Hematocele y hemoperitoneo como manifestación inicial de carcinoma hepatocelular: caso clínico / Hematocele and hemoperitoneum as initial manifestation of hepatocellular carcinoma: report of one case

Hepatocellular carcinoma (HCC) rupture is a rare complication, with a higher prevalence in countries of Asia and Europe. Its clinical manifestations can be nonspecific, from abdominal pain and bloating to hemodynamic involvement. We report a 70-year-old male patient with a history of chronic liver disease, presenting with an enlargement and ecchymosis of the scrotum, associated with abdominal bloating. The initial abdominal ultrasound study showed increased liquid content in the scrotal sac and regional edema. A CT of the abdomen and pelvis showed a liver mass with characteristics of hepatocellular carcinoma, associated with extensive hemoperitoneum that drained into the scrotal sac. The patient was treated with embolization of the right hepatic artery and later with surgical resection of the tumor mass, with a good clinical evolution.

Hemoperitoneo masivo como presentación de un caso de percretismo placentario / Massive hemoperitoneum as a rare presentation of placental percretism

El acretismo placentario se define como la invasión anómala de la placenta al miometrio, denominado percretismo en su forma más severa. En la actualidad se describe la coexistencia de placenta previa con cicatriz de cesárea, como el principal factor de riesgo. Siendo esta última variable la que explica su incidencia al alza en los últimos años. El pronóstico depende mayoritariamente del grado de adherencia, del diagnóstico prenatal y del adecuado manejo multidisciplinario. Con el objetivo de mostrar una presentación poco frecuente de percretismno placentario se presenta a continuación un caso clínico sin diagnóstico prenatal con requerimiento de cirugía de urgencia y su respectivo outcome.

Placental acretism is defined as an abnormal invasion of the placenta to the myometrium, it's most severe presentation being placenta percreta. The main risk factor for this disease is the coexistence of placenta previa and previous cesarean section. Its incidence has been progressively rising, mainly because of the increase in cesarean sections. Extent of adherence, prenatal vs intra surgery diagnosis, and multidisciplinary management are accountable for the prognosis of placental acretism. A case report with no prenatal diagnosis, which required emergency surgery, and its outcome is presented.

Tratamiento mínimamente invasivo de una lesión de la vía biliar secundaria a un traumatismo abdominal cerrado: Caso clínico / Minimally invasive treatment of biliary tract injury secondary to closed abdominal trauma: Clinical case

Las lesiones hepáticas y de las vías biliares por causa traumática son poco usuales en la edad pediátrica. Del total de pacientes con trauma abdominal cerrado, menos del 9 % presentan lesión hepática, y la frecuencia varía entre el 2 % y el 3 % de la lesión de las vías biliares. Actualmente, el tratamiento recomendado para el trauma abdominal cerrado con lesión hepática sin repercusión hemodinámica es conservador; en caso de presentar lesión de la vía biliar intra- o extrahepática, los abordajes de preferencia son mínimamente invasivos, como la cirugía percutánea o endoscópica, y se utiliza la laparotomía en casos seleccionados. Se presenta el caso de un paciente con trauma abdominal cerrado y trauma hepático, inicialmente laparotomizado en 2 ocasiones por inestabilidad hemodinámica y hemoperitoneo; presentó un bilioma subdiafragmático y coleperitoneo, en el que se realizó un manejo mínimamente invasivo por drenaje percutáneo bajo control tomográfico.

Hepatic and biliary tract injuries due to traumatic causes are rare in pediatric patients. Of the total number of patients with closed abdominal trauma, less than 9 % have liver injury, and the frequency varies between 2 and 3 % of biliary tract lesions. Currently, the recommended treatment for closed abdominal trauma with liver injury without hemodynamic repercussion is conservative. In case of presenting intra or extrahepatic biliary tract lesion, the preferred approaches are minimally invasive, such as percutaneous or endoscopic surgery, using laparotomy in selected cases. We present the case of a patient with closed abdominal trauma and liver trauma, initially laparotomized on 2 occasions due to hemodynamic instability and hemoperitoneum; presented a subdiaphragmatic and coleperitoneal bilioma; it was performed minimally invasive percutaneous drainage under tomographic control.

