Spontaneous abdominal hemorrhage: Causes, CT findings …...bleeding from renal cell carcinoma. A,...

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Spontaneous abdominal hemorrhage: Causes, CT findingsand clinical implications

Poster No.: C-074

Congress: ECR 2009

Type: Educational Exhibit

Topic: Abdominal and Gastrointestinal

Authors: A. Furlan1, S. Fakhran2, M. Federle3; 1Udine/IT, 2Pittsburgh, PA/

US, 3Stanford, CA/US

Keywords: computed tomography, abdominal hemorrhage

DOI: 10.1594/ecr2009/C-074

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Learning objectives

1.To review the most common causes of spontaneous abdominal hemorrhage (SAH).2. To describe the imaging manifestations of the various etiologies of SAH and the usefulCT signs for diagnosis as well as the implications for patient's management.

Background

DefinitionSpontaneous abdominal hemorrhage (SAH) is defined as the presence of intra-abdominal hemorrhage from a non-traumatic and non-iatrogenic cause.Common sources of SAH:

• Visceral: hepatic, splenic, renal, and adrenal• Obstetric - Gynecologic: ruptured ectopic pregnancy, HELLP syndrome,

ruptured ovarian cyst• Coagulopathy-related• Vascular: ruptured abdominal aortic aneurysm (AAA)

Clinical presentation and role of CT:• The clinical presentation is usually non-specific; thus frequently the

diagnosis is made on the basis of radiologic findings.• CT plays an important role for the assessment of the presence, location and

extent of hemorrhage and for the identification of the underlying cause [1-3].

Imaging findings OR Procedure details

Appearance of hemorrhage on CT [1-3]The appearance of hemorrhage on CT depends on its age and location:Density of blood on unenhanced images:

• Acute bleeding: about 30-45 Hounsfield units (HU) due to its high proteincontent.

• Clotted blood: about 60 HU due to the increasing concentration ofhemoglobin.

• Geographic areas of high attenuation (clot) surrounded by areas of lowerattenuation (serum).

• Occasionally less dense because of pre-existing anemia, ascites, diluted byurine, bowel contents, etc.

• With time the clot decreases in size and density due to the progressive lysisof hemoglobin.

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Key CT findings/signs and clinical implication:Sentinel clot sign [2] (Figs. 1A, 1B)Rationale: Clots tend to form first near the site of bleeding;Clinical implication: The identification of a heterogeneous and relatively higherattenuation clot allows localization of the site of hemorrhage.

Fig.: 33-year-old man with AIDS and underlying Cytomegalovirus infection causingspontaneous splenic rupture.A and B, Axial unenhanced (A) and contrast-enhanced (B)CT sections obtained at slightly different levels, demonstrate splenic laceration (arrow,B) with hyperdense sentinel clot (ROI 1 = 52 HU, A) surrounding spleen, and relativelylower density lysed blood (ROI 2 = 35 HU, A) surrounding liver.

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Fig.: 33-year-old man with AIDS and underlying Cytomegalovirus infection causingspontaneous splenic rupture.A and B, Axial unenhanced (A) and contrast-enhanced (B)CT sections obtained at slightly different levels, demonstrate splenic laceration (arrow,B) with hyperdense sentinel clot (ROI 1 = 52 HU, A) surrounding spleen, and relativelylower density lysed blood (ROI 2 = 35 HU, A) surrounding liver.Active extravasation [3]Rationale: on contrast-enhanced images, blood is isodense to opacified vessels andhyperdense to enhanced organs.Clinical implication: to localize for source of active bleeding, look for high-attenuationfoci nearly isodense to adjacent vessels.Hepatic causesSpontaneous hepatic bleeding is a rare condition, mainly due to the rupture of anunderlying hypervascular tumor, such as hepatic adenoma or hepatocellular carcinoma(HCC) [4]. Rupture of otherhepatic masses, while possible, is distinctly uncommon.Ruptured hepatic adenoma [4] (Figs. 2A, 2B)

• Rare but well known complication of large hepatic adenomas.• Usually presenting with acute abdominal pain in a young female on long-

term oral contraceptive therapy.

