Conservative management of a rare case of idiopathic spontaneous intraperitoneal haemorrhage: A case report

Abstract

Idiopathic spontaneous intraperitoneal haemorrhage, previously known as abdominal apoplexy, refers to bleeding into the peritoneal cavity due to the non-traumatic rupture of a visceral artery. It is a rare clinical condition that requires prompt diagnosis and management. The aetiology remains unclear, though factors such as atherosclerosis, coagulopathies, pancreatitis, malignancy and hypertension are often implicated. Very few cases have been reported where no clear aetiological cause could be identified. Here, we present the case of a 52-year-old man who was diagnosed with idiopathic spontaneous intraperitoneal haemorrhage and successfully managed conservatively. The diagnosis was confirmed through contrast-enhanced computed tomography and magnetic resonance imaging, which revealed a spontaneous mesenteric haematoma located in the right lumbar region with mild haemoperitoneum. The patient was managed with blood transfusion, IV fluids, and close monitoring; eventually, the haematoma showed signs of resolution and patient was discharged on day 10 and followed up on an outpatient basis till the haematoma completely resolved. This case report emphasis the need to maintain a high index of suspicion for spontaneous mesenteric haematoma in patients presenting with unexplained abdominal pain and haemodynamic instability, even in the absence of trauma as well as how unnecessary surgery can be avoided to reduce morbidity and improve recovery in carefully selected cases.

Introduction

Idiopathic spontaneous intraperitoneal haemorrhage refers to the potentially lethal condition of haemoperitoneum, caused by the spontaneous rupture of a visceral artery without any preceding trauma or identifiable aetiology. The condition was first identified by Barber in 1909, who observed it in a woman undergoing labour. ¹ Since then, only around 110 cases have been reported, and very few are truly idiopathic. ² Commonly attributed causes include coagulopathies, collagen vascular disorders, hypertension, atherosclerosis, pregnancy and pancreatitis. A spontaneous non-traumatic mesenteric haematoma usually presents with non-specific symptoms, and the diagnosis is made based on contrast-enhanced computed tomography (CT), ultrasound or magnetic resonance imaging (MRI). Conservative management may be considered if the patient does not exhibit progressive worsening of symptoms. In the literature, many cases describe surgical management, but this report highlights a rare instance of a large mesenteric haematoma successfully managed conservatively, following the guidelines for Surgical Case Reports.

Case report

A 52-year-old male patient presented to the emergency department with complaints of severe colicky abdominal pain and diarrhoea for the past 2 days. The pain began in the right lumbar quadrant, radiating to the back and was associated with abdominal distension. The patient had experienced three to four bouts of watery diarrhoea. He denied any history of trauma, fever, nausea, vomiting or prior surgeries. He did not smoke or consume alcohol and had a history of well-controlled hypertension. There was no history of anticoagulant use.

Upon examination, the patient’s vital signs showed a thready pulse rate of 150 bpm, blood pressure of 90/50 mmHg and normal oxygen saturation on room air. Generalized pallor was noted, with tenderness in the right hypochondriac and lumbar quadrants, and sluggish bowel sounds. Laboratory tests revealed severe anaemia (Hb 5.2 g/dL), total leukocyte count of 14,800 cells/L, platelet count of 100,000/µL, and packed cell volume of 17%. Amylase was slightly elevated (139 mg/dL), while renal function tests, PT-INR and lipase levels were normal. Peripheral smear, tumour marker analysis (carcinoembryonic antigen 19-9) and serology were negative.

Resuscitation was initiated with transfusion of two units of packed red blood cells and IV fluids, after which the patients’ vital signs stabilized. Ultrasonography revealed an ill-defined heterogeneous hypoechoic collection measuring 13 × 6.4 × 9.3 cm in the right hypochondrium and lumbar region, with no evidence of solid organ injury. Since the subsequent vital signs of the patient remained stable, he was shifted for contrast-enhanced CT of the abdomen and pelvis which confirmed a heterogeneous collection (10.2 × 12.5 × 15 cm) in the right lumbar region extending to the sub hepatic space, with mild haemo-peritoneum (Figure 1). MRI confirmed the diagnosis of a mesenteric haematoma, showing a lesion measuring 14.3 × 12.2 × 9.0 cm in the mesentery of the right hypochondrium and lumbar region, with mild T2 iso- to hyper-intense free fluid in the peritoneal cavity. The haematoma was located medial to the hepatic flexure and ascending colon, and lateral to the second, third and fourth parts of the duodenum and the pancreas (Figure 2).