Hemoperitoneo como manifestación inicial de carcinoma hepatocelular: reporte de tres casos / Hemoperitoneum as initial manifestation of hepatocellular carcinoma: report of three cases

Hepatocellular carcinoma (HCC) is the main primary liver malignancy. Its prevalence is increasing and is associated in 90% to cirrhotic patients. Hemoperitoneum secondary to spontaneous rupture of the tumor is an uncommon complication in Latin America and the Western world, being more prevalent in Asian races. However, it is associated to hemodynamic repercussion with high mortality, therefore high level of suspicion and early treatment are required. Regarding the management of the condition, in addition to hemodynamic stabilization, active hemostatic control is recommended over conservative management, transarterial chemoembolization being currently the chosen alternative. We present a series of three clinical cases of patients who debuted with clinical manifestation of hemoperitoneum during the diagnostic process of a HCC.

El carcinoma hepatocelular (CHC) corresponde a la principal neoplasia maligna primaria hepática. Su prevalencia va en aumento y se asocia en 90% a pacientes cirróticos. El hemoperitoneo secundario a rotura espontánea del tumor constituye una complicación infrecuente en Latinoamérica y Occidente, siendo más prevalente en razas asiáticas. Sin embargo, se asocia a repercusión hemodinámica con alta mortalidad, por lo que requiere un alto índice de sospecha y tratamiento oportuno precoz. En cuanto al manejo del cuadro, junto a la estabilización hemodinámica se recomienda un control hemostático activo por sobre manejo conservador, siendo la embolización transarterial la alternativa de elección actualmente. Describimos a continuación una serie de tres casos clínicos de pacientes que debutan con manifestación clínica de hemoperitoneo durante el proceso diagnóstico de un CHC.

Hematoma retroperitoneal de causa infrecuente: a propósito de un caso / Retroperitoneal hematoma of unusual cause: a case report

The spontaneous retroperitoneal hematoma (SRH) is defined as a spontaneous hematic collection located in any of the retroperitoneal compartments. The most frequently encountered cause of retroperitoneal hemorrhage is a ruptured abdominal aortic aneurysm, followed by renal and adrenal tumors, along with some other less common causes. Performing accurate diagnosis of patients at admission has proven to be difficult, given that the clinical presentation is ample and variable and may mimic other pictures of abdominal or lower back pain. Imaging techniques, mainly angiography, computed tomography, and MR Imaging, represent a fundamental tool for both timely diagnosis and proper management of the condition. We report the case of a 56-year-old male patient with diagnosis of HIV, who presented with a history of abdominal pain and palpable abdominal mass. After a thorough imaging evaluation, patient was diagnosed with retroperitoneal hematoma, whose histological analysis revealed a Burkitt lymphoma.

El hematoma retroperitoneal espontáneo (HRE) se define como una colección hemática espontánea, situada en cualquiera de los compartimentos retroperitoneales. Dentro de las causas más frecuentes se encuentran las roturas de aneurisma de aorta abdominal, tumores renales y suprarrenales, entre otras. Habitualmente es difícil realizar el diagnóstico al ingreso del paciente, ya que la presentación clínica es variable y puede simular otros cuadros de dolor abdominal o lumbar. Las técnicas de imagen, especialmente la angiografía, tomografía computada y resonancia magnética, son una herramienta fundamental en el diagnóstico y manejo oportuno del cuadro. Presentamos el caso de un varón de 56 años de edad con diagnóstico de VIH en tratamiento, que debutó como un cuadro de dolor y masa abdominal palpable. Luego de un acabado estudio de imágenes, se diagnosticó un HRE cuyo estudio histológico reveló un Linfoma de Burkitt.

