Theiyallen Ambikapathi 1, Sentilnathan Subramaniam1 and Firdaus Hayati2
1. Department of Surgery, Queen Elizabeth Hospital, Ministry of Health Malaysia, Kota Kinabalu, Sabah, Malaysia
2. Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
Correspondence to: Firdaus Hayati; email: email@example.com
Received: 07 Dec 2020; Revised: 07 July 2021; Accepted: 12 July 2021; Available online: 7 Aug 2021
Abdominal apoplexy, or idiopathic spontaneous intraperitoneal hemorrhage (ISIH), is a rare but often fatal condition resulting from a variety of disease processes affecting abdominal vasculature. A 30-year-old woman presented with acute abdominal pain and breathlessness and was in class II hypovolemic shock. She had a history of multiple episodes of retching with non-bilious vomiting prior to that. Computed tomography (CT) reported a non-rotation of the gut, gross intraperitoneal free fluid with debris, and possible perforated appendicitis. Laparoscopy revealed a gross hemoperitoneum of 2.5 L, with bowel findings consistent with non-rotation of the gut, but technical difficulty in identifying the source of bleeding led to conversion to laparotomy. A ruptured short gastric artery was ascertained to be the source of bleeding and was successfully ligated. A retrospective review of the preoperative CT showed intraperitoneal free fluid with Hounsfield unit measurements of 48 and 52, suggestive of acute hemoperitoneum. ISIH is often a delayed diagnosis or missed diagnosis due to its low incidence. The presence of vomiting and abdominal pain with hypovolemic shock, especially in a young individual, should raise the suspicion of ISIH, which can be confirmed via early CT imaging to facilitate achieving hemostasis during surgery.
Keywords: Intraperitoneal hemorrhage, abdominal apoplexy, acute abdomen, short gastric artery, hemoperitoneum
Ann Afr Surg. 2022; 19(1): 54-57
Conflicts of Interest: None
© 2022 Author. This work is licensed under the Creative Commons Attribution 4.0 International License
Abdominal apoplexy, or idiopathic spontaneous intraperitoneal hemorrhage (ISIH), is a rare but often fatal condition resulting from a variety of disease processes affecting abdominal vasculature. ISIH was first reported by Barber in 1909, as he described a case of a pregnant woman who had intraperitoneal hemorrhage in the absence of trauma or surgery and the source of bleeding could not be identified (1). A total of 110 cases of ISIH have been reported between 1909 and 1998 by Carmeci et al. (2). In their series, a preponderance to the male sex (male/female ratio: 3:2) and the fifth and sixth decades of life were noted (2). Patients often presented with hypovolemic shock and an acute abdomen (2). We herein report a case of 30-year-old lady with a significant history of retching who presented with abdominal pain and hypovolemic shock that turned out to be ISIH secondary to a ruptured short gastric artery.
A 30-year-old woman presented with acute epigastric pain and breathlessness with a duration of 1 day. She had a history of multiple episodes of retching for more than 10 times with non-bilious vomiting prior to that. She was diagnosed with type 2 diabetes mellitus 8 years ago but was not on treatment or regular follow-up. She had no prior history of abdominal trauma or surgery. Physical examination revealed a pale, conscious woman. She was in class II hypovolemic shock, with a weak, rapid pulse of 107 bpm and blood pressure of 135/72 mmHg. She was able to maintain saturation with oxygen supplementation of 2 L/min. Her abdomen was distended but was soft with generalized tenderness. Blood investigations revealed a hemoglobin of 8.3 g/dL (normal, 11–13 g/dL) with a hematocrit level of 30% (normal, 42–52%) and total white cell count of 10.4 109/L (normal, 4.5–11.0 109/L). Her blood sugar level, platelet count, and coagulation profile were normal. Serum amylase and cardiac enzymes were within normal limits, and her urine pregnancy test was negative. Electrocardiogram showed no signs of ischemia. Chest radiography had no signs of pneumoperitoneum or pneumomediastinum.
She responded to resuscitation with fluids followed by packed cell transfusion and was subsequently subjected to computed tomography (CT) of the abdomen. CT imaging reported non-rotation of the gut, gross intraperitoneal free fluid (Figure 1) with debris, and an elongated thickened appendix suggestive of a perforated appendicitis. In view of the clinico-radiological discrepancy, a decision was made for a diagnostic laparoscopy.
Laparoscopy revealed a gross hemoperitoneum of 2.5 L, with small bowel loops located to the right and the right hemicolon located centrally consistent with non-rotation of the gut. Continuous pooling of blood was noted from the left hypochondrium, but the source was not identifiable laparoscopically. Conversion to laparotomy revealed active arterial bleeding from a short gastric artery. The bleeding vessel appeared normal, with no obvious aneurysmal dilatation or pathology and was successfully ligated with non-absorbable sutures. The rest of the abdominal organs were examined and noted to be grossly normal.
Click to view Figure 1. Abdominal CT scan (axial) with intravenous contrast demonstrating free fluid (black arrow) in the right iliac fossa. The extraluminal fluid is denser than the intraluminal water contrast. 124x87mm (762 x 762 DPI)