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Fig.: 29-year-old woman with surgically proven ruptured hepatic adenoma. A, Axialunenhanced CT section demonstrates subcapsular hematoma with higher densitysentinel clot (arrow) along right posterior hepatic lobe.

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Fig.: 29-year-old woman with surgically proven ruptured hepatic adenoma. B, Axialcontrast-enhanced CT section, obtained at slightly different level than A, demonstratesspherical, heterogeneously hypervascular, hepatic mass (arrow), adjacent to clot,proven to be ruptured hepatic adenoma at resection.Ruptured HCC [5] (Fig. 3A, 3B)

• Uncommon condition with a higher incidence in Asia and Africa.• Cirrhotic patients.• Usually the tumor is located at the periphery of the liver or protruding beyond

the original liver margin.

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Fig.: 54-year-old man presenting with acute abdominal pain and surgically provenruptured hepatocellular carcinoma (HCC). A, Axial unenhanced CT section showsdiffusely low-attenuation liver parenchyma and surrounding hyperattenuatingperihepatic fluid (white arrows) with an ill-defined, subtle area of higher attenuation inthe left hepatic lobe (black arrows), suggestive of underlying mass.

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Fig.: 54-year-old man presenting with acute abdominal pain and surgically provenruptured hepatocellular carcinoma (HCC). B, Axial contrast-enhanced CT section,obtained at same level as A, shows spherical, heterogeneously hypervascular mass(arrow) in left hepatic lobe. Hepatectomy proved bleeding HCC associated withhemoperitoneum.Key CT findings/signs and clinical implication:

• On unenhanced CT images, the ruptured tumor is usually hyperdense (Figs.2A, 3A).

• However, it may be completely obscured by the adjacent subcapsularhematoma.

• Use the sentinel clot sign to recognize the hepatic source of hemorrhage.• The intravenous administration of contrast material helps to detect foci of

active extravasation.

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• After contrast injection, the ruptured hepatic tumor appear as a large,spherical and partially exophytic, enhancing mass, contiguous with thesubcapsular hematoma (Figs. 2B, 3B).

• CT plays an important role in the early diagnosis of these potentiallyfatal conditions, leading to emergency treatment, such as transarterialembolization or liver resection.

Splenic causes [6, 7]• The spleen is the second most common solid organ to rupture

spontaneously (after the liver).• Patients usually present with acute left-side upper abdominal pain. Possible

shoulder pain due to diaphragmatic irritation.• The most common cause is an underlying infection, usually due to

Cytomegalovirus or Epstein-Barr virus.• Rarely the hemorrhage is due to rupture of an underlying splenic mass such

as lymphoma or leukemia.

Key CT findings/signs and clinical implication:• Grossly abnormal spleen with perisplenic hemorrhage and clot within the

organ (Fig. 4).• Timely identification by CT often mandates immediate surgical intervention.

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Fig.: 43-year-old man with underlying B-cell lymphoma presenting with spontaneoussplenic rupture. Axial contrast-enhanced CT section shows splenomegaly withparenchymal laceration (white arrow) and large eccentric mass (black arrows), provedto be tumor and hematoma, with foci of calcification (curved arrow).Renal causes [8]

• Usually due to rupture of a renal tumor such as angiomyolipoma (AML) orrenal cell carcinoma (RCC).

• Tumor can rupture because of an increase in the venous pressure, tumorvascular invasion or necrosis (or in minor trauma).

• Spontaneous renal or perirenal hemorrhage may also result fromcoagulopathy or vasculitis, such as polyarteritis.

Key CT findings/signs and clinical implication:

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• RCC: solid mass with less contrast enhancement than the adjacent renalparenchyma at contrast-enhanced CT (Fig. 5).

• However, small tumors may be initially obscured by the hematoma;therefore follow-up imaging after resolution of the initial hematoma isessential (Fig. 5).

