Blood Is Everywhere!

Important Poten�al and Emergent Causes of Bleeding In the Abdomen and Pelvis

EugeneHuo,MDLauraEisenmenger,MD

SpencerBehr,MD

UniversityofCalifornia,SanFranciscoAbstractCID:2622776

Disclosures:Dr.Behr:GEHealthcare–GrantandConsultant.Navidea–GrantandConsultant

Hemoperitoneum  Manytraumaandatrauma�ccauses  CTremainsthe“workhorse”ofevalua�on

  Fastwithmul�ple�me-pointimaging

  CTsignsofhemoperitoneum:  “Sen�nelclot”  Ac�vearterialextravasa�on  Mesentericfluid

  BloodhaséHUthanotherbodyfluids.However…  Dependsonage,extent,andloca�on  Unclo�edextravascularblood=~30–45HU  <30HUif(a)êserumhematocritlevel,(b)an�coagula�on,or(c)hemorrhage>48hoursold

  Loca�ngthesourceofintraperitonealhemorrhagecanhelpdirectmanagement

Trauma   LeadingcauseofdeathintheUS<45yearsold  Fourthhighestoverallcauseofdeath  FASTscanultrasonography

  Assessforhemopericardiumandhemoperitoneum  Imagethehepatorenalrecess(Morison'spouch),perisplenicspace,pericardium,andpelvis

 Mostcommonloca�onofbleed:liver,spleen Uniquecomplica�on:“Pagekidney”  Traumagrading:AmericanAssocia�onfortheSurgeryofTrauma(AAST)

h�p://www.aast.org/Library/TraumaTools/InjuryScoringScales.aspx

Important CT findings of trauma   Solidorganinjury

  Sen�nelclot  High-a�enua�onfluid

  Nearoraroundtheinjuredorgan  Inthecul-de-sacs,paracolicgu�ers,pelvis

  Ac�veextravasa�on:1.  Ac�vebleedingfromavesselonangiographicphase2.  Serpiginousborderofhigh-a�enua�on3.  Changesina�enua�on/morphologyonmul�phaseimaging

  Mesentericorbowelinjury

  Triangularhigh-a�enua�oninterloopmesentericfluidcollec�ons  Bowelwallthickening  Othersignsofac�veextravasa�oninmesenteryorbybowelloops

Case 1: Trauma   HISTORY:53yostatuspostmotorvehiclecollision,unstablevitals  IMAGING:

  Post-contrastCT:Hypoa�entua�ngspleniclacera�ons(arrow)andac�veextravasa�onofcontrast  Angiography:Splenicarteryaneurysmnearthehilumandac�veextravasa�on(arrow)  Angiographypost-emboliza�onwithcoilsplacedinthesplenicaneurysm(orangearrow).Noflowdistaltothespleenandnofurtherextravasa�on

  TREATMENT:Emboliza�on,solidorganremoval,orobserva�ondependingonpa�entstabilityandavailabletherapies

Axial

Angiography

Angiography–postemboliza�on

Case 2: Trauma, now hypertensive   HISTORY:32yos/pmotorvehicleaccidentandwithsubsequenthypertension  IMAGING:

  Post-contrastCT(top):Subcapsularhypera�enua�ngfluid(arrow)compressingthele�renalparenchyma,findingsconsistentwithtrauma�cpagekidney

  Pagekidney:Hypertensionsecondarytorenalcompressionusuallyassociatedwithaperinephricorsubcapsularhematoma

  Fluoroscopy(bo�om)a�erdrainplacementwithinjectedcontrastinthesubcapsularspace

  TREATMENT:Surgicalapproach(nephrectomyorhematomaevacua�on)andan�hypertensivetreatment

Fluoroscopy

Axial

Vascular   Intraperitonealbleedingfromvascularlesionsislesscommonthanretroperitonealhemorrhage;however,morbidityandmortalitycanbehigh  Acquiredvascularlesions:

  Aneurysms  Pseudoaneurysms  Angiodysplasia

  Congenitalvascularlesions:  Arteriovenousmalforma�ons

  Specialcase:Inyoungpa�ents,splanchnicarteryaneurysmsshouldincreasesearchforsystemicvasculardisease,mostnotablytypeIVEhlers-Danlossyndrome.Inpa�entswithEhlers-Danlossyndrome:  Maypresentwithaspontaneousaneurysmrupture  Angiographymaybecontraindicatedbecauseoftheriskofaneurysmforma�onatthesiteofpunctureandothervascularinjury/complica�ons

Aneurysm vs pseudoaneurysm   Aneurysm:

  Arterialdila�onwithintactvesselwalllayers  Abdominalaor�caneurysm:

  300millionpeopleglobally  Elec�verepaircommonat5.5cm  Withoutrepair,rupturediso�enfatal

  Splenicarteryaneurysm:  Mostcommonvisceralaneurysm(60%)  Spontaneousruptureoccursin3%–10%ofsplenicarteryaneurysms  Dangerofruptureiflarge,inpregnantpa�ent,orinpa�entwithadvancedliverdisease

  Pseudoaneurysm:  Injurytoall3layersofthearterialwall  Containedrupturewithperfusedsacthatcommunicateswithartery  Pseudoaneurysmsofthehepa�c,splenic,andgastroduodenalarteriescanbecomplica�onsofpancrea��s  Riskfactorsformajorvascularcomplica�onsofpancrea��sinclude:necro�zingpancrea��s,mul�-organfailure,sepsis,andpancrea�cfluid-collec�onssuchasabscesses,pseudocystsorwalled-offnecrosis

Case 3: Abdominal pain and syncope   HISTORY:93yomalepresen�ngwithprogressiveabdominalpainfor24hours  IMAGING:

  Pre-contrastCTwithfreeabdominalfluidmeasuring38HU.  Arterialphase(axialandsagi�al)CT:Enlargedabdominalaortawithac�veextravasa�onofcontrast(arrows)andsignificantperiaor�cfatstranding/hemorrhageindica�nganabdominalaor�caneurysmrupture.  Sagi�alCT:Aor�cwalldefect(orangearrow)  Delayedimagesdemonstra�ngextravasatedcontrastspreadingthroughouttheperitonealcavity  Pa�entdiedwithin1hourofCT

  TREATMENT:Stabilizepa�entandemergentsurgicalorendovascularaor�crepair

Pre-contrast

Arterial

Delayed

Sagi�al

Case 4: Recent pancrea��s   HISTORY:58yoMwithepisodeofacutepancrea��s,nowwithnewonsetupperabdominalpain  IMAGING:

  Post-contrastCTaxialandcoronalimageswithasplenicarterypseudoaneurysm(arrowhead)withinapancrea�cpseudocyst(arrow)andsurroundingfatstranding  Angiographydemonstra�ngthesplenicarterypsuedoaneurysm(arrowhead)withac�veextravasa�on(arrow)

  TREATMENT:Stabiliza�onifbleedingac�vely.Emboliza�onduetocurrentbleedingortopreventfuturebleedingbecauseofthehighrisk

Angiography

Gastrointes�nal bleed   Thoughnottypicallyacauseofhemoperitoneum,gastrointes�nal(GI)bleedscanbelifethreatening  GIbleed

  CanoccuranywherealongtheGItractandpassthroughthebowel  E�ologies:mass,angiodysplasia,inflamma�on

  CTAremainsanimportantdiagnos�ctoolfornonvaricealupperGIbleedsbutislessusefulinlowerGIbleeds  ACRAppropriatenessCriteriaforlowerGIbleedsstateCTAuseisusuallyappropriateasthenextprocedure/interven�onfor:  Ac�vebleedingwithhematocheziaormelenainahemodynamicallystablepa�ent  Intermi�entorobscurenon-localizedrecurrentbleeding

