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]

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

  The patient had no fever. On physical exam no cardiac murmurs were heard. Blood cultures, viral serologies, and ANA and anti- DNA antibodies were negative.Lupus anticoagulant was positive in two occasions. [revistanefrologia.com]

  The same clinical picture recurred in April 1998, with fever and an elevated serum CRP. The patient was treated with analgesics and made a good recovery. [academic.oup.com]

  She had a short history of fever and pain in the right hypochondrium, with findings of hypovolaemic shock due to intraperitoneal haemorrhage. [karger.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]

  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]

• 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]

• Acute Abdomen

  Here we present a case that led to acute abdomen and hemoperitoneum in a young woman. [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]

  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]

  There was no history of vomiting, dysuria, constipation or loose stools. She had history of prolonged bleeding from minor cuts and wounds and was a known case of some undiagnosed bleeding disorder. [jpma.org.pk]

  The patient had 2-3 episodes of vomiting and was febrile from last one day. She gave a history of giddiness on standing. On examination, she was conscious and oriented with pulse of 98 beats per minute and BP of 90/65 mmHg. [onlinejets.org]

• 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]

  Method(s) A nulligravid 24-year-old attended the accident and emergency department (AED) with a sudden onset of worsening lower abdominal pain associated with nausea, which had lasted several hours. She collapsed whilst awaiting review at AED. [gynecolsurg.springeropen.com]

  Two days later, the patient developed two episodes of nausea, vomiting, confusion, and sweating associated with abdominal discomfort. [intjem.springeropen.com]

  The abdominal pain appeared while he was at work without known provocation, followed by intense pain and nausea; he then quickly fainted. [omicsonline.org]

• Abdominal Tenderness

  Heterotopic pregnancy should be kept in the differential diagnosis of any patient with an intrauterine pregnancy presenting with abdominal pain, abdominal tenderness, or free fluid in the abdominal cavity. [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]

  Two days later, the case was reviewed by senior doctors on the ward, at that time, the patient continued to have generalized abdominal pain, and on examination she was found to have generalized abdominal tenderness with rebound tenderness and easily palpable [bmcresnotes.biomedcentral.com]

  Abdominal tenderness which was not associated with active profuse vaginal bleeding but with signs of hypovolemic shock was suggestive of a hemoperitoneum secondary to the rupture of a vessel or an abdominal organ. [panafrican-med-journal.com]

• 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]

  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]

• Cervical Incompetence

  CASE: A 35-year-old, nulli-gravid woman at 18 weeks of gestation was referred due to cervical incompetence. Her first symptom was genital bleeding. [ncbi.nlm.nih.gov]

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].

• Right Pleural Effusion

  Ascites with right pleural effusion initially suggested fetal hydrops. However, a decrease in hemoglobin with bloody ascites from the paracentesis gave the impression of hemoperitoneum. [ncbi.nlm.nih.gov]

• 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

  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]

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.