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Intraperitoneal & retroperitoneal haemorrhage

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Presentation on theme: "Intraperitoneal & retroperitoneal haemorrhage"— Presentation transcript:

1 Intraperitoneal & retroperitoneal haemorrhage

2 Complex ethiology any vascular lesion if big enough
Lesions of solid organs Liver, spleen, kidney, pancreas Lesions of hollow organs and mesentery Lesions of parietal vessels (cirrhosis) Genital lesions: extra uterine pregnancy Fractures of vertebral column Lesions of big retroperitoneal vessels (aorta, IVC, etc) Postoperative Many others

3 Symptoms Hemorrhagic syndrome Clinical presentations
Symptoms develop in hours Cataclismic hemorrhage Clinical presentations Pale Agitation, pseudo-psychotic manifestations Hypotension Oliguria/anuria

4 Abdominal evaluation Inspection: may be enlarged, especially in massive haemorrhage Sensibility: spontaneous and o palpation Ausculation: intestinal sound may be diminished due to peritoneal irritation Percution: free liquid in the abdomen (movable dullness) Increased liver or splenic dullness

5 Careful anamnesis: STRANGE SITUATION
Ectopic pregnancy – major cause of hemoperitoneum Progression of a hematoma in sequences Pelvic griddle and vertebral fractures can bleed in the free peritoneum Iatrogenic lesions

6 Progression with a FREE INTERVAL
Trauma Silent period – almost no symptoms SUBCAPSULAR HEMATOMA will form in this time Hematoma ruptures in the peritoneal cavity - hemoperitoneum

7 Lab work Plain abdominal X-Ray Abdominal US Paracentesis + lavaj
Can demonstrate free liquid in the peritoneal cavity + specific character of blood Can show lesions and abnormalities in the structure of solid organs Can demonstrate pregnancy or signs associated with ectopic preganancy Paracentesis + lavaj

8 Particular aspects of retroperitoneal hemorrhage
Frequently in the context of polytrauma “No room” closed space –possible spontaneus hemostasis Clinical forms Small unnoticed hematoma Large volume: “tumor like” appearance Echimosis may appear due to blood migration

9 Special evaluation aiming for a retroperitoneal hematoma
US scan – special attention for kidney and large vessels Intravenous urography Rx for vertebral column and pelvic griddle CT scan Paracentesis + lavaj

10 Syndrome: GROUP of diseases which may be unrelated
Upper GI bleeding Syndrome: GROUP of diseases which may be unrelated

11 Upper GI bleeding - definition
Internal hemorrhage becoming exteriorized Hematemesis – above the angle of Treitz Melena – above the ileo-cecal valve Hematochesis (fresh blood per anum) – bellow splenic flexure Hypovolemic shock – the only manifestation

12 Main causes Duodenal ulcer 24% Erosive gastritis 23% Gastric ulcer 21%
Esofageal varices 10% Esofagitis 8% Sdr. M-W 7% Erosive duodenitis 6% Tumors 3% Large geographical variations

EMERGENCY Urgent treatment should precede complete diagnostic Sequence Positive diagnostic - GI bleeding Resuscitation Empiric treatment Ethologic diagnostic Specific treatment

14 Homodynamic evaluation pulse + blood pressure
Shock – systemic blood pressure in decubitus <90mmHG – 50% din VC No shock – BP and pulse checked in ortostatism BP<90 lost = 25-50% BP-10 or pulse >120/min = 20-25%

CONTINUOUS BLEEDING No response to treatment No major rebleeding Clinical observation = ESSENTIAL MAJOR REBLEEDING EPISODE Sudden onset Most frequently in ICU Cases only with hypovolemic shock

16 Rebleeding – major prognostic factor
Definition: bleeding after a succesfull attempt to maintain hemodynamic stability High mortality: 3x 3 major risk factors for morbidity and mortality Major rebleeding in the hospital Old age Total amount of transfused blood

17 WHAT IS THE CAUSE? endoscopy “GOLD DIAGNOSTIC” Clinical evaluation
X-Ray and US scan endoscopy “GOLD DIAGNOSTIC”

18 ANAMNESIS patient + relatives
Describe bleeding Quantities can not be approximated Other signs during or before onset PMH – suggestive for a medical problem that may cause bleeding Hereditary problems Alcohol intake False bleeding, false upper GI bleeding Medication Coughing before hematemesis Mouth bleeding