Massive hemorrhage from spontaneous ruptured hepatocellular carcinoma controlled by isoamyl 2-cyanoacrylate: a case report

To report a case of ruptured hepatocellular carcinoma with massive hemoperitoneum which was successfully controlled with isoamyl 2-cyanoacrylate. A 46-year-old Bangladeshi gentleman presented to our casualty complaining of acute abdominal pain and distension, associated with jaundice. Bedside abdominal ultrasound showed multiple focal lesions in the liver with fluid in the abdomen. The patient was vitally unstable, so he was resuscitated and underwent emergency laparotomy for massive hemoperitoneum due to a ruptured tumor nodule. Isoamyl 2-cyanoacrylate was applied to the ruptured nodule which stopped bleeding within 1-2 min. This case shows the effectiveness of isoamyl 2-cyanoacrylate in controlling bleeding in ruptured liver tumors

A Case of Spontaneous Hemoperitoneum Presenting as the Initial Manifestation of Systemic Lupus Erythematosus

Thrombocytopenia is included in the classification criteria for systemic lupus erythematosus (SLE). However, severe thrombocytopenia causing spontaneous bleeding is rare. Here, we describe a 22-year-old woman who presented with spontaneous hemoperitoneum as the first manifestation of SLE. Laboratory findings compatible with SLE included positive antinuclear antibody and a false-positive venereal disease research laboratory. Symptoms suggesting the disease were not prominent early after admission, but headache and seizures that developed on the 3rd day of admission led to the diagnosis of SLE. The brain magnetic resonance imaging and angiography findings were compatible with the neuropsychiatric manifestations of SLE. High-dose steroid and monthly intravenous cyclophosphamide pulse therapy were effective at improving the headache and seizure, as well as the hemoperitoneum.

Incidental Detection of Interstitial Pregnancy on CT Imaging

Ectopic pregnancy is a potentially life-threatening condition. Detection of ectopic pregnancy on CT images is rare. In this case, we describe the CT findings of interstitial pregnancy both before and after rupture. If CT images demonstrate the presence of a strong enhancing ring-like mass in the pelvis, ectopic pregnancy should be considered.

Stray bullet in inferior vena cava

A young boy presented in emergency with history of being hit by a stray bullet injuring the right hypochondrium. Ultrasound of abdomen showed hemoperitoneum and the radiograph showed bullet in the pelvis. Exploratory laparotomy showed injuries to liver and cystic duct with tract leading retroperitoneally into the inferior vena cava. The bullet was found wandering inside the vena caval lumen. Stray bullets are presumed to remain limited to the soft tissues. However, the trajectory, impact velocity and the involved region ultimately determine the outcome and influence management

Cierre primario en trauma de colon / Primary closure in colon trauma

Objetivo: Informar si la evolución > 6 horas, grado de contaminación y lesión, sitio anatómico lesionado, PATI (penetrating abdominal trauma index) > 25 y presencia de otras lesiones en trauma de colon, se asocian a mayor morbimortalidad en pacientes con lesión colónica a quienes se les realizó cierre primario. Material y métodos: Estudio prospectivo, observacional, longitudinal, descriptivo, en el Hospital Central “Dr. Ignacio Morones Prieto”, San Luis Potosí. Se incluyeron pacientes con trauma abdominal sometidos a cirugía que presentaron lesión colónica. Análisis estadístico básico con χ2. Resultados: 481 pacientes fueron intervenidos por trauma abdominal; 77 (16.1 %) tuvieron lesión colónica, de los cuales 90 % (n = 69) se intervino en las primeras seis horas; 91 % fue lesión penetrante. El colon transverso fue el más lesionado (38 %, n = 29); las lesiones grado I y II representaron 75.3 % (n = 58). Se efectuó cierre primario en 76.66 % (n = 46), resección con anastomosis en 8.3 % (n = 5) y colostomía en 15 % (n = 9). Hubo lesiones asociadas en 76.6 % (n = 59) y contaminación en 85.7 % (n = 66); 82.8 % (58) tuvo PATI < 25; complicaciones asociadas al procedimiento operatorio, 28.57 % (n = 22); reintervenciones, 10 % (n = 8); estancia hospitalaria promedio, 11.4 días; mortalidad no relacionada a lesión de colon, 3.8 % (n = 3). Conclusiones: El cierre primario es un procedimiento seguro para el tratamiento de lesiones colónicas. Los pacientes con cierre primario presentaron menor morbilidad (p < 0.009). Los pacientes con cirugía en las primeras seis horas (p < 0.006) y estabilidad hemodinámica (p < 0.014) tuvieron menor riesgo de complicación.