Fig.: 50-year-old man presenting with acute left flank pain due to spontaneousbleeding from renal cell carcinoma. A, Axial unenhanced CT section throughleft kidney, demonstrates perirenal hemorrhage (white arrows) and very subtlerenal peripheral mass (black arrow) nearly isodense to the surrounding renalparenchyma. No IV contrast given due to prior anaphylactic reaction to its use.

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Fig.: B, Coronal unenhanced T1W (TR/TE, 145/4.2 ms) MR image demonstrates leftrenal exophytic mass (black arrow) isointense to the surrounding renal parenchyma,with hyperintense adjacent hematoma (white arrows).

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Fig.: C, Axial unenhanced CT section performed 4 weeks later than A, demonstratespartial resolution of perirenal hemorrhage and well-detectable renal exophytic mass(arrow); proven renal cell carcinoma at partial nephrectomy.

• AML: large heterogeneous mass with low attenuation areas of fat (Fig. 6).

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Fig.: 25-year-old man with tuberous sclerosis presenting with acute onset of rightflank pain due to spontaneous rupture of renal angyomiolipoma. Axial unenhancedCT section demonstrates large, fat containing mass (arrow) within right kidney withextensive perirenal hemorrhage (asterisk).Adrenal causes [9]

• Uncommon condition, usually bilateral and associated with anticoagulationtherapy, severe stress or sepsis.

• Bilateral adrenal hemorrhage may be complicated by life-threatening adrenalinsufficiency.

Key CT findings/signs and clinical implication:• Enlarged, hyperdense adrenal glands (Fig. 7A) without appreciable

enhancement after intravenous administration of contrast material (Fig. 7B).

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Fig.: 46-year-old woman with abdominal pain and hypotension following surgeryfor colon carcinoma; spontaneous adrenal hemorrhage and insufficiency. A andB, Axial unenhanced (A) and contrast-enhanced (B) CT sections obtained at thesame level, show hyperattenuating, enlarged bilateral adrenal glands (arrows, A)with no enhancement (arrows, B) after contrast material injection.

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Fig.: 46-year-old woman with abdominal pain and hypotension following surgeryfor colon carcinoma; spontaneous adrenal hemorrhage and insufficiency. A and B,Axial unenhanced (A) and contrast-enhanced (B) CT sections obtained at the samelevel, show hyperattenuating, enlarged bilateral adrenal glands (arrows, A) with noenhancement (arrows, B) after contrast material injection.Gynecologic - Obstetric causesRupture of an ectopic pregnancy or an ovarian cyst are the most common causes ofspontaneous hemoperitoneum in women of childbearing age [10, 11].Rupture of ectopic pregnancy

• Potentially life-threatening condition that must be considered in everywoman of reproductive age with abdominal or pelvic pain.

• Usually, diagnosed by measuring the serum #-human chorionicgonadotropin (#-HCG) and performing a pelvic ultrasonography.

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Key CT findings/signs and clinical implication:• In the emergency setting, CT may be performed in these patients due to the

presenting severe symptoms and a falsely negative urine pregnancy test.• Ectopic pregnancy commonly occurs in the fallopian tube and presents as

a ring enhancing adnexal cystic mass surrounded by hemoperitoneum (Fig.8).

• Correct diagnosis often leads to emergency laparotomy.

Fig.: 42-year-old woman presenting with increasing pelvic pain and negative urinepregnancy test. Axial contrast-enhanced CT section demonstrates pelvic hematoma(black arrows) around ring-enhancing left adnexal mass (white arrow) with adjacenthigh-attenuation foci indicative of active bleeding (curved arrow). Rupture of ectopicpregnancy in left fallopian tube was confirmed at surgery (Serum #-human chorionicgonadotropin test confirmed elevated levels after completion of the CT scan).Ovarian cyst rupture [11]

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• Young women presenting with pelvic pain and negative serum #-HCG.• Usually, diagnosis is reached with a combination of laboratory and US

findings.• When the source of bleeding cannot be localized at US, CT better detects

the ruptured cyst as a mixed-attenuation mass in the context of a high-density pelvic hematoma (Fig. 9).

