Spontaneous abdominal hemorrhage: imaging evaluation

Transcription

1 Pictoril essy Spontneous dominl hemorrhge: imging evlution G. Espil, N. Lrrñg, N. Díz Villrroel, A. Oyrzun, G. Mtzke* nd S. Kozim Hospitl Generl de Agudos Dr. Cosme Argerich, Ciudd Autónom de Buenos Aires, Argentin Astrct Spontneous dominl hemorrhge is defined s intr-dominl hemorrhge from non-trumtic cuse. The clinicl presenttion of this condition is nonspecific, therefore the dignosis is usully mde on the sis of imging findings. Imging serves three sic purposes: detecting the presence of intr-dominl hemorrghe, locting the source of leeding nd determining the presence or sence of ctive rteril extrvstion. The cuses of non trumtic intr-dominl hemorrghe re diverse nd cn e clssified ccording to the orgn of origin in heptic, splenic, pncretic, drenl, renl, gynecologic nd ostetric, vsculr, nd soft tissue-relted (peritonel nd musculr) Sociedd Argentin de Rdiologí. Pulished y Elsevier Spin, S.L.U. This is n open ccess rticle under the CC BY-NC-ND license ( Keywords: Hemorrhge; Spontneous; Clot; Sentinel. Introduction When intr-dominl hemorrghe is suspected, ultrsonogrphy my e used s the initil method of evlution, ecuse its widespred vilility nd cpcity for detecting free fluid in the domen. Computed tomogrphy (CT) is the modlity of choice ecuse its speed nd specificity to detect smll mounts of intrdominl lood, llowing identifiction of the source nd cuse of leeding y identifying the sentinel clot 1-3. Mgnetic resonnce (MR), hs high sensitivity for chrcteriztion of lood t its vrious stges, ut its role is een limited y its lower vilility nd higher cost, lso is not useful for unstle ptients ecuse its longer time proceding 1-3. Cuses of dominl leeding re diverse nd re summrized in tle 1. The im of this rticle is to review the vrious cuses nd imging findings of spontneous dominl leeding tht my help to estlish correct dignosis nd to provide guidnce on the proper tretment. Topic review Signs of spontneous dominl leeding On unenhnced CT, leeding hs n ttenution of Hounsfield units (HU) in the hypercute stge nd of over 60 HU in the cute stge (then decresing over time). Clots tend to form ner the site of leeding, llowing the identifiction of the site of the hemorrhge (scentinel clot) surrounded y res of lower ttenution. (fig. 1). Figure 1 Sentinel clot. Unenhnced CT in 56-yer-old ptient with cirrhosis nd spontneous rupture of heptocellulr crcinom: sentinel clot sign (rrowhed) nd periheptic free lood (rrow). 86

2 G. Espil et l. On contrst-enhnced CT, the site of ctive leeding my e occsionlly depicted n re or foci of high ttenution, of 85 nd 300 HU, suggestive of ctive hemorrhge. This finding my e indictive of the need for emergency emoliztion or surgery 1-3 (fig. 2). Ultrsonogrphy my e used s the initil method of evlution for detecting intrdominl fluid. Its my e hypoechoic or pper s heterogeneous collection, with multiple hyperechoic res surrounding solid orgns or owel loops. This finding ply n importnt role, in mking the dignosis of spontneous dominl leeding secondry to gynecologic cuses. MRI is highly sensitive for detecting lood content t vrious stges, ut it plys limited role in the emergency setting. Figure 2 Active leeding. Thirty-eight yer-old ptient with cogultion normlities nd spontneous mesenteric leeding: fter contrst dministrtion, the presence of smll re of hyperdense vessels suggests ctive leeding (rrow). Heptic cuses Spontneous heptic hemorrhge is n uncommon disorder Tle 1: Cuses of spontneous dominl hemorrhge ccording to the orgn of origin. Origin *Heptic *Splenic Cuses - Adenom - Heptocellulr crcinom (HCC) Others: metstsis, hemngiom or ngiosrcom - HELLP Syndrome - Infectious spontneous rupture: cytomeglovirus nd mononucleosis - Lymphoprolifertive spontneous rupture: lymphom nd leukemi - Rupture of focl tumors * Renl - Angiomyolipom - Renl cell crcinom - Spontneous leeding (cogulopthy nd vsculitis) *Adrenl *Pncretic *Gynecologic *Ostetric *Vsculr *Soft tissues - Spontneous leeding - Tumors - Necrohemorrhgic pncretitis - Rupture of peripncretic pseudoneurysm - Rupture of hemorrhgic cyst - Rupture of endometriom - Rupture of ectopic pregnncy - HELLP Syndrome - Rupture of rteril neurysm - Dissection - Wll hemtoms - Vsculr erosion y tumor, inflmmtion, vsculitis or cysts. -Hemtom in the psos -Hemtom in the rectus sheth - Mesenteric hemtom 87