BACKGROUND: Primary repair of colon injuries is an accepted therapeutic option; however, controversy persists regarding its safety. Our objective was to report the evolution and presence of complications in patients with colon injury who underwent primary closure and to determine if the time interval (>6 h), degree of injury, contamination, anatomic site injured, PATI (Penetrating Abdominal Trauma Index) >25, and the presence of other injuries in colon trauma are associated with increased morbidity and mortality. METHODS: This was a prospective, observational, longitudinal and descriptive study conducted at the Central Hospital "Dr. Ignacio Morones Prieto," San Luis Potosí, Mexico, from January 1, 2003 to December 31, 2007. We included patients with abdominal trauma with colon injury subjected to surgical treatment. chi(2) was used for basic statistical analysis. RESULTS: There were 481 patients with abdominal trauma who underwent surgery; 77(16.1%) had colon injury. Ninety percent (n = 69) were treated in the first 6 h; 91% (n = 70) were due to penetrating injuries, and gunshot wound accounted for 48% (n = 37). Transverse colon was the most frequently injured (38%) (n = 29). Grade I and II injuries accounted for 75.3% (n = 58). Procedures included primary repair (76.66 %) (n = 46); resection with anastomosis (8.3%) (n = 5); and colostomy (15%) (n = 9). Associated injuries were present in 76.6% (n = 59). There was some degree of contamination in 85.7% (n = 66); 82.8% (58) had PATI <25. Complications associated with the surgical procedure were observed in 28.57% (n = 22). Reoperation was necessary in 10% (n = 8). Average hospital stay was 11.4 days. Mortality was 3.8% (n = 3); none of these were related to colon injury. CONCLUSIONS: Primary repair is a safe procedure for treatment of colon injuries. Patients with primary repair had lower morbidity (p <0.009). Surgery during the first 6 h (p <0.006) and in hemodynamically stable patients (p <0.014) had a lower risk of complications.

Clampeamiento hepático prolongado: una alternativa en el trauma hepático severo / Clampeamiento prolonged liver: an alternative in severe hepatic trauma

Exponer la experiencia en el manejo del trauma hepático con clampeamiento prolongado, en el Servicio de Cirugía Uno. Hospital General del Este "Dr. Domingo Luciani". Paciente masculino de 28 años que ingresa a la Unidad de Politraumatizados (UPT) posterior a accidente en motocicleta. Hemodinámicamente estable, examen físico, tórax: murmullo vesicular disminuido en base derecha y abdomen; signos de irritación peritoneal, Rx de tórax hemoneumotórax y fractura del tercero al séptimo arcos costales derechos; toracotomía mínima que drena abundante burbujeo y 500 cc serohemático, FAST: moderada cantidad de líquido libre. Se realiza laparotomía exploradora con hallazgos de: hemoperitoneo 3000cc y lesión hepática grado IV; se realiza primera fase de control de daños, con clampeamiento y empaquetamiento hepático como estrategia para el control de la hemorragia; y cierre abreviado. Segunda fase de control de daños en la Unidad de Terapia Intensiva (UTI) durante 48 horas, posterior a lo cual, se realiza tercera fase de control de daños, con hallazgos de ausencia de hemoperitoneo, 100cc de secreción biliar, lesión en segmento VIII hepático no sangrante. Se retiran comprensas y clamps hemostático lavado, drenaje de cavidad y cierre con puntos de tensión. Evoluciona satisfactoriamente, egresando de la UTI, complicado con fístula biliar resuelta con papilotomía electiva en el postoperatorio tardio.