Fig.: 23-year-old woman with sudden onset of pelvic pain due to ruptured corpusluteum with hemoperitoneum.A and B, Axial contrast-enhanced CT sections throughpelvis (A) and lower abdomen (B) demonstrate corpus luteum with enhancing walland intracystic hemorrhagic component (arrow, A) in left ovary, surrounded by pelvichematoma (ROI, A - mean attenuation = 77 HU, sentinel clot) and relatively lowerdensity blood in paracolic gutters (ROIs, B - mean attenuation = 34 HU).

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Fig.: 23-year-old woman with sudden onset of pelvic pain due to ruptured corpusluteum with hemoperitoneum.A and B, Axial contrast-enhanced CT sections throughpelvis (A) and lower abdomen (B) demonstrate corpus luteum with enhancing walland intracystic hemorrhagic component (arrow, A) in left ovary, surrounded by pelvichematoma (ROI, A - mean attenuation = 77 HU, sentinel clot) and relatively lowerdensity blood in paracolic gutters (ROIs, B - mean attenuation = 34 HU).HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets) syndrome [12]

• Severe variant of preeclampsia.• May be associated with hepatic necrosis and intrahepatic hemorrhagic

infarction.• Treatment consists of expeditious delivery of the baby and emergency

surgery or selective embolization of hepatic arteries in case of liver rupture.

Key CT findings/signs and clinical implication:• CT is the study of choice to detect hepatic subcapsular hematomas,

intrahepatic liver hemorrhage and infarcts (Fig. 10).

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Fig.: 36-year-old woman with toxemia of pregnancy, right upper quadrant pain andfalling hematocrit (HELLP syndrome). Axial contrast-enhanced CT section showsnonenhancing hepatic foci (white asterisk) due to infarction and hematoma, foci ofactive bleeding (white arrows), along with subcapsular and perihepatic hemorrhage(black asterisks).Coagulopathy-related SAH [13, 14]

• Abdominal hemorrhage due to anticoagulation or bleeding diathesis.• Common causes are: hepatic failure, hemophilia, idiopathic

thrombocytopenic purpura, systemic lupus erythematosus.• Treatment is usually conservative and mainly based on withholding of

anticoagulant medications.

Key CT findings/signs and clinical implication:

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• Body wall muscle compartments, such as the rectus sheath (Fig. 11A) or theiliopsoas muscle (Fig. 11B).

• Hematocrit effect: (Figs. 11A, 11B)Rationale: cellular-fluid level due to the settling of cellular elements in thedependent portion of a hematoma.Clinical implication: its identification is highly sensitive (87%) and specific forcoagulopathic hemorrhage [14].

Fig.: 80-year-old man on chronic warfarin therapy with acute onset of abdominal painand palpable abdominal wall mass due to spontaneous coagulopathic hemorrhage.Axial unenhanced CT section demonstrates enlargement of right rectus abdominalmuscle with cellular-fluid level (hematocrit effect, arrow) diagnostic of coagulopathicrectus sheath hematoma.

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Fig.: 45-year-old woman with hemophilia and back pain due to spontaneouscoagulopathic hemorrhage. Axial contrast-enhanced CT section shows multi-compartment hemorrhage including left perirenal (asterisk) and right iliopsoas withhematocrit effect (arrow) and active extravasation of contrast material (curved arrow).

• Abdominal viscera are less commonly involved (perirenal and intramuralbowel hematomas) (Fig. 12).

• When contrast-enhanced CT detects associated active extravasation, this isusually venous or capillary, not necessarily requiring embolization.

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Fig.: 50-year-old man on heparin therapy for prevention of deep venous thrombosiswith spontaneous perirenal hemorrhage.A, Axial unenhanced CT section shows largehyperdense clot (asterisk) in right perirenal space.