3 Spontneous dominl hemorrhge: imging evlution due to the rupture of tumor or, less frequently to the HELLP syndrome (hemolysis, elevted liver enzymes, low pltelet count). Adenom nd heptocellulr crcinom (HCC) hve the highest incidence of spontneous rupture. Adenom usully occurs in women receiving orl contrceptives, nd its compliction should e suspected in the presence of hemorrhgic tumor nd sucpsulr hemtom, or lood in the peritonel cvity (fig. 3) 4. Rupture of the HCC occurs in cirrhotic ptients, minly in exophytic or peripherlly locted tumors (fig. 4) with discontinuity of the heptic surfce, presence of lood in the sucpsulr region or peritonel cvity 5. Rrely, hemngiom my rupture fter heptic trum 5. Bleeding hs lso een reported in ssocition with hypervsculr metstses nd ngiosrcoms. The HELLP syndrome is serious vrint of preeclmpsi tht my e ssocited with necrosis nd heptic infrctions, s well s with intrheptic or sucpsulr hemtoms 6 (fig. 5). Splenic cuses Spontneous splenic rupture my occur in ssocition with severe or mssive splenomegly due to hemtologic mlignncies (such s lymphom or cute leukemi) nd infectious cuses (like mononucleosis nd infection y cytomeglovirus [CMV])7 CT shows n enlrged spleen with perisplenic lood nd the sentinel clot sign within the spleen (fig. 6). Less frequently, some splenic tumors (meststses, hemngiom nd ngiosrcom) my e complicted y leeding. In these cses, imging scns show focl lesion ssocited with intrtumorl nd perisplenic lood (fig. 7). Renl cuses Figure 3 Compliction of heptic denom with leeding in 35-yer-old womn with cute dominl pin nd decrese in hemtocrit levels. Renl tumors, such s renl cell crcinoms (RCC) nd ngiomyolipom (AML) my complicte nd cuse spontneous leeding into the sucpsulr nd perinephric spce. Dignosis of complicted AML is sed on the identifiction of gross ft in the tumorl lesion (fig. 8). RCC ppers s solid hypervsculr lesion with lood content (fig. 9) nd rrefction of djcent ft. If the tumor is too smll, it my remin occult within the hemtom nd e overlooked (for this reson, it is importnt to monitor progress of the lesion). Figure 4 Spontneous rupture of heptocellulr crcinom in ptient with chronic liver disese. () Contrst-enhnced CT nd () T2-weighted MRI. Note the peripherl loction of the tumor nd the free lood content towrds the peritoneum (rrows). 88

4 G. Espil et l. Figure 5 HELLP syndrome in pregnnt 27-yer old womn with dominl pin nd decrese in hemtocrit levles. () Unenhnced CT shows lrge cute heptic sucpsulr hemtom. () CT slices t the level of the pelvis show pregnnt uterus. c Figure 6 Spontneous splenic rupture in ptient with cute lympholstic leukemi nd splenomegly. () Unenhnced CT shows the sentinel clot sign (rrow), while ( nd c) intrvenous contrst-enhnced CT shows hypodense intrsplenic lesion, hemoperitoneum nd smll focus of ctive leeding (rrow in ). 89