Ruptura espontánea de metástasis hepática de cáncer anal espinocelular y hemoperitoneo masivo: reporte de un caso / Spotanous rupture of hepatic metastasis of spinocelular anal cancer and masive hemoperitoneum: case report

Presentamos el caso de un hombre de 61años ingresado al servicio de urgencia por hematemesis y síncope. Previamente había sido tratado por cáncer anal espinocelular sin evidenciade recidiva. Al examen físico destacaba palidez, taquicardia y sudoración. Se realizó endoscopia alta que evidenció lesiones no significativas. El paciente evolucionó con shock hipovolémico y coagulación intravascular diseminada.La tomografía computarizada de abdomen demostró líquido libre intrabdominal y tumor hepático con signos de ruptura. Se realizó laparotomía de urgencia, posteriormente se efectuó embolización selectiva de arteria hepática derecha con buen resultado clínico. La biopsia del tumor hepático resultó compatible con metástasis de cáncer anal espinocelular.

A 61 years old man was admitted in emergency room by syncope and hematemesis. He has been treated by spinocellular carcinoma of the anus without evidence of relapse. At physical examination pallor, sweet and tachycardia, were observed. Upper endoscopy showed no significant lesions. The patient progressed to a hypovolemic shock and intravascular disseminated coagulation. The Abdominal CT revealed massive hemoperitoneum and a single hepatic mass with signs of rupture. The initial treatment was emergency surgery. In a second time selective hepatic artery embolization was done with successful clinical outcome. Biopsy o the liver tumor revealed hepatic metastasis of anal cancer.

Recurrence of uterine rupture in a pseudo-unicornuate uterus at 17 weeks of amenorrhea: case report and literature review

Pregnancy in a rudimentary horn is a very rare condition. It is responsible for several complications. Prognosis is reserved because the natural evolution generally leads to a cataclysmic uterine rupture at the beginning of the second trimester. Classically, the treatment after foetal extraction consists of ablation of the rudimentary horn and associated fallopian tube. We report the obstetric outcome of a patient with history of rudimentary uterine horn rupture, the treatment of which was ablation of the rudimentary horn

Management of a heterotopic pregnancy presenting with haemorrhagic shock and massive haemoperitoneum

The incidence of heterotopic pregnancy is on the rise, from 1 in 30000 pregnancies, to as high as 1 in 3800 today. We report here a case of a 31-year-old Asian lady who presented with sudden onset of acute abdominal pain and massive haemoperitoneum. An ultrasound scan confirmed a viable 10 weeks intrauterine pregnancy, with massive free fluid in the abdomen warranting surgery. A provisional diagnosis of a ruptured corpus luteal cyst/ ruptured ectopic/ heterotopic pregnancy was made. Laparoscopy revealed a bleeding ectopic pregnancy in the isthmus region of the right tube, which was treated by linear salpingotomy. Skilled surgical expertise in dealing with the massive haemoperitoneum enabled us to accomplish the surgery with minimal trauma to the continuing intrauterine pregnancy

Hemoperitoneum Caused by Hepatic Necrosis and Rupture Following a Snakebite: a Case Report with Rare CT Findings and Successful Embolization

We report the computed tomographic and angiographic findings in the case of a recently obtained successful clinical outcome after embolization of the hepatic artery in the case of a snakebite causing hemoperitoneum associated with hepatic necrosis and rupture with active bleeding.