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Fig.: B, Axial unenhanced CT section obtained at same level as A, 14 days afterwithholding heparin, shows slow resolution of hematoma (asterisk), decreased in sizeand attenuation.Vascular causes - Ruptured abdominal aortic aneurysm (AAA) [15-17]CT is usually performed in patients with known AAA presenting with abdominal pain, toexclude rupture or to identify other etiologies for the patient's symptoms.Key CT findings/signs and clinical implication:

• On unenhanced CT images, findings associated with increased risk ofrupture include:

• Diameter > 5 cm.• Focal discontinuity in circumferential wall calcifications.• Hyperattenuating crescent sign (Fig. 13): presence of a crescent-shaped

area of high attenuation within the mural thrombus or in the aneurysmal wall[16].

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Fig.: 74-year-old man with back pain and impending or early rupture of knownabdominal aortic aneurism (AAA). Axial unenhanced CT section demonstrateslarge AAA with crescent-shaped area of high attenuation within mural thrombus(hyperattenuating crescent sign, arrow)which is associated with increased risk ofrupture.

• Draped aorta sign (Figs. 14A, 14B): the posterior wall of the aorta is notidentifiable as distinct from adjacent structures. It indicates early containedrupture [17].

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Fig.: 70-year-old man with abdominal pain and hypotension due to rupture of AAA.Aand B, Axial contrast-enhanced CT sections obtained at slightly different levels, showlarge AAA (arrow, A) with eccentric posterior bulge (draped aorta sign) and indistinctmargins with iliopsoas compartment (arrows, B).

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Fig.: 70-year-old man with abdominal pain and hypotension due to rupture of AAA.Aand B, Axial contrast-enhanced CT sections obtained at slightly different levels, showlarge AAA (arrow, A) with eccentric posterior bulge (draped aorta sign) and indistinctmargins with iliopsoas compartment (arrows, B).

• Rupture usually manifests as a large retroperitoneal hematoma adjacent tothe aneurysm (Figs. 15A, 15B) [15].

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Fig.: 62-year-old female with ruptured AAA.A and B, Axial unenhanced (A) andcontrast-enhanced (B) CT sections obtained at same level, shows AAA with largeadjacent hemorrhage involving multiple right retroperitoneal compartments (asterisks,A) and periaortic extravasation (arrow, B).

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Fig.: 62-year-old female with ruptured AAA.A and B, Axial unenhanced (A) andcontrast-enhanced (B) CT sections obtained at same level, shows AAA with largeadjacent hemorrhage involving multiple right retroperitoneal compartments (asterisks,A) and periaortic extravasation (arrow, B).Retroperitoneal hematoma: coagulopathy-related or ruptured AAA ?In case of retroperitoneal hematoma in a patient with concomitant AAA andcoagulopathic condition, it is critical to determine the cause of the hemorrhage todirect the patient to the most adequatetreatment, since a ruptured AAA requiresprompt treatment by surgery or endovascular intervention, whereas surgery is usuallycontraindicated in cases of coagulopathic hemorrhage [14, 15]. Diagram inFigure 16can be used as a guide for the diagnosis making process.

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Fig.: 1: cellular-fluid level due to the settling of cellular elements in the dependentportion of a hematoma;2: hematoma from ruptured AAA may involve the ileo-psoascompartment due to the communication with the retroperitoneal spaces; 3: highattenuation crescent sign; draped aorta sign;A: distant from AAA;B: contiguous withAAA.

Conclusion

Knowledge of the common CT manifestations of various causes of SAH allows theiraccurate diagnosis with a direct impact on clinical decision-making.

Personal Information

Alessandro Furlan, MDInternational Postdoctoral AssociateDepartment of RadiologyUniversity of Pittsburgh Medical Center200th Lothrop Street,15213 Pittsburgh (PA)[email protected] Fakhran, MDResident (IV)Department of RadiologyUniversity of Pittsburgh Medical Center200th Lothrop Street,

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15213 Pittsburgh (PA)Michael Federle, MDProfessor of RadiologyAssociate Chair for EducationDepartment of RadiologyStanford University Medical CenterStanford, CA 94305-5105

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