5 Spontneous dominl hemorrhge: imging evlution Figure 7 Spontneous rupture of splenic hemngiom in 54-yer-old womn with cute dominl pin. ( nd ) Intrvenous contrst-enhnced CT shows hypervsculr nodulr lesion in the upper region of the spleen (rrow in ) nd lrge perisplenic hemtom (rrow in ). Figure 8 Spontenous rupture of renl ngiomyolipom in 40-yer-old femle ptient with tuerous sclerosis. Contrstenhnced CT shows ilterl ngiomyolipoms with the sentinel clot sign (rrow) nd site of ctive leeding (rrowhed) in the right kidney. Figure 9 Renl cell crcinom with srcomtoid trnsformtion in 39-yer-old womn who presents with pin of 3 dys durtion nd decrese in hemtocrit levels. () Unenhnced CT scn shows lrge left renl mss with internl leeding nd () T1-weighted MRI in the sme ptient shows the lood content of the tumor t different stges. 90

6 G. Espil et l. Less frequently, sucpsulr or perinephric hemtoms occur in ssocition with cogulopthy or vsculitis (fig. 10), s such s Wegener s disese or polyrteritis nodos, nd they my cuse cute lood hypertension y prenchyml compression (known s Pge kidney) 8,9. Adrenl cuses Figure 10 Spontneous sucpsur perinephric hemtom on unenhnced CT in ptient with Wegener s disese who presents with pin nd cute onset hypertension (Pge kidney). Spontneous drenl hemtoms my occur in ssocition with nticogultion therpy, sepsis, severe stress nd hemtologic or idiopthic disese. CT shows enlrged hyperdense drenl glnd with no chnges in density fter intrvenous dministrtion of contrst mteril (fig. 11). Some tumors, such s metstses, drenl crcinom nd lymphom (fig. 12) my occsionlly leed 10. Pncretic cuses Pncretic necrosis occurs in 20% of cute pncretitis nd it is ssocited with hemorrhgic chnges ffecting the pncretic prenchym nd neighoring tissues. The leeding is usully smll in volume nd self-limited, ut mrked hemorrhge cn occur (fig. 13). Formtion of peripncretic pseudoneurysm in the splenic or gstroduodenl rtery my occur in 10% of cses. Rupture nd leeding cn occur into the peritoneum, djcent hollow orgns, or pncretic duct (hemosuccus pncreticus) 11. Gynecologic nd ostetric cuses Figure 11 Right drenl hemtom in 67-yer-old mn on nticogultion therpy who developed dominl pin nd suspected ruptured ortic neurysm. () Enlrgement nd incresed density of right drenl glnd. ( nd c) Unenhnced nd contrst-enhnced mesurement of HU shows no enhncement: this finding is suggestive of hemtom. Rupture of hemorrhgic cyst or rupture of n ectopic pregnncy re the most common cuses of spontneous dominl leeding in women of childering ge. These conditions my hve similr clinicl nd imging fetures, ut the key differentiting finding is the incresed et-humn chorionic gondotropin (hcg) in ectopic pregnncy. On ultrsonogrphy, they pper s complex dnexl cystic mss or imges with dense content nd free fluid in the pelvis extending to the rest of the domen (fig. 14). CT my confirm the existence of dnexl lood content nd free fluid (fig.15). Dignosis of complicted ectopic pregnncy my e definitively estlished upon visuliztion of dnexl ring on ultrsound or y the presence of ring-enhncing mss on contrst-enhnced CT 12,13. Very rrely endometrioms or other cysts my e complicted y intrcvitry leeding. In ddition, nother cuse of spontneous dominl leeding is the HELLP syndrome (previously descried). 91

