Making the Diagnosis
To accurately assess and diagnose this patient’s condition, the clinician needs to consider all causes of abdominal pain and syncope and find out where they overlap. A vasovagal episode is a common cause of syncope that can be triggered by any severe pain; typically, however, this should be considered a diagnosis of exclusion. More dangerous causes of syncope and abdominal pain include intestinal perforation, myocardial infarction, abdominal aortic aneurysm, ruptured ectopic pregnancy, or other causes of internal bleeding. A gastrointestinal (GI) bleed might be considered but typically is painless and presents with a positive fecal occult test. If pain is the first sign of a GI bleed it usually presents earlier.
The CT scan does not show any significant aortic pathology but does show free fluid, most notably as a dark rim around the outside of the liver. The free fluid is identified as blood indicating a hemoperitoneum. No free air is present, which would rule out intestinal perforation. The slightly elevated troponin level is likely caused by the episode of hypotension but these levels should be repeated.
Discussion
Nontraumatic hemoperitoneum is a rare cause of abdominal pain most classically caused by a ruptured ectopic pregnancy. Other fairly well-known causes include ruptured spleen from mononucleosis or hemorrhagic pancreatitis. Less well-known causes include ruptured splenic artery aneurysm, ruptured intra-abdominal neoplasm, and ruptured ovarian cyst.
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The typical presentation of hemoperitoneum is sudden generalized abdominal pain with or without syncope or near syncope. A significant number of patients may have a positive Kehr sign, which is pleuritic shoulder pain caused by irritation of the diaphragm. Some patients may not have pain per se but rather just complain of bloating. Blood accumulation outside of the rectum may cause tenesmus.
Significant bleeding may cause low heart rate, low blood pressure, or unstable vital signs, while vital signs with small bleeds may be normal. On physical examination, classically diffuse abdominal tenderness is typically found with guarding and rebound but some patients may have less irritation from the blood and less tenderness.
Laboratory reports may reveal anemia. The patient with a recent or small bleed will present with a hemoglobin measurement that is normal initially. With time the hemoglobin typically will drop. If pregnancy is suspected or confirmed, bedside ultrasound is the test of choice and will typically show free fluid, which should be presumed to be blood. In nonpregnant patients, CT has the benefit of providing fluid density and possibly identifying a source of bleeding.
Treatment of hemoperitoneum often requires blood transfusion and surgery to control the source of the bleed, especially in a ruptured ectopic pregnancy; in milder cases, the bleeding may stop on its own or be controllable via embolization performed by interventional radiology. Typically, treatment decisions will be made in collaboration with the appropriate surgical specialist, which would depend on whether the source of bleeding is adnexal, vascular, or from a solid viscus injury or tumor.
Case Conclusion
General surgery and interventional radiology were both consulted and the patient was admitted. Serial testing of her hemoglobin level showed a drop from approximately 12.5 g/dL to 8.5 g/dL, after which it stabilized. Her vital signs remained stable. Computed tomography angiography and tagged red blood cell scans were negative for additional bleeding. The source of bleeding was never determined.
Case Lessons
Always consider nontraumatic hemoperitoneum with abdominal pain and syncope. Surprisingly, sometimes the pain is not severe and the main complaint is bloating and feeling light-headed or weak. Ectopic pregnancy is the most common cause of nontraumatic hemoperitoneum but there are many other possibilities such as ovarian cyst, splenic artery aneurysm, liver tumor, and mononucleosis.
Brady Pregerson, MD, is an emergency physician at Tri-City Medical Center, Palomar Health System, and Scripps Coastal Urgent Care, all in San Diego, California.
Reference
Pregerson DB. Gastroenterology chapter. Emergency Medicine 1-Minute Consult. 5th ed. 2017;5. http://www.erpocketbooks.com/emergency_medicine_reference_books/quick-essentials-emergency-medicine/
