Postoperative encapsulated hemoperitoneum in a patient with gastric stromal tumor treated by exposed endoscopic full-thickness resection: A case report

BACKGROUND Gastric stromal tumors,originating from mesenchymal tissues,are one of the most common tumors of the digestive tract.For stromal tumors originating from the muscularis propria,compared with conventional endoscopic submucosal dissection(ESD),endoscopic full-thickness resection(EFTR)can remove deep lesions and digestive tract wall tumors completely.However,this technique has major limitations such as perforation,postoperative bleeding,and post-polypectomy syndrome.Herein,we report a case of postoperative serous surface bleeding which formed an encapsulated hemoperitoneum in a patient with gastric stromal tumor that was treated with exposed EFTR.Feasible treatment options to address this complication are described.CASE SUMMARY A 47-year-old male patient had a hemispherical protrusion found during gastric endoscopic ultrasonography,located at the upper gastric curvature adjacent to the stomach fundus,with a smooth surface mucosa and poor mobility.The lesion was 19.3 mm×16.1 mm in size and originated from the fourth ultrasound layer.Computed tomography(CT)revealed no significant evidence of lymph node enlargement or distant metastasis.Using conventional ESD technology for mucosal pre-resection,exposed EFTR was performed to resect the intact tumor in order to achieve a definitive histopathological diagnosis.Based on its morphology and immunohistochemical expression of CD117 and DOG-1,the lesion was proven to be consistent with a gastric stromal tumor.Six days after exposed EFTR,CT showed a large amount of encapsulated fluid and gas accumulation around the stomach.In addition,gastroscopy suggested intracavitary bleeding and abdominal puncture drainage indicated serosal bleeding.Based on these findings,the patient was diagnosed with serosal bleeding resulting in encapsulated abdominal hemorrhage after exposed EFTR for a gastric stromal tumor.The patient received combined treatments,such as hemostasis under gastroscopy,gastrointestinal decompression,and abdominal drainage.All examinations were normal within six months of follow-up.CONCLUSION This patient developed serous surface bleeding in the gastric cavity following exposed EFTR.Serosal bleeding resulting in an encapsulated hemoperitoneum is rare in clinical practice.The combined treatment may replace certain surgical techniques.

Exophytic inflammatory myofibroblastic tumor of the stomach in an adult woman:A rare cause of hemoperitoneum

Inflammatory myofibroblastic tumor （INT） of the stomach in adults is extremely rare, with unpredictable prognosis. We present a 55-year-old woman with a gastric IMT. She experienced sudden abdominal pain 4 d previously. Physical examination showed mild abdominal tenderness in the hypogastrium, but no palpable abnormal abdominal mass. Abdominal CT showed a mass of approximately 8 cm in the gastrocolic ligament. On laparoscopic exploration, unexpected hemoperitoneum of approximately 1.5 L of blood was found, and an exophytic gastric mass of approximately 10 cm, appeared from the anterior wall of the gastric body along the greater curvature. Laparoscopy further showed that non- clotting blood in the abdominal cavity seemed to be from the gastric tumor. After conversion to open surgery for more precise evaluation of the cause of hemoperitoneum and the large friable tumor, gastric wedge resection, including the tumor, was conducted. The final diagnosis was consistent with IMT that originated from the gastric wall.

Malignant fibrous histiocytoma presenting as hemoperitoneum mimicking hepatocellular carcinoma rupture

Malignant fibrous histiocytoma (MFH) is a pleomorphic mesenchynal sarcoma. It is uncommonly arises primarily from the intra-peritoneal cavity. Primary peritoneal MFH with tumor bleeding and rupture is rare. We describe the imaging features of a 70-year-old patient presenting with ruptured hemorrhagic peritoneal MFH at subhepatic area,accompanied by massive hemoperitoneum,mimicking a ruptured pedunculated hepatocellular carcinoma. Computed tomography (CT) revealed a large heterogeneous enhanced subhepatic mass with adjacent liver,gallbladder and colon invasion. Tumor hemorrhage and rupture complicated with peritoneal seeding and massive bloody ascites were also detected. Angiography showed a hypervascular tumor fed by enlarged right hepatic arteries,cystic artery and omental branches of gastroepiploic artery. The patient underwent laparotomy for tumor resection,but the tumor recurred one month after operation. To our knowledge,the CT appearance of ruptured intraperitoneal MFH complicated by hemoperitoneum has not been previously described.

