 G needle and 20 ml syringe in 2/12 collections and directly into syringes from the open abdomen at the time of surgery in 3/12 collections. A median volume of 50 ml (range 25-80 ml) was collected and administered, meaning a median volume of 16.5 ml/kg (range 9-26 ml/kg) was administered. The autologous transfusions were given over a median of 3 h (0.25-6 h). Five cats were given another blood product alongside the autotransfusion. Median percentage PCV increase was 5% (range 1-7%). Anticoagulant was used in 5/12 autotransfusions. No clinically relevant adverse effects were reported. Six of the eight cats survived to discharge. Two month survival was 60% (3/5). CONCLUSIONS AND RELEVANCE: Autologous transfusion appears to be a safe and effective technique for stabilising cats with haemoperitoneum. This technique allows rapid and cheap provision of blood and avoids the need for an allogenic blood donor.

Percutaneous Endoscopic Gastrostomy Tube Insertion-induced Superior Mesenteric Artery Injury Treated with Angiography / 대한소화기학회지

Percutaneous endoscopic gastrostomy (PEG) is widely used to provide nutritional support for patients with dysphagia and/or disturbed consciousness preventing oral ingestion, and PEG tube placement is a relatively safe and convenient non-surgical procedure performed under local anesthesia. However, the prevention of PEG-insertion-related complications is important. A 64-year-old man with recurrent pneumonia underwent tracheostomy and nasogastric tube placement for nutritional support and opted for PEG tube insertion for long-term nutrition. However, during the insertion procedure, needle puncture had to be attempted twice before successful PEG tube placement was achieved, and a day after the procedure his hemoglobin had fallen and he developed hypotension. Abdominal computed tomography revealed injury to a pancreatic branch of the superior mesenteric artery (SMA) associated with bleeding, hemoperitoneum, and pancreatitis. Transarterial embolization was performed using a microcatheter to treat hemorrhage from the injured branch of the SMA, and the acute pancreatitis was treated using antibiotics and supportive care. The patient was discharged after an uneventful recovery. Clinicians should be mindful of possible pancreatic injury and bleeding after PEG tube insertion. Possible complications, such as visceral injuries or bleeding, should be considered in patients requiring multiple puncture attempts during a PEG procedure.

Robotic Right Colectomy with Modified Complete Mesocolic Excision: Long-Term Oncologic Outcomes.

BACKGROUND: A modified complete mesocolic excision (mCME) technique for the treatment of right-sided colon cancer recently was shown by Hohenberger and colleagues to provide impressive long-term oncologic outcomes. This report aims to describe the authors' experience with robotic right colectomy using mCME. The safety, feasibility, and efficacy of this procedure are measured by complications, conversion rates, and 4-year oncologic outcomes. METHODS: A retrospective study analyzed 100 consecutive patients who underwent robotic right colectomy with mCME and intracorporeal anastomosis at the authors' institution between November 2005 and November 2013. Intra- and postoperative clinical outcomes, pathologic data, and survival were analyzed. RESULTS: Robotic right colectomy with mCME was successfully performed for all the patients. No conversions or intraoperative complications occurred. The major complication rate (Dindo 3 or 4) was 4 %. During a median follow-up period of 48.5 months (range 24-114 months), the survival rates were 94.5 % for disease-specific survival, 91.4 % for disease-free survival, and 90.3 % for overall survival. CONCLUSIONS: The authors' experience confirms the feasibility and safety of mCME for the treatment of right-sided colon cancer. This technique provided satisfying short-term outcomes with promising 4-year oncologic results. However, the real benefits of the CME technique should be evaluated further by well-conducted randomized studies before its adoption in routine practice is recommended.

Autotransfusion in dogs using a 2-syringe technique.

OBJECTIVE: To describe the successful use of an autotransfusion technique utilizing 2 syringes in 4 dogs. CASE SERIES SUMMARY: All 4 dogs in this series had a hemoabdomen and subsequent hypovolemic shock. During surgery blood was collected from the abdominal cavity by the surgeon and passed to an assistant. The blood was then transferred to a second syringe for direct IV administration. The blood was passed through an inline blood filter prior to reaching the patient. Given the transfusion volume and administration time frame, 3 cases were classified as a massive transfusion. All 4 dogs survived the transfusion, were discharged within 3 days of surgery/transfusion and no complications were noted. NEW OR UNIQUE INFORMATION PROVIDED: This case series describes a relatively simple method of performing an autotransfuion in patients with hemoabdomen and hypovolemic shock.

