Case Report

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American Journal of Emergency Medicine

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Acute abdominal pain due to Spontaneous rupture of the right gastric artery?,??

Abstract

Abdominal apoplexy was reported by Barber in 1909 [1], and the occurrence rate of the apoplexy is known to be quite rare, but the mortality is high if untreated. We report an unusual case of abdominal apoplexy due to spontaneous rupture of gastric artery. A male patient in his fifth decade with recently diagnosed liver cirrhosis history arrived to the emergency department with severe abdominal pain, which led to abdominal computer tomography indicating spontaneous rupture of gastric artery. Celiac angiogram and embolization were conducted, and Exploratory laparotomy was followed. The outcome of the patient was poor, and he died on the second day of admission. As in our case, the mortality can be high, so prompt restoration of circulation volume and early diagnosis should be made in similar cases.

A 49-year-old male patient with history of liver cirrhosis and diabetes was admitted to the emergency department because of severe abdominal pain, which woke him during his sleep. He was looking acutely ill, and the vital signs showed a blood pressure of 75/55 mm Hg, temperature of 34.1?C, pulse rate of 88 beats/min, and respiratory rate of 26 breaths/min. The laboratory results showed a hemoglobin level of 6.7 g/dL, platelets of 62,000/uL, and glutamic oxaloacetic transaminase/ glutamic pyruvic transaminase of 101/21 IU/L. Whole abdominal tenderness was detected during the physical examination, which led to abdominal computer tomography for further evaluation (Fig. 1). Celiac angiogram was conducted for further evaluation, and the angiogram showed Contrast material leakage in the right gastric artery. Embolization was tried using gelfoam and microcoil, but follow-up angiogram still showed suspicious stain (Fig. 2). Hence, emergency laparotomy was conducted, but the exact Bleeding focus could not be found in the operating room. The patient was brought to the intensive care unit for close observation, but his condition deteriorated and he died on the second day of hospital admission.

Abdominal apoplexy, or idiopathic spontaneous intraperitoneal

hemorrhage (ISIH), was first described by Barber in 1909, and the cause for resulting ISIH is known as aneurysmal rupture, solid-organ malignancy, or inflammatory erosive processes; it can also be idiopathic as the terminology implies [2]. The common aneurysmal rupture sites are splenic, renal, and hepatic, whereas celiac and mesenteric arteries are less commonly found [3]. There was also a case of abdominal apoplexy caused by anticoagulant use due to history of atrial fibrillation [4].

Although the angiogram conducted in our hospital displayed stains of an enhancing material in the right gastric artery, the exact bleeding focus could not be found in the operating room. Also, there were cases of abdominal apoplexy where it was difficult to find the exact bleeding site even after repeated exploration [5,6].

? Sources of support: None.

?? The article has not presented before.

A patient with abdominal apoplexy and gastroepiploic artery rupture was successfully treated in a case report by Hassani et al [7], but the overall mortality rate is known to be about 40% to 66% in surgical cases of ISIH [3]. The time consumed in the transfer of the patient from local hospital to our hospital could have contributed to the adverse outcome, and because abdominal pain in these cases is known to relate to the volume of extravasation rather than the irritation caused by blood, it might have taken time for the patient to become aware of the abdominal symptoms [8]. Cawyer and Stone [3] stated that there are latent phases in the disease process of ISIH when patients are unaware of the pain. Hence, when treating a patient with abdominal pain who shows signs of hypovolemic shock, we should also take abdominal apoplexy into account. Also, because abdominal apoplexy might lead to detrimental outcome, as in our case, the emergency physician should pay attention to details.

Seungwoon Choi, MD Seokyong Ryu, MD, PhD Taekyung Kang, MD Hyejin Kim, MD Sungchan Oh, MD Sukjin Cho, MD

Department of Emergency Medicine Inje University Sanggye Paik Hospital

Seoul, South Korea E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2013.11.026

Fig. 1. Computer tomography showing hemoperitoneum with an enhanced material in the right gastric artery.

0735-6757/$ - see front matter (C) 2014

Fig. 2. Celiac angiogram showing arterial bleeding in a branch of the right gastric artery (left); angiogram showing suspicious stain even after embolization (right).

References

1. Barber MC. Intra-Abdominal hemorrhage associated with labor. Br Med J 1909;2:203-4.
2. Carr SR, Dinsmore RC, Wilkinson NW. Idiopathic spontaneous intra peritoneal hemor- rhage: a clinical update on abdominal apoplexy in the year 2001. Am Surg 2001;67:374-6.
3. Cawyer JC, Stone CK. Abdominal apoplexy: a case report and review. J Emerg Med 2011;40(3):e49-52.
4. Salemis NS, Tsohataridis E. Abdominal apoplexy secondary to spontaneous rupture of the right gastric artery in a coagulopathic patient. Intern Emerg Med 2009;4(1):83-5.
5. Suber Jr WJ, Cunningham PL, Bloch RS. Massive spontaneous hemoperitoneum of unknown etiology: a case report. Am Surg 1998;64:1177-8.
6. Schattner A, Kozack N, Friedman J. Idiopathic spontaneous hemoperitoneum. Arch Intern Med 2001;161(7):1009-10.
7. Hassani KI, Bounekar A, Gruss JM. Spontaneous rupture of the right gastro- epiploic artery: unusual cause of acute abdomen and shock. World J Emerg Surg 2009;4:24.
8. Mortele KJ, Cantisani V, Brown DL, et al. Spontaneous Intraperitoneal hemorrhage: imaging features. Radiol Clin North AM 2003;41:1183-201.