Figure 1.

Contrast-enhanced computed tomography showing haematoma in sub-hepatic space.

Figure 2.

MRI abdomen pelvis: mesenteric haematoma (red line) with mild haemoperitoneum.

MRI: magnetic resonance imaging.

Given the absence of active intraperitoneal haemorrhage and stable vital signs, we opted for conservative management, the patient was started on IV fluids, tranexamic acid, analgesics, antiemetics and antacids. Haemoglobin, packed cell volume and abdominal girth were monitored regularly. On day 2, haemoglobin increased to 7 g/dL after transfusion. By day 5, haemoglobin increased to 10 g/dL, and the haematoma size reduced to 6 × 4 × 4 cm. By day 10, the patient was tolerating an oral diet, with a haemoglobin level of 11.5 g/dL, packed cell volume 30% and was discharged with antacids and iron supplements. Follow-up showed continued resolution of the haematoma without further complications.

Discussion

Mesenteric haematomas can be classified as traumatic or non-traumatic. Non-traumatic mesenteric haematomas are often associated with vascular diseases such as connective tissue disorders, vasculitis and aneurysmal bleeding, with mesenteric artery aneurysms being more common than aortic artery aneurysms. Other conditions, such as anticoagulant use, malignancy, hypertension and pancreatitis, have also been identified as possible aetiologies. In idiopathic cases, no underlying risk factors are identified. ³

The presentation of mesenteric haematoma can vary based on the size and location of the haematoma. Presenting symptoms may be abdominal pain, nausea, vomiting, melena, abdominal mass or diarrhoea. Some patients may experience complications like bleeding into the bowel lumen, bowel ischaemia, obstruction, shock or infection. ⁴ The diagnosis is often challenging, especially in spontaneous non-traumatic cases, requiring a high index of suspicion.

Contrast-enhanced CT is the preferred imaging modality, as it allows assessment of haematoma size, bowel condition and possible active bleeding. Angiography may be used if active bleeding is detected. The bleeding vessels are usually the branches of superior mesenteric artery (61%), inferior mesenteric artery (19%) and sometimes from unknown origin (19%). ⁵ We hypothesized that the source of bleeding may have been a smaller branch of the superior mesenteric artery, based on the anatomical location of the haematoma in the right lumbar and sub hepatic region. The containment of the haematoma likely contributed to the subsequent stabilization of the patient’s blood pressure and haemoglobin levels. Surgical intervention, such as exploratory laparotomy or laparoscopy with haematoma evacuation, is generally required for patients in haemodynamic distress or with significant bleeding. However, in stable patients with no evidence of active bleeding, conservative management with close monitoring can be successful. Such cases, however, require regular follow-up to ensure complete resolution and to detect any recurrence, as demonstrated in our case. There are few documented cases of spontaneous mesenteric haematoma managed conservatively, where contrast-enhanced CT confirmed the absence of an obvious source of bleeding. These patients typically presented with abdominal pain and no significant aetiological factors were identified. They also had stable vital signs and demonstrated resolving haematomas on follow-up imaging. These findings are consistent with our case and support the decision to pursue conservative management in the absence of haemodynamic instability or active bleeding.^6,7 Careful case selection for conservative management can prevent the patient from experiencing a morbid procedure like negative exploratory laparotomy or laparoscopy. There have been reports of intervention radiological techniques like angioembolization of the offending vessel which can be life-saving procedure in a patient who is rapidly losing blood and cannot tolerate general anaesthesia. ⁸

Conclusion

This case highlights the successful conservative management of a large spontaneous mesenteric haematoma, a rare condition with few reported cases. While surgical intervention is often required, conservative management with adequate resuscitation, serial imaging, and close monitoring can be an effective approach for stable patients.