Serum 25-hydroxyvitamin D concentrations in dogs - correlation with health and cancer risk.

25-hydroxyvitamin D (25(OH)D) is important in bone health as well as many diseases including cancer. Supplementation may increase responsiveness of cancer cells to chemotherapy. Serum 25(OH)D, intact parathyroid hormone (iPTH) and canine C-reactive protein (c-CRP) were measured in healthy dogs and dogs with haemoabdomen. Regression analysis determined optimal 25(OH)D concentrations. In healthy dogs (n = 282), mean iPTH concentrations correlated inversely (r(2) = 0.88, P < 0.001) to 25(OH)D concentrations. Variation in both iPTH and c-CRP plateaued at 25(OH)D concentrations of 100-120 ng mL(-1) . Haemoabdomen dogs (n = 63, 43 malignant and 20 benign) had 25(OH)D concentrations ranging from 19.4 to >150 ng mL(-1) . Relative risk of cancer increased with decreasing 25(OH)D concentrations [RR = 3.9 for 25(OH)D below 40 ng mL(-1) (P = 0.0001)]. Serum 25(OH)D concentrations in dogs vary widely, and are influenced by dietary VitD content. Serum vitD measurement can identify dogs for which supplementation may improve health and response to cancer therapy.

Management of hemorrhage complicated by novel oral anticoagulants in the emergency department: case report from the northwestern emergency medicine residency.

Anticoagulation has long complicated the care of hemorrhage in the emergency department and other acute care settings. With the advent of novel anticoagulants such as direct thrombin inhibitors and direct factor Xa inhibitors, the absence of any direct antidote for these medications presents new and difficult challenges in the management of hemorrhagic complications in these patients. We present 2 cases of patients with hemorrhagic complications taking novel oral anticoagulants, their management, and outcomes.

Autologous blood transfusion following red blood cell salvage for the management of blood loss in 3 dogs with hemoperitoneum.

OBJECTIVE: To describe the use of autologous transfusion using a red blood cell salvage device for the management of large volume hemorrhage in 3 dogs with hemoperitoneum. CASE SERIES SUMMARY: Three dogs were managed for large volume hemorrhage by autologous transfusion of red blood cells after cell salvage. In all cases, blood was salvaged from the abdominal cavity during surgery. The causes of hemorrhage included testicular arterial hemorrhage after castration, hepatic parenchymal hemorrhage following hepatic dissection for intrahepatic portosystemic shunt ligation, and intra-abdominal serosal hemorrhage associated with Angiostrongylus vasorum infection. In all cases, autologous transfusion was not associated with any identified complications and contributed to improved cardiovascular stability and packed cell volume. NEW OR UNIQUE INFORMATION PROVIDED: This case series is the first to describe the use of a semiautomated red blood cell salvage system for the clinical management of acute hemorrhage in dogs. This case series provides evidence that this procedure can be used safely and effectively for the management of clinical hemorrhage. On this basis, further veterinary evaluation can be justified.

Hemoperitoneum Resulting From Injuries to Liver with a Benign Vascular Tumor During Acupuncture: A Case Report / 대한법의학회지

Various complications following acupuncture have been reported. In most cases, complications occur from the close apposition of vital organs and acupuncture sites. These complications can be avoided if acupuncturists are trained in appropriate medical science such as anatomy. However, our case is somewhat different from the norm. The deceased received acupuncture on the abdomen, provided by an acupuncturist. Unexpected symptoms occurred suddenly and she was transported to a hospital where she died of hemoperitoneum. On the postmortem examination, a well-defined vascular tumor was identified on the front of the liver, which was also cirrhotic; a few localized injuries were identified on the cystic wall of the tumor and surrounding liver parenchyma. We assumed these injuries were complications of acupuncture. Therefore, we present this case to suggest that acupuncturists should be educated to be vigilant for complications following treatment to reduce the risk of these tragedies.

Selective ligation of portal vein and hepatic artery for ruptured hepatocellular carcinoma in a 13-year-old boy.