Successful laparoscopic management of hemoperitoneum due to spontaneous venous rupture overlying a uterine fibroid

Spontaneous venous rupture overlying a uterine fibroid is a rare cause of hemoperitoneum. A 38-year-old woman presented to the emergency department with acute onset of abdominal pain. The ultrasound revealed multiple fibroids and free fluid in the peritoneum. There was a significant drop of the hemoglobin and hematocrit. The patient underwent emergent exploratory laparoscopy. A subserosal uterine leiomyoma was found, with a bleeding vein on its basis and massive hemoperitoneum. Laparoscopic myomectomy was successfully performed with local injection of vasopressin and intraoperative autologous blood transfusion. This case suggests that spontaneous intraperitoneal haemorrhage associated with uterine fibroids, although rare, should be considered in women with hypovolemic shock and a pelvic mass.

Hemoperitoneum in cirrhotic patients without abdominal trauma or tumor

BACKGROUND:Hemoperitoneum is associated with several emergency conditions and is especially evident when it occurs in patients with liver cirrhosis.This study aimed to assess the clinical characteristics of cirrhotic patients who did not have abdominal trauma or tumor but who developed hemoperitoneum.METHODS:We reviewed the clinical records of 1276 consecutive cirrhotic patients with hemoperitoneum at our center between January 2007 and December 2009.Hemoperitoneum was confirmed by abdominal paracentesis.RESULTS:Of the 1276 cirrhotic patients,19 were found to have hemoperitoneum,but only 6 did not have abdominal trauma or tumor.The occurrence of spontaneous hemoperitoneum in the cirrhotic patients was therefore 0.5%.Hemoperitoneum can occur spontaneously in severely decompensated cirrhotic patients with intra-abdominal collateral vessels and high scores on the model for end-stage liver disease and Child-Pugh-Turcotte test.Most patients presented with abdominal distension,abdominal pain,increased abdominal girth and hemodynamic instability with a significant drop in the hemoglobin level.Three patients died of hemorrhagic shock within 24 hours,and the other 3 died of hepatic encephalopathy or spontaneous bacterial peritonitis after 5 to 10 days because of further decompensation of the liver.CONCLUSIONS:Hemoperitoneum can occur in cirrhotic patients who do not have abdominal trauma or tumor.It mainly occurs in severely decompensated end-stage cirrhotic patients.Cirrhotic patients with hemoperitoneum have a poor prognosis.

Hemoperitoneum secondary to rupture of cystic artery pseudoaneurysm

BACKGROUND:Spontaneous hemoperitoneum of hepato- biliary origin is commonly due to hemorrhage from a liver tumor.It is rarely caused by spontaneous rupture of aneurysm in visceral arteries. METHODS:We report an unusual case of hemoperitoneum caused by rupture of cystic artery pseudoaneurysm,and also outline the approach to its management through surgical and radiological methods. RESULTS:In our patient,the pseudoanurysm was initially treated with percutaneous thrombin injection.However this method of treatment failed after initial success.The pseudoanurysm was finally obliterated successfully using microcoil embolization. CONCLUSIONS:The mainstay of treatment of cystic artery pseudoaneurysm is cholecystectomy and ligation of the aneurysm.Recent publications showed success in using microcoil embolisation.In this case we also outline the use of percutaneous thrombin injection as a definitive treatment method and discuss its success or failure as a new method of treatment.

Spontaneous hemoperitoneum from hepatic metastatic trophoblastic tumor

Spontaneous hemoperitoneum(SP) is defined as the presence of blood within the peritoneal cavity that is unrelated to trauma.Although there is a vast array of etiologies for SP,primary hepatocellular carcinoma and hepatic adenoma are considered to be the most common causes.Hepatic metastatic tumor associated with spontaneous rupture is rare.SP from hepatic metastatic trophoblastic tumor may initially present with a sudden onset of abdominal pain.Abdominal computed tomography(CT) plays an important role in establishing the diagnosis of SP,indicating its origin and etiology,and determining subsequent management.Herein,we report an uncommon case of hemoperitoneum from spontaneous rupture of a hepatic metastatic trophoblastic tumor in a young female patient.Interestingly,the contrast-enhanced CT findings demonstrated hypervascular hepatic masses with persistent enhancement at all phases,which were completely different from the common appearances of hepatic metastases.For SP resulting from hepatic metastatic tumors,surgical intervention is still the predominant therapeutic method,but the prognosis is very poor.