7 Spontneous dominl hemorrhge: imging evlution c d Figure 12 Bilterl drenl hemtom in ptient with Burkitt lymphom who developed cute dominl pin. () Unenhnced CT shows n enlrgement of oth drenl glnds with internl density (suggestive of hemorrhge). () T2-weighted STIR MRI differentites liquid re nd solid re in oth glnds. (c nd d). Unenhnced nd gdolinium-enhnced T1- weighted imges identify posterior hemorrhgic res, with no enhncement nd t different stges of lood (rrows), nd n nterior solid re tht enhnces with contrst (rrowheds). Figure 13 Necro hemorrhgic pncretitis in 35-yer-old mle ptient. Unenhnced CT shows lrge hemtom in the region of the hed nd neck of pncres. 92

8 G. Espil et l. Figure 14 Acute rupture of ectopic pregnncy in 25-yer-old womn with signs of shock nd incresed levels of the et suunit of humn chorionic gondotropin in lood. Ultrsonogrphy () in xil view of the uterus nd () longitudinl view of the kidney shows hyperechogenic right complex dnexl mss nd prticulte fluid in the pelvis nd Morrison s pouch. Figure 15 Compliction of n dnexl cyst in 25-yer-old womn with cute sudden-onset pin. ( nd ) Unenhnced nd contrst-enhnced CT shows lood content in the pelvis nd denexl cysts (one of them, on the left side, with lood-fluid level). Surgery confirmed complicted endometriotic cyst. Vsculr cuses Arteril leeding my e due to rupture of n normlly dilted vessel or vessel of norml size with wekened wlls. These cuses include neurysm, pseudoneurysm, rteril dissection, wll hemtoms or erosion of vessel y n djcent mss, inflmmtory disorders, vsculitis or cysts. The most common cuse of vsculr leeding is ruptured dominl ortic neurysm, followed y ruptured neurysms of ilic, splenic nd heptic rteries. CT shows ctive leeding, retroperitonel hemtom nd loss of wll continuity (fig. 16) Soft tissues Hemtom of the iliopsos muscle or the rectus sheth my e found in ssocition with cogulopthy, vsculitis or unknown etiology 14. CT shows n enlrgement nd incresed density of the muscle (figs. 17 nd 18). Hemtom of the rectus sheth my extend extrperitonelly towrds the pelvis elow the line l nd e misdignosed s pelvic msses (fig. 18); while spontneous mesenteric hemtom my e misdignosed s denomegly or tumor mss, hence the importnce of follow-up of the lesion (fig. 19). 93

9 Spontneous dominl hemorrhge: imging evlution Figure 16 Ruptured dominl ort neurysm. Contrst-enhnced CT shows typicl signs: discontinuity of the ortic wll (rrow), contrst extrvstion (rrowhed) nd retroperitonel hemtom (sterisk). Figure 17 Hemtom of the rectus sheth in ptient on nticogultion therpy. () Unenhnced CT shows hemtom with hemtocrit effect in the rectus sheth on the left side, extending contrlterlly nd extrperitonelly towrds the right pelvis elow the line l. () Ultrsonogrphy of the sme ptient showing complex fluid mss on the right pelvis tht ws initilly misdignosed s dnexl lstom. Figure 18 Hemtom of the right psos in ptient with norml cogultion fctors. Unenhnced CT shows enlrgement of the right psos muscle with hemtocrit effect (cellulr-fluid level). 94