Hepatocellular carcinoma (HCC) in children is rare, and the prognosis has been poor because of its advanced stage at diagnosis and unresponsiveness to chemotherapy. We report a 13-year-old boy with ruptured HCC in the left trisegment. When hemostasis of the ruptured surface was achieved in the emergency operation, the left branch of the portal vein and the left hepatic artery were ligated at the same time. The volume of the future liver remnant (FLR), that is, his right posterior sector, increased from 56% on admission to 70% of his standard liver volume on day 2. Blood level of serum protein induced by vitamin K absence or antagonist ІІ started to decrease immediately. Left trisegmentectomy was successfully performed 10 days later, followed by chemotherapy. He has been well with a 2-year survival without recurrence. When the FLR is considered relatively small for a major hepatic resection, the selective ligation of the portal vein and the hepatic artery, which feed HCC, seems to be beneficial. This is because it may induce enlargement of the FLR, increasing the safety of the hepatectomy as preoperative portal vein embolization does before a major hepatectomy in adult patients with HCC, and the latter suppresses the tumor while waiting for the planned hepatectomy.

Management of ruptured corpus luteum cyst of pregnancy occurring in a 15-year-old girl by laparoscopic surgery with intraoperative autologous blood transfusion.

BACKGROUND: Laparoscopic surgery is a minimally invasive procedure with many advantages. However, laparoscopic treatment of ruptured corpus luteum cyst of pregnancy with massive hemoperitoneum occurring in a young girl has not previously been reported. CASE: A 15-yr-old girl presenting with acute abdomen and hemoperitoneum was referred to our department. A urinary pregnancy test was positive and an ultrasound revealed a gestational sac in the uterine cavity, the preoperative differential diagnosis was narrowed to either intrauterine pregnancy with ruptured corpus luteum cyst or heterotopic pregnancy. Emergency laparoscopic surgery was performed to investigate the cause of hemoperitoneum and a diagnosis of ruptured corpus luteum cyst of pregnancy was established. After retrieving pooled blood in the abdominal cavity for intraoperative autologous blood transfusion, the rupture site with active bleeding was laparoscopically sutured and hemostasis was achieved. At the same time, intrauterine pregnancy was electively terminated at the request of the patient and her family. The postoperative course was uneventful. CONCLUSION: Ruptured corpus luteum cyst of pregnancy manifesting massive hemoperitoneum is a rare but life-threatening disorder that can occur even in a young girl. Ovarian conservative treatment can laparoscopically be performed with intraoperative autologous blood transfusion.

Intra-operative autotransfusion--a simple and cost effective method.

Recovery of intrathoracic and intraperitoneal blood and reinfusion by autotransfusion has been demonstrated to be safe and practical in selected cases. This study has basically aimed at using a very simple method for collection and reinfusion of blood in haemothorax and haemoperitoneum. Autotransfusion was done in 50 cases admitted in Dayanand Medical College and Hospital, Ludhiana who were diagnosed to have haemothorax or haemoperitoneum which fulfilled the set criteria. There were increased haemoglobin levels in 26 patients and a decreased haemoglobin in 24 patients. The coagulation profile was deranged in 7 patients pre-operatively while it was deranged in only 2 patients postoperatively. There was no significant change in renal function tests and liver function tests preoperatively and postoperatively. This study had shown that intra-operative autotransfusion with this very simple, affordable and easily available technique is feasible and practical and its use should be encouraged.

Management of patients with ectopic pregnancy with massive hemoperitoneum by laparoscopic surgery with intraoperative autologous blood transfusion.