Acute abdomen caused by nontraumatic hemoperitoneum is the first manifestation of gastric low grade stromal tumor

Gastrointestinal stromal tumors （GISTs） are the most common mesenchymal tumors of the gastrointestinal tract in adults. We treated surgically a man with acute abdomen caused by non-traumatic hemoperitoneum and diagnosed by low grade gastric GIST. A 51-year-old Caucasian man came to the hospital for abdominal pain for 3 hours. He had no history of abdominal trauma. On admission, he was conscious and alert, and he had hypotension （80/50 mmHg） and moderate tachycardia. Abdominal ultrasonography showed the presence of free peritoneal fluid. Abdominal magnetic resonance imaging （MRI） showed diffuse intraabdominal hemorrhage and solid mass lesion at the greater curvature of the stomach. At an emergency laparotomy, a pedunculated, fragile mass of 5x6 cm originating from the posterior wall of the stomach was seen. The tumor was resected. Histopathologically a gastrointestinal stromal tumor was detected. The patient had an uneventful postoperative course and was discharged on the sixth postoperative day. Follow-up showed no recurrence of the tumor 8 months after surgery. Intraabdominal bleeding is a rare presentation of gastrointestinal stromal tumors. The diagnosis of the tumor should be based on whether sudden abdominal pain occurs in patients with an intraabdominal mass.

Hepatic angiosarcoma manifested as recurrent hemoperitoneum

Angiosarcoma is a rare tumor that account for less than 1% of all sarcomas. Although hepatic angiosarcoma usually presents with unspecific symptoms, it rapidly progresses and has a high mortality. We report a rare case of primary hepatic angiosarcoma manifested as recurrent hemoperitoneum.

Greater omentum gastrointestinal stromal tumor with PDGFRA-mutation and hemoperitoneum

Although gastrointestinal stromal tumor(GIST) occurs generally in the digestive tract,omental GIST is very rare.We report the first case of an adult greater omental GIST with a new platelet-derived growth factor receptor α gene(PDGFRA)-mutation with hemoperitoneum.A 43-year-old man was admitted to our hospital complaining of acute abdominal pain.Abdominal contrast-enhanced computed tomography revealed a huge mass in the right abdominal cavity,and a large accumulation of fluid in the pelvic cavity,suggesting hemoperitoneum.We diagnosed the rupture as an intra-abdominal tumor,and an emergency tumorectomy was performed with resection of the greater omentum.This tumor was located in the distal right side ofthe greater omentum,and showed no continuity with the gastric wall.The tumor occurred primarily in the greater omentum.The resected tumor was about 19 cm × 12 cm × 14 cm in diameter,and weighed 1529 g.Histologically,the tumor was composed of epithelioidshaped cells with high cellularity,and was positive for CD117 and CD34,and negative for S-100,α-smooth muscle actin.The mitosis was 6/50 under high power field.This case showed exon 18 mutation of PDGFRA with 846(Asp to Glu) substitution,848(Asn to Lys) substitution.This is the first report of this PDGFRA mutation in omental GIST,and this might play an important role in the tumorigenesis of this case.Based on these findings,the tumor was diagnosed as high risk GIST primarily occurring in the greater omentum.The patient was treated with imatinib at a dose of 400 mg/d as adjuvant chemotherapy,and has been followed up for 24 mo with no evidence of recurrence.

Neonatal Hemoperitoneum: Diagnosis Always Delicate

The hemoperitoneum is a rare and severe disease in neonatal period that can cause a condition of hemorrhagic shock. We presented the case of an infant hospitalized for hemodynamic disorders which could to suspect maternofetal infection. The clinical deterioration with the appearance of shock signs, anemia, abdominal distension and Ultrasound allowed to correct diagnosis. Labour dystocia (apart from unnoticed minimal obstetrical trauma) does not seem to be responsible for hemoperitoneum as the majority of the reported cases. According to current recommendations, the treatment of this condition is primarily based on reanimation measures. Surgery is rarely needed in certain cases. Conservative treatment should be considered.

