Patients may be asymptomatic for a significant period of time after the initial event that caused bleeding, but the clinical presentation may include varying degrees of abdominal or pelvic pain and discomfort, hypotension, fatigue, and weakness. Blood loss may lead to shock and compartment syndrome in severe cases [4], which is why the focus should be on an early diagnosis.

• Fever

  The presence of some of the warning signs (B-symptoms such as fevers or subfebrile temperatures, fatigue, weight loss; and paraneoplastic laboratory findings such as elevated C-reactive protein and erythrocyte sedimentation rate) should raise suspicion [ncbi.nlm.nih.gov]

  Patients commonly present with respiratory tract symptoms and fever. However two third are asymptomatic and unusual presentation is evolving. This has cause management dilemma among physicians. [scienceopen.com]

  Heavy recurrent bleeding associated with pain and fever should prompt urgent evaluation. An effluent hematocrit greater than 2% suggests severe bleeding. [advancedrenaleducation.com]

  She had a low-grade fever related to the haematoma, with negative blood cultures. After one week the patient re-started peritoneal exchanges with no signs of bleeding in the peritoneal fluid. She has had no further complications since this episode. [revistanefrologia.com]

• Falling

  Traumatic hemoperitoneum can be caused by: Falling from heights Car accidents Direct blows to your abdomen, like kicks Falling onto objects, like falling on handlebars Sports contact Stabbings Gunshots Nontraumatic hemoperitoneum is caused by other health [webmd.com]

  Hemoperitoneum will be readily considered in the differential diagnosis of patients who have been injured, who are treated with anticoagulants, who have a known abdominal tumor when they exhibit the signs and symptoms of hypovolemia, or who have a falling [jamanetwork.com]

  […] illegal immigrant and transferred to the emergency department with the conditions of the bilateral facet subluxation of C5-6 spine, including incomplete cord lesion (American-Spinal-lnjury-Association: grade-C) and without associated injury, caused by falling [ncbi.nlm.nih.gov]

  There was no history suggestive of fall or any blunt trauma over the abdomen. The patient was on irregular treatment and had not followed up for 4 years. [jpgo.org]

  Conclusions: If pregnant women with a history of previous endometriosis treatment present with acute abdominal pain, a fall in hemoglobin, and the absence of vaginal bleeding, intraabdominal hemorrhage should be considered. endometriosis, pregnancy, spontaneous [oatext.com]

• Sepsis

  Culdocentesis will differentiate hemoperitoneum (ruptured ectopic pregnancy or hemorrhagic cyst) from pelvic sepsis (salpingitis, ruptured pelvic abscess, or ruptured appendix). [diki.pl]

  In addition, a differential diagnosis, including hemorrhagic disease of the newborn, sepsis with disseminated intravascular coagulation, and a solid organ injury (adrenal injury, liver and a splenic injury) was performed. [ijponline.biomedcentral.com]

  Inflammation of diverticula can progress to perforation of varying severity as described by the Hinchey classification4 and can lead to intraabdominal sepsis. Patients present with pain, fever, and leukocytosis. [facs.org]

  If the fetus is dead, surgery is necessary due to the risk of disseminated intravascular coagulopathy (DIC) or sepsis, although a period of 4–8 weeks may be allowed for observation to allow atrophy of placental vessels [ 3, 9 ]. [bmcresnotes.biomedcentral.com]

• Pallor

  Significant findings on clinical examination were marked pallor, gross abdominal distension with doughy feel, and forniceal fullness on vaginal examination. [jpgo.org]

  She developed marked pallor within a short span of time. Abdominal examination revealed marked generalized tenderness. Examination of other systems was normal. [jpma.org.pk]

  General examination revealed marked pallor, tachycardia and hypotension (pulse 120 bpm, blood pressure 90/60 mmHg). On examination, her abdomen was tender and tense. A urine pregnancy test was negative. [ogscience.org]

  The general examination was normal except for pallor, and his hemodynamic parameters were stable with a blood pressure of 110/80 mmHg, pulse of 70/min, and O2 saturation of 99% on room air. [intjem.springeropen.com]

  She was anicteric, afebrile but had marked conjunctival and buccal mucosal pallor. The pulse rate was 128 beats per minute, blood pressure 150/60 mmHg, but the jugular venous pressure was not raised. [njcponline.com]

• Inguinal Hernia

  Scrotal swelling with/without bluish discoloration in newborns can arise from hydrocele, inguinal hernia, orchitis, meconium peritonitis, testicular trauma, a testicular tumor, and/or testicular torsion [7]. [ijponline.biomedcentral.com]

• Abdominal Pain

  We present an unusual case of 38-year-old woman that came to the emergency department with acute abdominal pain. [ncbi.nlm.nih.gov]

• Vomiting

  Signs of bleeding in the upper digestive tract include Bright red blood in vomit Vomit that looks like coffee grounds Black or tarry stool Dark blood mixed with stool Signs of bleeding in the lower digestive tract include Black or tarry stool Dark blood [icdlist.com]

  Prior to her death the deceased had complained of abdominal pain, nausea and vomiting followed by collapse. She was unable to be resuscitated. [ncbi.nlm.nih.gov]

  CASE REPORT: A 27-year-old single woman presented with generalized acute abdominal pain and vomiting. Clinical examination showed a distended abdomen and unstable vital signs. [amjcaserep.com]

  We present a case of 32 –years –old male who presented to Accident and Emergency Department with history of abdominal pain, vomiting and diarrhea, there was no history of trauma. [journals.ub.bw]

  Some symptoms of hemoperitoneum include: tenderness at the site of your abdomen sharp or stabbing pain in your pelvic area dizziness or confusion nausea or vomiting cold, clammy skin Car accidents and sports injuries account for some cases of hemoperitoneum [healthline.com]

• Acute Abdomen

  Endometriosis is a cause of acute abdomen because of the leakage or rupture of endometriotic cyst and tubo-ovarian abscess. However, massive hemoperitoneum as a cause of acute abdomen with endometriosis is very rare. [ncbi.nlm.nih.gov]

• Nausea

  Prior to her death the deceased had complained of abdominal pain, nausea and vomiting followed by collapse. She was unable to be resuscitated. [ncbi.nlm.nih.gov]

  Haemoperitoneum secondary to intrahepatic gallbladder perforation Summary A 70-year-old man presented to the accident and emergency department with a 1-day history of right upper quadrant pain and nausea. [casereports.bmj.com]

  The patient presented to the emergency department after few hours of sudden-onset epigastric pain, radiating to the back, and with associated nausea. A peritoneal exchange was performed, in which significant haemoperitoneum was observed. [revistanefrologia.com]

  Some symptoms of hemoperitoneum include: tenderness at the site of your abdomen sharp or stabbing pain in your pelvic area dizziness or confusion nausea or vomiting cold, clammy skin Car accidents and sports injuries account for some cases of hemoperitoneum [healthline.com]

• Severe Abdominal Pain

  These episodes were characterized by severe abdominal pain and the presence of palpable abdominal masses, hypotension, and anemia without evidence of overt blood loss. Full Text [jamanetwork.com]

  Torbati, MD Cedars-Sinai Medical Center, Department of Emergency Medicine, Los Angeles, California Case report Discussion CASE REPORT A 34-year-old woman presented to the emergency department (ED) with acute onset of severe abdominal pain and distention [westjem.com]

  Serial abdominal exams were also performed. The patient’s vitals remained normal; however, his abdominal pain progressed. Labs were repeated 10 hours later during which time he received 2 L of crystalloid. [facs.org]

  Case Report We present the case of a 41-year-old primigravida, who presented at 32 weeks with sudden onset of severe lower abdominal pain without any uterine activity. [hindawi.com]

  A 18-year-old nulliparous woman presented to the department of obstetrics and gynecology with severe abdominal pain and dizziness. Her last menstrual period occurred 15 days prior and her past menstrual pattern was regular. [ogscience.org]

• Jaundice

  However, when severe it can manifest as jaundice, hepatomegaly, liver failure and haemoperitoneum. In the same patient haemoperitoneum and haemothorax occurred and in a further patient a large subcutaneous haematoma was seen. [diki.pl]

  No fevers, jaundice, vomiting, or bowel habit changes were reported. He had no previous surgical or medical history, and no known biliary disease in the past. [gastrojournal.org]

• Hypotension

  Three days after initiating chemotherapy, he experienced abdominal discomfort with hypotension. Computed tomography revealed a ruptured liver metastasis and the presence of hemorrhagic ascites. [ncbi.nlm.nih.gov]

  Examination revealed initial hypotension epigastric abdominal tenderness, no palpable masses. An-abdominal ultrasound revealed massive free fluid and splenic hematoma; an emergency splenectomy was performed successfully. [journals.ub.bw]

  These episodes were characterized by severe abdominal pain and the presence of palpable abdominal masses, hypotension, and anemia without evidence of overt blood loss. Full Text [jamanetwork.com]

• Tachycardia

  Snap Shot A 53-year-old women develops hypotension, sinus tachycardia, and oliguria 24 hours after abdominal surgery for cholecystitis. Her skin is cold and clammy. [medbullets.com]

  Intraperitoneal hemorrhage usually presents as acute abdominal pain and sometimes accompanies symptoms such as abdominal distension, hypotension, syncope, and tachycardia. [ogscience.org]

  […] blood loss causing hemorrhagic shock large volume of blood can accumulate before patients present with any significant symptoms Presentation Symptoms common symptoms lightheadedness abdominal pain Physical exam inspection hemorrhagic shock hypotension tachycardia [step2.medbullets.com]

  If a patient presents with shock due to massive intra peritoneal bleeding then the EKG may show sinus tachycardia. X-ray If the hemoperitoneum is due to perforation of any hollow visceral organ, then it may show air under the diaphragm. [wikidoc.org]

  There was tachycardia, but the heart sounds were normal. The abdomen was full and more in the flanks. There was generalised tenderness and guarding; and shifting dullness was elicited. [njcponline.com]

• Skin Rash

  Mild symptoms, such as arthritis and skin rash, predominate in frequency, but life-threatening manifestations requiring aggressive immunosuppressive therapy can also develop. [kjim.org]

• Cryptorchidism

  Abstract Cryptorchidism is associated with increased risk of malignancy and infertility. [ncbi.nlm.nih.gov]

• Scrotal Mass

  Neonatal adrenal hemorrhage presenting as a right scrotal mass. J Am Med Assoc. 1989;261(20):2958. https://doi.org/10.1001/jama.1989.03420200048034. Article CAS Google Scholar Francis XS, Mark FB. [ijponline.biomedcentral.com]

• Metrorrhagia

  They may remain asymptomatic or result in menorrhagia, metrorrhagia, pain or pressure symptoms prompting treatment. Fibroid uterus presenting as an acute abdomen is extremely uncommon. [gynecolsurg.springeropen.com]

A thorough patient history can provide important details regarding the underlying cause, but the radiographic assessment is vital in diagnosing hemoperitoneum. Ultrasonography is a very good initial method of detecting fluid in the peritoneal cavity in emergency settings but computed tomography is the gold standard [1]. Due to its speed and increased sensitivity for small blood effusions, it is more commonly used. Moreover, the highest attenuation is seen closest to the site of bleeding (as a result of accelerated clotting), whereas lower-attenuated unclotted blood is located at the periphery, which can suggest the source of bleeding [1].

• Hemoglobin Decreased

  The main outcome - mean intraoperative hemoglobin decrease - was 1.5 +- 1.2 g/dl in the laparoscopic and 1.9 ‚+-1.4 in the open approach (p=0.344). [ncbi.nlm.nih.gov]

  We considered surgical intervention only when patients had unstable vital signs, a significant hemoglobin decrease or increasing hemoperitoneum on a follow up imaging study, or severe or persistent abdominal pain. [journals.plos.org]

• Hemorrhagic Ascites

  Patient(s) Thirty-two-year-old woman with endometriosis presenting with hemorrhagic ascites. [fertstertdialog.com]

  Ultrasonography revealed massive hemorrhagic ascites. Exploratory laparoscopy was urgently performed to achieve hemostasis. The volume of hemoperitoneum evacuated from the pelvis was 1,890 mL. [ncbi.nlm.nih.gov]

  Historically, trauma and nonmalignant gynecological conditions account for more than 90% of intra-abdominal hemorrhage, whereas hemorrhagic ascites is encountered in only 5% of cirrhotic patients [1, 10]. [hindawi.com]

Various surgical procedures may be employed, but the mainstay of therapy is angiography with subsequent arterial embolization, with a goal of repairing the injured vessel from which blood accumulates in the peritoneum [1] [4].

The prognosis depends on the extent of the injury and the nature of the condition, as bleeding may be slow and gradual or abrupt and life-threatening, promptly bringing patients into hemorrhagic shock [4]. For this reason, it is imperative to make an early diagnosis.

Conditions in which hemoperitoneum may develop as a complication include [1] [2] [3] [4] [5]:

• Trauma - Solid organ (liver, spleen, kidney), mesenteric or bowel injury.
• Iatrogenic - Surgical or diagnostic procedures, particularly dialysis, as well as inadequate coagulation therapy.
• Gynecologic conditions - Ruptured ovarian cysts, ectopic pregnancy, a variant of pre-eclampsia known as hemolysis with elevated liver enzymes and low platelet count (HELLP syndrome) and endometriosis open link.
• Vascular - Visceral artery aneurysms, Ehlers-Danlos syndrome
• Hematologic - Polycythemia, hemophilia
• Neoplastic - Hepatocellular carcinoma, hepatic adenoma or vascular metastatic disease.

Some studies suggest that hemoperitoneum is more frequently seen in women due to its association with several gynecologic disorders [3]. Its occurrence in clinical practice, however, remains unknown.

Vascular injury and subsequent hemorrhage into the peritoneal cavity is the main pathological mechanism of hemoperitoneum.

Early recognition of bleeding may be one of the most important strategies in preventing the onset of more severe complications that may endanger the patient's life.

Hemoperitoneum is a clinical entity describing the accumulation of blood in the peritoneal sac, which can occur due to trauma, surgery and a range of gynecologic, hepatic, vascular, renal, neoplastic or hematologic conditions [1] [2]. Regardless of the cause, a varying amount of blood pools into the peritoneum and the importance of an early diagnosis lies in preventing the onset of life-threatening blood loss. Abdominal pain and weakness are main clinical features. Ultrasonography and computed tomography (CT) are used to make the diagnosis and confirm the presence of blood in the peritoneum, as well as the source of bleeding [1]. Emergency embolization or surgery are necessary therapeutic procedures [1].

Hemoperitoneum is a condition in which blood accumulates in the space between in the peritoneum, a membrane covering the majority of abdominal organs. Most important causes include trauma to the abdomen, injury during surgical or diagnostic procedures, gynecologic disorders (ectopic pregnancy, rupture of ovarian cysts) and tumor-associated bleeding (seen in liver cancer). As the blood leaks from damaged vessels into the peritoneum, signs of shock may appear - decreased blood pressure and profound weakness. Blood loss may be life-threatening, which is why an early diagnosis is necessary and imaging studies such as ultrasonography and computed tomography of the abdomen are recommended. Surgical repair of injured organs and vessels is the mainstay of treatment.

1. Lubner M1, Menias C, Rucker C, Bhalla S, Peterson CM, Wang L, et al. Blood in the belly: CT findings of hemoperitoneum. Radiographics. 2007;27(1):109-125.
2. Stolz A1, Fourcade J, Klisnick A, Souweine B, Abergel A, Baguet JC, et al. Hemoperitoneum in patients receiving hemodialysis. Am J Kidney Dis. 2000;36(2):E11.
3. Balsera C, Guest S. Hemoperitoneum in a peritoneal dialysis patient from a retroperitoneal source. Adv Perit Dial. 2013;29:69-72.
4. Kumar S, Khanna S, Roy A, Gupta S. An unusual cause of hemoperitoneum: case report with review of literature. Int J Surg Case Rep. 2015;12:120-122.
5. Kim JH, Lee SM, Lee J-H, et al. Successful Conservative Management of Ruptured Ovarian Cysts with Hemoperitoneum in Healthy Women. Hawkins SM, ed. PLoS ONE. 2014;9(3):e91171.