Hemodynamic evaluation Confirm upper GI bleeding HEMATEMESIS, MELENA or RECTAL ENT evaluation. Clinical signs suggestive for liver cirrhosis (liver and spleen size, ascites,colateral circulation, spider hemangioma,Dupuytren,etc) Tumors Other diseases that can produce GI bleeding

20 IMAGISTICS Can be of major interest Rx thorax US abdominal Barium meal
Pleuresia Tuberculosis Primary or secundary tumors US abdominal Liver cirrhosis Abdominal tumors Barium meal Bad alternative when endoscopy is irrelevant



23 Esophageal causes Varices Mallory-Weiss Hiatal hernia and reflux
Esophageal tumors

24 Varices Endoscopic diagnosis can be difficult
Massive bleeding Clots Gastric varices Portal encephalopathy 60% of cirrhotic pateints bleed form varices

Lesions are short lived Hypovolemic shoch is unlikely but not impossible Short hospital stay Very small risk of rebleeding

26 Hiatus hernia and reflux
Stigmata of recent bleeding HH is very frequent

27 TUMORS Overt GI bleeding is rare, frequently occult bleeding

28 Gastric sources of bleeding
Hemorrhagic gastritis Gastric ulcer Benign tumors Malignant tumors

29 Hemorrhagic gastritis
DG: morphologic criteria Endoscopic aspect is not diagnostic Barium meal: useless and loss of money

30 Gastric ulcer Diagnostic can be difficult
EDS: stigmata of recent bleeding Risk of rebleeding evaluation

31 Benign tumors Very unlikely, round circumscribed tumors with central ulcerations

32 Malignant tumors Ex. endoscopic US scan Locally advanced tumor
Endoscopic hemostasis US scan MTS + lymphnodes

33 Upper GI bleeding with duodenal origin
Very frequent Empiric treatment of upper GI bleeding It is much to easy to say that a bleeding originates from a duodenal ulcer without endoscopy

34 Erosive gastritis Term misused for many unknown situations responsible for bleeding Superficial ulcerations usually described as superficial ulcer – easier to comprehend HP infection

35 Bleeding peptic duodenal ulcer
Relatively frequent although potent medication is on the market 53% previous diagnostic of ulcer 17% iterative: More serious, high risk of rebleeding 25% no previous cause!!! Known diagnostic-treat that

36 Rebleeding risk


38 Small bowell obstruction

39 Essentials of diagnostic
Complete high obstruction Vomiting Abdominal discomfort Rx changes Low obstruction Colicky pain Vomiting Abdominal distension No intestinal transit Hyperperistaltic movements A/F levels

40 2 major forms of obstruction
Simple Mechanical Paralitical Strangulation Vascular component

41 Causes Postoperative adhesions – most frequent All hernias
Tumors (intraluminal, parietal sor extraintestinal) Invagination Volvulus Foreign bodies Billiary ileus Inflammatory bowel disease Stenosis Hematoma Etc

42 Symptoms Colicky abdominal pain (no in very high small bowell obstruction) Crescendo-descrescendo Seconds - minutes No pain between Vomiting Dominant symptom Intervals depending on localization of obstruction More distal - fecaloid

43 Symptoms No transit for feaces or gas per anum
Feaces can be present in large bowel. Initial normal defecation General signs may be absent or minimal Dehydration No fever Abdomen: Abdominal distension (not in high obstruction) Hyperperistaltic waves can be seen on the abdomen Abdomen may be tender NO signs of peritoneal iritation Abnormal sounds CHECK FOR HERNIA

44 Paraclinical Lab: non-specific Plain abdominal X-Ray
Hemoconcentration (increased WBC, hyperglicemia) Electrolytic imbalance High level serum amilase Plain abdominal X-Ray A/F levels and their position and form Hydrosoluble contrast media

45 Particularities of strangulation
Shock develops very early Pain is less colicky and becomes permanent Fever Vomiting + blood strikes Abdominal guarding