STUDY OBJECTIVE: To evaluate the feasibility and safety of surgical laparoscopy with intraoperative autologous blood transfusion for ectopic pregnancy with massive hemoperitoneum. DESIGN: Retrospective analysis (Canadian Task Force classification II-1). SETTING: Department of gynecology at a general hospital. PATIENTS: Seventeen consecutive patients with ectopic pregnancy with massive hemoperitoneum. INTERVENTION: Laparoscopic surgery with salvage device-based intraoperative autologous blood transfusion. MEASUREMENTS AND MAIN RESULTS: From January 2000 through June 2005, one hundred and twelve women with ectopic pregnancy (interstitial/cornual: 4; isthmic: 18; ampullary: 86; and ovarian: 4) were treated by laparoscopic surgery. Seventeen patients who demonstrated more than 501 g of intraabdominal bleeding were classified as having massive hemoperitoneum and retrospectively analyzed. Site of pregnancy in these 17 patients was interstitial/cornual: 3; isthmic: 5; ampullary: 7; and ovarian: 2. Except for two women with tubal abortion of ampullary pregnancy, all other patients had rupture at the pregnancy site. During laparoscopic surgery, blood pooled in the abdominal cavity was collected by an irrigation and aspiration procedure, and sent to an autologous blood-salvage device to make concentrated red blood cell solution. Processed blood was immediately transfused back to the patient through a leukocyte reduction filter. The mean amount of estimated intraabdominal bleeding, which was calculated by the difference between the volumes of aspirated and irrigated fluids, was 1362.1 +/- 491.4 g, and the mean volume of reinfused processed blood was 680.6 +/- 209.5 g. No patient received banked blood at any time. The degree of hemoperitoneum was well correlated with the shock index calculated by dividing the heart rate by systolic blood pressure at triage (r = 0.72; 95% CI 0.37-0.89; p = .001). In all cases of massive hemoperitoneum, there was no need for laparotomic conversion, and homologous blood transfusion was avoided. CONCLUSIONS: Even in women with ectopic pregnancy with massive hemoperitoneum, laparoscopic surgery can be safely conducted by experienced laparoscopists with intraoperative autologous blood transfusion if hemodynamic stability is achieved by perioperative management.

[Rupture of the spleen in angiosarcoma: a case report and review of the literature]. / Rottura di milza in angiosarcoma: considerazioni su di un caso clinico e revisione della letteratura.

Splenic angiosarcoma is a rare neoplasm originating from endothelial cells of the blood vessels. Its incidence is about 0.14-0.25 per million. We report the case of a patient admitted in a state of hypovolaemic shock with haemoperitoneum due to rupture of the spleen. Splenectomy was performed with evacuation of the haemorrhagic effusion. The blood was aspirated and in part instilled during the operation through intraoperative blood salvage due to the large haemoperitoneum. Histological examination revealed a splenic angiosarcoma. Splenic angiosarcoma should be suspected in cases of splenomegaly with unknown anaemia and no lymphoma, leukaemia or myelofibrosis, because of its neoplastic aggressiveness and its invariably fatal outcome. It is important to perform a splenectomy before splenic rupture owing to its negative impact on long-term survival.

Intraoperative autologous blood transfusion for hemoperitoneum resulting from ectopic pregnancy or ovarian bleeding during laparoscopic surgery.

OBJECTIVE: Our purpose was to evaluate the efficacy and safety of intraoperative autologous blood transfusion during laparoscopic surgery for hemoperitoneum in benign gynecologic disease. METHODS: The Cell Saver, Haemo Lite 2, an intraoperative autologous blood salvage device, was used in laparoscopic surgery on 18 patients with ectopic pregnancies or ovarian bleeding who had a large hemoperitoneum with/without severe anemia and hypovolemic shock. RESULTS: The blood loss was 1186 +/- 789 mL, and the volume of reinfused processed blood was 661 +/- 405 mL in ectopic pregnancy cases. The blood loss was 716 +/- 219 mL, and the volume of reinfused processed blood was 496 +/- 138 mL in ovarian bleeding. Laparoscopic surgery was performed and homologous blood transfusion was not required in any patient. No adverse reactions or procedural difficulties associated with the autologous blood transfusions occurred. CONCLUSIONS: Intraoperative autologous blood transfusion enabled the performance of laparoscopic surgery for large hemoperitoneum caused by ectopic pregnancies or ovarian bleeding without a homologous blood transfusion.

Hemoperitoneum in a continuous ambulatory peritoneal dialysis patient caused by a hepatocarcinoma treated with percutaneous embolization.

Hemoperitoneum is an infrequent but normally benign complication in continuous ambulatory peritoneal dialysis (CAPD) patients. It can occur at any time during peritoneal dialytic treatment. Hemoperitoneum is not associated with a specific disease and usually disappears spontaneously. In 20% of cases, however, hemoperitoneum is severe and requires specific investigation and emergency therapy. We report a case of hemoperitoneum in a 70-year-old, anti-hepatitic C virus-positive woman. After 48 months of CAPD treatment, a bloody peritoneal effluent developed, with severe anemia (hematocrit decreased from 30% to 20%). An abdominal computed tomography scan showed three hepatic lesions with signs of hepatic neoplasms; selective hepatic arteriography confirmed the diagnosis. Chemoembolization of the three lesions was performed, and hemoperitoneum disappeared within a few hours.