10 G. Espil et l. Figure 19 Mesenteric hemtom in 45-yer-old ptient with renl trnsplnt, nd cute domen. CT without intrvenous contrst shows hemorrhgic foci t the center of the dominl mesentery with rrefction of neighoring ft. Follow-up CT scns showed complete resolution of the lesion. Conclusion Dignosis of spontneous dominl leeding is minly sed on rdiologic findings. For this reson, the imging specilist should e le to recognize its signs nd e wre of the vrious cuses tht my originte such leeding. Conflicts of interest The uthors declre no conflicts of interest, except for Dr. Kozim who declres possile conflict of interest s memer of the Executive Committee of SAR. References 1. Furln A, Fkhrn S, Federle MP. Spontneous dominl hemorrhge: cuses, CT findings, nd clinicl implictions. AJR Am J Roentgenol. 2009;193: Luner M, Menis C, Rucker C, Bhll S, Peterson CM, Wng L, et l. Blood in the elly: CT findings of hemoperitoneum. Rdiogrphics. 2007;27: Willmnn JK, Roos JE, Pltz A, Pfmmtter T, Hilfiker PR, Mrincek B, et l. Multidetector CT: detection of ctive hemorrhge in ptients with lunt dominl trum. AJR Am J Roentgenol. 2002;179: Csills VJ, Amendol MA, Gscue A, Pinnr N, Levi JU, Perez JM. Imging of nontrumtic hemorrhgic heptic lesions. Rdiogrphics. 2000;20: Kim HC, Yng DM, Jin W, Prk SJ. The vrious mnifesttions of ruptured heptocellulr crcinom: CT imging findings. Adom Imging. 2008;33: Nunes JO, Turner MA, Fulcher AS. Adominl imging fetures of HELLP syndrome: 10-yer retrospective review. AJR Am J Roentgenol. 2005;185: Gyer G, Zndmn-Goddrd G, Kosych E, Apter S. Spontneous rupture of the spleen detected on CT s the initil mnifesttion of infectious mononucleosis. Emerg Rdiol. 2003;10: Belville JS, Morgentler A, Loughlin KR, Tumeh SS. Spontneous perinephric nd sucpsulr renl hemorrhge: evlution with CT, US, nd ngiogrphy. Rdiology. 1989;172: Pintr TJ, Zimmermn S. Hyperreninemic hypertension secondry to sucpsulr perinephric hemtom in ptient with polyrteritis nodos. Am J Kidney Dis. 1998;32: Kwshim A, Sndler CM, Ernst RD, Tkhshi N, Rouidoux MA, Goldmn SM, et l. Imging of nontrumtic hemorrhge of the drenl glnd. Rdiogrphics. 1999;19: Documento descrgdo de el 08/09/2015. Copi pr uso personl, se prohíe l trnsmisión de este documento por culquier medio o formto. 11. Shni VA, Mortelé KJ. The loody pncres: MDCT nd MRI fetures of hypervsculr nd hemorrhgic pncretic conditions. AJR Am J Roentgenol. 2009;192: Phm H, Lin EC. Adnexl ring of ectopic pregnncy detected y contrstenhnced CT. Adom Imging. 2007;32: Hertzerg BS, Kliewer MA, Pulson EK. Ovrin cyst rupture cusing hemoperitoneum: imging fetures nd potentil for misdignosis. Adom Imging. 1999;24: Zissin R, Ellis M, Gyer G. The CT findings of dominl nticogulntrelted hemtoms. Semin Ultrsound CT MR. 2006;27: Federle MP, Pn KT, Peler KM. CT criteri for differentiting dominl hemorrhge: nticogultion or ortic neurysm rupture? AJR Am J Roentgenol. 2007;188: Siegel CL, Cohn RH, Korokin M, Alpern MB, Courney DL, Leder RA. Adominl ortic neurysm morphology: CT fetures in ptients with ruptured nd nonruptured neurysms. AJR Am J Roentgenol. 1994;163: Arit T, Mtsung N, Tkno K, Ngok S, Nkmur H, Ktym S, et l. Adominl ortic neurysm: rupture ssocited with the high-ttenuting crescent sign. Rdiology. 1997;204: Hllidy KE, l-kutoui A. Drped ort: CT sign of contined lek of ortic neurysms. Rdiology. 1996;199: Lmert CJ Jr, Willimson JW. Splenic rtery neurysm: rre cuse of upper gstrointestinl leeding. Am Surg. 1990;56: