Idiopathic Spontaneous Intraperitoneal Hemorrhage Due to Vascular Malformations in the Muscularis of the Stomach: A Case Report

Abstract

Idiopathic spontaneous intraperitoneal hemorrhage (ISIH) is a phenomenon caused by spontaneous rupture of intra-abdominal visceral vessels, and vascular malformations (VMs) leading to ISIH are rare in previously reported cases. VMs of the gastric wall, which are commonly located in the mucosa and submucosa, mostly lead to upper gastrointestinal bleeding rather than intraperitoneal hemorrhage. To our knowledge, this is the first report of ISIH caused by VMs in gastric muscularis. In the current case, a 22-year-old male patient presented with sudden abdominal pain for 4 h, accompanied by tachycardia and hypotension. CT revealed a hematoma in the omental bursa and fluids in abdominopelvic cavities. Then intraperitoneal hemorrhage was confirmed after abdominal paracentesis. Furthermore, ultrasonic gastroscopy indicated that vascular malformation in the muscularis of the stomach probably led to intraperitoneal hemorrhage. The patient recovered after conservative treatment based on fluid resuscitation and remained stable for 12 months of follow-up. This case suggests that VMs located in the gastrointestinal tract may lead to ISIH and ultrasonic gastroscopy is helpful in the diagnosis of VMs in the gastrointestinal tract.

Idiopathic Spontaneous Intraperitoneal Haemorrhage (ISIH): A Diagnostic Dilemma and Its Conservative Management

“…They stated that ISIH is often mistaken for a perforated peptic ulcer or acute pancreatitis. Since then cases have been reported with variable presentations from nonspecific abdominal pain associated with vomiting and anorexia to severe abdominal pain with shock and cardiovascular collapse [ 3 , 7 ]. Typically, a peritonitic and rigid abdomen was noted on clinical examination [ 6 ].…”

“…In these cases, arteriosclerosis and hypertension are believed to be predisposing aetiological factors [ 2 , 5 , 9 ]. Consequently, when blood pressure rises, in the presence of a weakened tunica media, a rupture occurs [ 3 ]. In our case, the patient lacked these risk factors.…”

“…Many cases have only been diagnosed during the surgical intervention such as laparoscopy or laparotomy [ 3 , 5 , 9 , 11 ]. Resuscitation and urgent surgical intervention, to identify and ligate the bleeding vessel, is the optimal management of unstable patients where ISIH is suspected [ 2 , 8 ].…”

“…Resuscitation and urgent surgical intervention, to identify and ligate the bleeding vessel, is the optimal management of unstable patients where ISIH is suspected [ 2 , 8 ]. Ruptures of the middle colic artery, left gastric artery, superior mesenteric artery and splenic artery have been identified as sources of bleeding [ 2 , 3 , 5 ]. Haematomas within the mesentery have also been found during operative management [ 11 ].…”

“…Intra-abdominal haemorrhage is usually attributable to a ruptured aortic aneurysm, following a vascular injury (traumatic or iatrogenic), secondary to autoimmune conditions, malignancy or as a consequence of systemic coagulopathy [ 1 , 2 ]. Idiopathic spontaneous intraperitoneal haemorrhage or ISIH is the term given to atypical and atraumatic cases with spontaneous rupture of an intrabdominal vessel [ 2 , 3 ]. ISIH is defined as haemoperitoneum secondary to the tear of an intra-abdominal visceral vessel, in the absence of trauma or underlying pathology, the cause of which cannot be easily identified [ 1 , 2 ].…”