  CTAusemaybeappropriatewhen:  Ac�vebleedinginahemodynamicallyunstablepa�entorapa�entwhohasrequiredmorethan5unitsofblood

  However,transcatheterarteriography/interven�on(TAI)isusuallyrecommendedinthiscircumstance

  CTAisusuallyNOTrecommendeda�erlowerGIbleedingsourceisalreadyiden�fied

Case 5: Melena   HISTORY:71yowithmelena  IMAGING:

  AxialandcoronalCTAimagesdemonstra�ngac�veextravasa�onintotheascendingcolonnearthehepa�cflexure(arrows),consistentwithalowerGIbleed  Angiographyimagesfromaselec�veinjec�ondemonstra�ngbriskpassageofcontrast(arrows)intothecoloniclumen

  TREATMENT:Stabiliza�onofthepa�ent.Endoscopictreatmentorendovascularemboliza�on.Ifunavailable,opensurgerymaybenecessary

Axial Coronal

Angiography-early Angiography-later

Gynecologic  Reproduc�vetractisthemostcommonsourceofspontaneoushemoperitoneuminwomenofchildbearingage PrimaryimagingmodalityusedisUS;

  CTusediftheclinicalfindingsarenonspecific

 Mostcommon:ectopicpregnancyandrupturedovariancyst  Lesscommon:endometriosis,uterinerupture,andHELLPsyndrome(subcapsularhematomaorhepa�crupture)

Case 6: Abdominal pain, vaginal bleeding   HISTORY:31yopresen�ngwithacuteonsetabdominalpain

  IMAGING:  Post-contrastCT:A�entua�ngbloodproductsrangingfrom35-50HUinthepelvis,consistentwithhemoperitoneum  Peripherallyenhancingcys�cmassintherightadnexa,consistentwithahemorrhagiccyst(arrow)  Transvaginalultrasound2dayslater:Smallamountofresidualfluid.Pa�entsymptomsresolvedbythis�me.

  TREATMENT:Ifstable,observa�on.Inunstablepa�ents,bloodtranfusionorsurgicalinterven�onmayberequired

Transvaginal

Axial

Case 7: Posi�ve β-HCG, abdominal pain   HISTORY:36yowithaposi�veβ-HCGandacuteonsetle�lowerquadrantabdominalpain

  IMAGING:  TransvaginalUS:Thickenedendometriallining(arrowheads)withnointrauterinegesta�onalsac  M-modetransvaginalUS:Le�adnexawithdetectablefetalheartrate,consistentwithaliveectopicpregnancy(arrow)

  TREATMENT:Emergentsurgicalinterven�on

M-mode

Ectopic pregnancy   1%ofpregnancies

  97%ofoccurrenceslocatedineithertheampullary(mostcommon)ortheisthmicpor�onofthefallopiantube

 Riskfactors:  Previousectopicpregnancy  Pelvicinflammatorydisease  Invitrofer�liza�on  Intrauterinedevice  Tubalsurgery

  Signsofectopicpregnancy:  Posi�vehumanchorionicgonadotropinlevelofmorethan2000IU/Landnointrauterinepregnancy  Extraovarianmass

Case 8: Pregnant pa�ent with RUQ pain   HISTORY:30yopregnantfemalepresen�ngwithsevererightupperquadrantpain,hypertension,andelevatedliverenzymes.Emergencyc-sec�onwasperformedfollowedbyCT  IMAGING:

  Non-contrastCT:Largehighdensitysubcapsularhematoma(arrow)withadjacenthepa�cedema.Dependenthigherdensityfluidcorrespondingtobloodintheparacolicgu�er(arrowhead)

  HELLPsyndrome  Peripartumtriad:hemolysis,elevatedliverenzymes,andlowplateletcount

  Disseminatedintravascularcoagula�onin20%-40%ofpa�ents

  Othercomplica�ons:hepa�cinfarc�on,hematoma,hepa�crupture,andplacentalabrup�on

  TREATMENT:Stabilizepa�entanddeliveryofthepregnancy

Iatrogenic bleeds  Anysurgicalproceduremaycausehemoperitoneum

  Evenminimallyinvasivepercutaneousorendovascularproceduresoccasionallyleadtointraperitonealhemorrhage