A ruptured recurrent small bowel gastrointestinal stromal tumour causing hemoperitoneum

Hemoperitoneum is a rare and potentially life-threatening complication of GIST. We reported a 54- year-old man who developed disseminated intra-abdominal recurrence from a previously resected gastrointestinal stromal tumour （GIST） of the small bowel, and the patient presented with hemoperitoneum. Emergent debulking surgery was performed. A high dose imatinib was prescribed. Despite the presence of residual disease, the patient was well clinically 8 months after the operation. Even though, there is no evidence to support the routine use of debulking surgery in the management of GIST. In our patient, disease progression after second line targeted therapy and the absence of alternative treatment options for spontaneous rupture and hemoperitoneum prompted us to treat the patient aggressively. Resection of the ruptured GIST was carried out for control of bleeding and to prevent recurrent bleeding in this patient with good surgical risks. During the treatment decision-making, the patient＇s general condition, the risk of surgery and the extent of dissemination were taken into consideration. In this patient who presented with spontaneous rupture of a small intestinal GIST, the novel use of targeted therapy and aggressive surgical treatment produced reasonably good survival outcome.

Hemoperitonium: Atypical Presentation Caused by Spontaneous Rupture of Hepatocellular Carcinoma in an Undiagnosed Patient

Introduction: Acute hemoperitoneum due to the spontaneous rupture of hepatocellular carcinoma (HCC) is a rare case of non-traumatic intra-abdomen bleeding that requires a high index of suspicion to approach, especially if no known history of HCC. It can mislead the physicians when the patient presents in an atypical way. Case Presentation: In this case report, we describe a fortuitous rupture of hepatocellular carcinoma in a 58-year-old male who was not previously diagnosed as having HCC and who came with atypical symptoms and signs of hemoperitoneum. He was then treated by trans-arterial embolectomy. Discussion: Diagnosis of hemoperitoneum in a case with bradycardia and hypotension is uncommon, as it goes more towards cardiogenic shock than hypovolemic shock, especially in a patient who is previously not symptomatic and has no risk factor for hepatocellular carcinoma. Conclusion: physicians should be alert to the possibility of encountering a hemorrhagic shock, although no trauma injury in any hypotensive patient with no clear reason for his condition.

肝硬化腹水患者非肿瘤非外伤性血腹的诊治

目的探讨肝硬化非肿瘤非外伤性血性腹水(血腹)的临床特征、诊断和治疗。方法经诊断性腹腔穿刺术诊断肝硬化非肿瘤非外伤性血腹患者24例,分别用腹部绷带加压法或垂体后叶素、思他宁(生长抑素)或善宁(奥曲肽)等方法进行治疗。结果肝硬化腹水患者2 340例,发生非肿瘤非外伤性血腹24例(1.03%)。腹腔内少量出血18例(75%),经用腹部绷带加压法或垂体后叶素止血,止血率为83.33%(15/18例);腹腔内大量出血6例(25.00%),经用思他宁或善宁止血,止血率为66.67%(4/6例),死亡率为16.67%(1/6例)。结论血腹是肝硬化腹水严重并发症,诊断性腹腔穿刺能明确其诊断,积极处理大量血性腹水具有重要意义。

家兔腹内出血动物模型的建立

目的为腹腔内出血诊断方法的研究建立一种家兔动物模型。方法(1)应用专用撞击器对家兔肝外部进行撞击,根据活塞距撞击器枪口距离,将家兔分为5.0 cm,9.0 cm及13.0 cm 3个撞击强度组,选择合适的撞击强度;(2)用选择的强度对15只家兔肝外部进行撞击,致肝损伤产生腹腔出血,用吸水纸法测量出血量。结果(1)活塞距枪口距离9.0 cm撞击组的撞击强度满足实验要求。(2)15只家兔被撞击后,均发生了肝出血,出血率为100%,出血量在35 mL^50 mL之间,15只家兔均在被撞击后存活3 h以上。结论家兔腹腔出血动物模型建立是成功的,这一模型能满足腹腔出血诊断方法研究的需要。