46 Particularities of strangulation
High WBC Rx: Loss of normal mucosal lining Air in portal veins or in intestinal wall F/A levels outside intestinal lumen: abscess or pneumoperitoneum


48 Essentials of diagnostic
Constipation or no feaces or flatus per anum Meteorism +/- guarding Abdominal pain Nausea and vomiting – late Important Rx findings

49 Frequent causes Colonic malignant tumor Volvulus
Diverticulosis - infected IBD Benign tumors Fecal impactation Lesions outside digestive tract

50 Symptoms Dependent on the cometepence of ileo-cecal valve
Valvular lesion – similar with ileal obstruction Competent valve – no vomiting Incompetent valve - vomiting Closed loop syndrome Risk of cecal perforation

51 Symptoms Progressive onset (mechanical obstruction)
Dull pain mainly in hypogastrium Fixed colonic lesion may produce localized pain Continuous pain - ischemia Borborism associated with colicky pain No feaces no flatus Vomiting: changing character

52 Clinica examination Meteorism and timpanism
Peristaltic waves on abdominal wall Specific sounds - obstruction Peritoneal irritation symptoms Rectal Bloos Tumor Invagination pseudotumor

53 Radiology Colonic distention with gas F/A levels (colonic)
Mixed A/F level signs if the ileo-cecal valve is incompetent Barium enema (or water-soluble solution) Level of obstruction Ethiology Devolvulation

54 Differential diagnostic
Low/high obstruction Ileus (paralitic) Pseudo-obstruction

55 Signs in acute pancreatitis
Abdominal drama

56 Essentials of diagnostic
ABDOMINAL PAIN Sudden onset Dull pain irradiating transverse and to the back Vomiting, Sweating, Fever Distended abdomen High WBC, amilazemia, amilazuria, lipazemia PMH: alcohol, billiary calculus

57 General data Severe inflammatory disease
Abnormal activation of pancreatic enzymes Causes: Alcohol, billiary calculus Hypercalcemia, hyperlipidemie, trauma, reaction to medicines, vasculitis, infections Inflamation: edema – hemorrhagic, necrotic severe form

58 Symptoms PAIN Epigastric, severe, continuous, relieved in genu-pectoral position ; IRRADIATION: TRANSVERSE Nauseam vomiting: CHARACTERISTIC – impossibility to eat or drink PMH: alcohol or billiary colicky

59 Abdominal examination
Very few elements Diffuse sensibility in upper half of the abdomen Ussually no guarding and no signs of peritoneal irritation Paralitic Ileus Abdominal distension No bowel sounds No flatus per anum Abdominal pseudotumor in epigastrium and left upper quadran

60 General status High fever>38
Septic state (tachycardia, hypotension, septic shock, palor, could periphery) Jaundice (either compression, obstruction or secondary liver failure) Renal failure

61 Lab WBC 10.000-30.000 Hyperglicemia High billirubin
High alkaline fosfataze Hypocalcemia (loss of albumin through extraasation) ~ severity Amilaze si lipaze serum + pleural and peritoneal effusion

62 Imagistic Plain abdominal X-Ray = MUST Differential dg. acute abdomen
Sentinel looop – left upper quadrant Left pleural effusion + atelectasis Incomplete F/A levels Billiary stones Fluid in the abdominal cavity

63 Imagistic US Standard procedure in screening PROBLEM: air content
Pancreas: dimensions, edema, liquid collection pseudocysts Free fluid in the abdomen and pleura Guided aspiration for diagnostic

64 Imagistic CT scan + contrast Best for diagnostic and follow up
Information on pancreatic structure and fluid collections Pancreatic tissue viability Evaluation of peripancreatic collections Free air in collections!!!!

65 Imagistic MRI No major advantages
Superior for the description of billiary duct Not specifically indicated in acute pancreatitis

66 Differential diagnostic
Anything in acute abdomen Myocardial infarction After ERCP Urlian virus infection Intestinal obstruction Aortic dissection Mesenteric obstruction

67 Differential diagnostic SIGNIFICANCE
NO LAPAROTOMY NO LAPAROSCOPY IF DIAGNOSTIC Sure No billiary obstruction (except compression) No suspicion of infection

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