 Causes:  Directvascularinjury

  Examples:endovascularinjury,percutaneousoropensurgicalinjury(eg.inferiorepigastricarteryduringparacentesis)

  Biopsyorsurgeryinvolvingasolidorganormass  Examples:liver,spleen,renalcellcarcinoma,hepatocellularcarcinoma

Case 9: Percutaneous liver biopsy   HISTORY:45yowithsevererightupperquadrantpains/ppercutaneousliverbiopsy

  IMAGING:  Post-contrastaxialCT:Hemoperitoneumandac�veextravasa�on(arrows)fromtheliverbiopsysiteconsistentwithbiopsy-relatedhemorrhage

  TREATMENT:Conserva�vemanagementwithstabiliza�on.Considerreversingan�coagula�on.Endovascularemboliza�onifpa�entdemonstrateshemodynamicinstabilityorcon�nuedhemorrhage

Arterial

PortalVenous

Case 10: Severe RUQ pain a�er TACE   HISTORY:64yowithabdominalpaina�erTACEviarightfemoralarteryaccess  IMAGING:

  Post-contrastCT:Noac�veextravasa�on.Higherdensityfluidwithintherightabdomenconcerningforhemoperitoneum  Metallicclosuredevice(arrowhead)superficialtotheexpectedloca�onofthefemoralarterywithinterposedhematoma  Angiographyshowingaccesssite.Hemorrhagefromacombina�onofhighfemoralaccessandfailedclosuredevice

  TREATMENT:Monitorforstability,ifac�vehemorrhagethenmayrequireendovascularsten�ngoropenrepair

Spontaneous bleeds   “Spontaneousbleeds”arelargelyamisnomer  Usuallyan�coagula�onrelated,withriskofbleedingpropor�onaltotothedegreeofan�coagula�on  An�coagula�onmostcommonlycauseshemorrhageintotheretroperitoneum/psoasorrectusmuscles,butoccasionallyresultsinhemoperitoneum

  Trulyspontaneoushemoperitoneumisrare  Mustexcluderuptureofoccultneoplasm

Pa�entwithportalveinthrombosis(arrowhead)treatedwithTIPS/declotandan�coagula�onwhopresentswithsuddenRUQpain,noreportedtrauma.Largehematoma(arrow)withruptureintotheperihepa�cspace.

Post-TIPSwithouthematoma

NewRUQpain10dayslater

Case 11: Pain and right abdominal bruising   HISTORY:61yowithchronicabdominalpainanddiarrheaonlow-molecularweightheparinforatrialfibrilla�on.Acuteonsetabdominalpainandhypotension  IMAGING:

  Post-contrastCT:Rightrectushematomaextendingintotheanteriorpelvis(tople�)andasecondintrapelviccollec�onwithlayeringdependenthighdensity(bo�omle�)  Angiographydemonstra�ngac�veextraperitonealhemorrhage(orangearrows)

  TREATMENT:Conserva�vemanagementwithstabiliza�on.Considerreversingan�coagula�on.Angiographycanbeu�lizedfordiagnos�candtherapeu�cpurposes

Angiography

Bleeding masses   Spontaneoushemoperitoneumintheabsenceoftrauma,instrumenta�on,oran�coagula�ontherapyisrare  Insuchcases,arupturedneoplasmmustbeexcluded

  Eitherprimaryormetasta�ctumorcanruptureandbleedintotheperitonealcavitybuthighlyvascularmassesmorecommonlybleed

  Primarymasses:  Mostcommonprimarylesionstocausehemoperitoneumareliverandrenal  Rupturingsplenicmassesaremorerarethanhepa�correnal