Hemoperitoneum as a first manifestation of HCC with bleeding from ruptured aberrant vessel: a case report.

A young man presented with a history of abdominal pain and distension for 4 days. Diagnosis of spontaneous hemoperitoneum was made after clinical examination, abdominal USG and a diagnostic peritoneal tap. Emergency laparotomy revealed massive hemoperitoneum with extensive bilobar hepato-cellular carcinoma (HCC). A ruptured aberrant vessel communicating between the intercostal vessel and HCC in the liver had caused massive hemoperitoneum.

Rotura de un aneurisma esplénico durante el embarazo: a propósito de 2 casos clínicos / Splenic artery aneurysm rupture in pregnancies: report of 2 clinical cases

Se presentan 2 casos de rotura de aneurisma de la arteria esplénica ocurridos a las 35 y 22 semanas de gestación. Una de las pacientes falleció por hemoperitoneo masivo.

Co-existence of spontaneous splenic rupture and tuberculosis of the spleen

A rare case of splenic tuberculosis complicated by splenic rupture is reported. A 73-year-old man, hospitalized for peptic ulcer bleeding, presented in oligemic shock, was transferred to the operating room. Hemoperitoneum, due to rupture of an enlarged spleen was detected. The pathology revealed splenic tuberculosis. He had an uneventful recovery. Postoperatively, he received a combination of anti-tuberculous therapy for 6 months

Hemoperitoneo secundario a la rotura espontánea de la vena mesentérica / Abdominal bleeding due to spontaneous mesenteric vein rupture

La cirrosis hepática es la principal causa de hipertensión portal y se asocia con el desarrollo de venas esplácnicas varicosas. La rotura de várices intraabdominales es una causa rara de hemoperitoneo. Se presenta el caso de hemoperitoneo espontáneo por rotura de vena mesentérica superior varicosa. Caso clínico: varón de 43 años con antecedentes de cirrosis alcohólica (estadio C de Child-Pugh) y múltiples internaciones por hemorragia digestiva variceal. Consulta por episodios sincopales y distensión abdominal. Al examen físico se presento: vigil, orientado, hipotenso, con tilt test positivo, distensión abdominal, estigmas cutáneos de hepatopatía crónica. Laboratorio: anemia, plaquetopenia, rolongación de los tiempos de coagulación. TAC de abdomen: líquido libre en cavidad peritoneal. Laparotomía exploradora: se extraen tres litros de sangre de cavidad abdominal. Se visualiza vena mesentérica superior varicosa con una zona en forma de pezón que muestra punto de sangrado en jet, intermitente. No se evidenció daño de otro órgano. Se procedió a la rafia de la lesión lográndose hemostasia. El paciente evolucionó favorablemente abandonando el hospital 10 días después del ingreso. Objetivo: presentar un paciente con una causa poco común de hemoperitoneo y remarcar la buena evolución, ya que este tipo de patología suele tener alta mortalidad.

Hepatic cirrhosis is the leading cause of portal hypertension and is usually associated with the development of splacnic varices. Variceal intraabdominal rupture is a rare cause of hemoperitoneum. A case of spontaneous mesenteric vein rupture is reported. Clinical case: 43 year old man with hepatic cirrhosis (Child-Pugh C stage) and previous bleeding of esophageal varices, admitted to hospital because of orthostatic hypotension episodes (positive tilt test) and abdominal distention. Laboratory: anemia, low platelet count and abnormal coagulation tests. CT scan showed abdominal fluid. Exploratory laparotomy was performed and 3 liters of blood were found into the abdominal cavity. The mesenteric vein had a ruptured variceal dilatation with intermitent jet bleeding. No organ abnormalities were found. Repair of the dilated vein was performed. The patient evolved well and was dismissed from hospital ten days after admittance. Objective: To present a case in which a rare cause of intraabdominal bleeding, usually associated with high mortality rate, is follawed by a good clinical evolution.