Peliosis hepatis: Personal experience and literature review

Peliosis hepatis(PH) is a disease characterized by multiple and small,blood-filled cysts within the parenchymatous organs. PH is a very rare disease,more common in adults,and when it affects the liver,it comes to the surgeon's attention only in an extremely urgent situation after the lesion's rupture with the resulting hemoperitoneum. This report describes the case of a 29-year-old woman affected by recurring abdominal pain. Computed tomography scans showed a hepatic lesion formed by multiple hypodense areas,which showed an early acquisition of the contrast during the arterial phase. Furthermore,it remained isodense with the remaining parenchyma during the late venous phase. We decided on performing a liver resection of segment Ⅶ while avoiding a biopsy for safety reasons. The histopathologic examination confirmed the diagnosis of focal PH. PH should always be considered in the differential diagnosis of hepatic lesions. Clinicians should discuss the possible causes and issues related to the differential diagnosis in addition to the appropriate therapeutic approach. The fortuitous finding of a lesion,potentially compatible with PH,requires elective surgery with diagnostic and therapeutic intents. The main aim is to prevent the risk of a sudden bleeding that,in absence of properly equipped structures,may have a fatal outcome.

Combined approach for spontaneous rupture of hepatocellular carcinoma

Ruptured hepatocellular carcinoma is a rare,emergency occurrence in western countries with high mortality risk.A number of hypotheses have been formulated in order to explain the precise mechanism that leads to hepatocellular carcinoma(HCC) rupture:sub-capsular location,dimensions,portal hypertension,tumour necrosis,local increase of venous pressure due to the outflow reduction caused by neoplastic invasion,and the presence of a previous vascular injury which might predispose to HCC rupture.There is still a debate in the literature concerning the best approach in cases of HCC rupture.Surgery is the first option for treatment of acute abdominal bleeding.However the advent of endovascular treatments widens the range of possible therapies for acute bleeding control and subsequent ablation purposes.We report a case of hemoperitoneum from spontaneous rupture of undiagnosed HCC,that was treated successfully by emergency surgical resection followed by transarterial chemo-embolizationfor local recurrence.

创伤性脾脏损伤72例CT平扫分析

目的 旨在进一步提高脾脏损伤的CT诊断水平。方法 采用CT平扫对 72例脾脏损伤患者进行中上腹部检查 ,层厚 10mm ,层间距 10mm ,部分病例作局部 3～ 5mm薄层扫描。结果 脾脏表面损伤合并腹腔积血 4例 ,脾脏裂伤合并腹腔积血 1例 ,脾内血肿及延迟性脾损伤 4例 ,脾脏挫裂伤 (脾碎裂 )合并腹腔积血 5 0例 ,脾脏包膜下血肿合并腹腔积血 10例 ,脾脏损伤合并肝脏损伤及左膈疝各 1例 ,误诊 1例。结论 腹部CT平扫在诊断早期及延迟性脾脏损伤有其独特优势 ,而腹腔积血则在脾脏损伤诊断有重要的意义。

妊娠晚期腹腔内出血一例报道并文献复习

妊娠期子宫血管破裂为临床罕见病例,尽早诊断、及时手术是抢救孕产妇及围生儿生命的关键。本院收治1例23岁孕妇,于妊娠29周无明显诱因突发下腹疼痛,超声提示双子宫和盆腔大量积液,后穹隆穿刺见不凝血,急诊开腹探查见妊娠子宫右后壁下方一静脉血管破裂。予缝扎止血,患者术后恢复好,创口愈合。

妊娠中晚期腹腔内出血31例临床分析

目的:探讨妊娠中晚期腹腔内出血的高危因素、临床特点及母儿预后。方法:回顾分析2012年1月至2018年4月中国医科大学附属盛京医院收治的31例妊娠中晚期腹腔内出血患者的临床资料。结果:31例妊娠中晚期腹腔内出血患者中,完全性子宫破裂出血23例(74.2%),肝破裂出血2例(6.5%),子宫血管破裂出血3例(9.7%),输卵管破裂出血1例(3.2%),子宫炎症渗出出血1例(3.2%),未找到出血点1例(3.2%)。除引产病例,患者的主要临床表现均为腹痛(23/25)。均行开腹探查,同时剖宫产或剖宫取胎。31例患者中,除1例患者死亡,其余患者均恢复良好后出院。进入围产期的20例患者中,8例发生胎死宫内,1例放弃治疗后死亡,4例脑白质损伤,7例预后良好,围产儿死亡率为达45%。外市转入我院的6例均发生胎死宫内。结论:妊娠中晚期腹腔内出血的病因应考虑多种可能,首先警惕子宫破裂的可能。腹腔内出血无论出于何种原因,都严重威胁母儿生命,围产儿预后较差,应积极处理,跨市转运不利于围产儿预后。