  E�ologies:Hemangiomatosis,angiosarcoma,leukemia,orlymphoma

 Metasta�cmasses:  Spontaneousruptureisrarebutcancausemassivehemoperitoneum  Mostcommon:Lungcarcinoma,renalcellcarcinoma,andmelanoma

Renal masses  Mostcommonspontaneouslyhemorrhagingmassisabenignormalignantneoplasm(61%)  Mostcommon:Angiomyolipoma(29%)  Secondmostcommon:Renalcellcarcinoma(26%)

 Angiomyolipoma  Associatedwithtuberoussclerosis  <4cm:usuallywatch  ≥4cm:prophylac�cemboliza�onduetoriskofhemorrhage

Case 12: Flank pain   HISTORY:61yowithacuteonsetle�flankpain  IMAGING:

  Post-contrastCT:Fatcontaininglesionintheinferiorle�kidney(arrow)  Surroundinghemorrhageintheperinephricspaceandlayeringinthele�paracolicgu�er(orangearrows),consistentwitharupturedangiomyolipoma(AML)

  TREATMENT:Stabiliza�onofthepa�ent.Endovascularemboliza�onorresec�onisalsoapossibility,eitheremergentlyorifthelesionis≥4cm

Axial

Coronal

Hepa�c masses   Hepatocellularcarcinoma(HCC)

  Mostcommoncauseofatrauma�chemoperitoneuminmalepa�entsofallages;  Nearly15%incidenceofrupture*  Largeorperipherallylocatedtumorswithoutnormaloverlying�ssueareatahigherriskforrupture

  Hepa�cadenoma  Benignlivertumorassociatedwithincreasedestrogen  Morecommoninfemalesandthoseonoralcontracep�ves  Avidlyenhanceandcancontainfat

  Cavernoushemangioma  Fewcasesofhemorrhageandspontaneousruptureandhemorrhageoftheselesionsreported  Gianthemangiomas>10cmmorelikelytorupture,par�cularlywithtraumaorduringpregnancy

*Kim,H.C.,Yang,D.M.,Jin,W.etal.AbdomImaging(2008)33:633.doi:10.1007/s00261-007-9353-7

Case 13: Acute RUQ pain   HISTORY:55yowithhepa��sCandcirrhosis.Acuterightupperquadrantabdominalpain  IMAGING:

  Post-contrastCT:Enhancingexophyichepa�cmass(arrow)withfocalruptureoftheoverlyingcapsule,andsurroundingperihepa�chemorrhage,consistentwithrupturedhepatocellularcarcinoma

  TREATMENT:Stabiliza�onofthepa�entandobserva�on.Endovascularemboliza�onorhepa�cresec�onifunstable.TreatmentoftheHCCa�erresolu�onofacutecondi�on

Axial

Coronal

Case 14: Acute RUQ pain   HISTORY:31yoonoralcontracep�veswithacuterightupperquadrantabdominalpain

  IMAGING:  Post-contrastCT:Enhancinghepa�cmass(arrows)withcapsulerupture(orangearrow)andsurroundingperihepa�chemorrhage,consistentwithrupturedhepa�cadenomaandhemoperitoneum  In-andout-of-phaseMRI:Mul�pleaddi�onallesionswithsignaldropout,consistentwithsmaller,fatcontaininghepa�cadenomas

  TREATMENT:Ini�alstabiliza�onofthepa�ent.Endovascularemboliza�onorhepa�cresec�ontostopac�vebleeding.Defini�vetreatmentishepa�cresec�onduetohighriskoffuturebleeding.

CT

MRIin-phase

MRout-of-phase

Conclusions  Abdominalandpelvichemorrhageareimportantcausesofmorbidityandmortalityinthese�ngofbothtrauma�candatrauma�ccases

  Theradiologistshouldbeabletoconveyemergentfindingsandrecommendappropriateaddi�onalimaging

 Accurateiden�fica�onofabdominalandpelvichemorrhageandconcisedescrip�onofassociatedinjurycanhelpguidepa�entcare

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Contact: eugene.huo@ucsf.edu