Case Report

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American Journal of Emergency Medicine

journal homepage: www. elsevier. com/ locate/ajem

Laparoscopic management for Spontaneous rupture of left gastroepiploic vessel after forceful retching?

Abstract

Spontaneous rupture of the left gastroepiploic vessel causing Abdominal apoplexy or spontaneous hemoperitoneum is extremely rare. Such ambiguous condition can delay diagnosis, resulting in hypo- volemic shock. Reporting such rare cases is valuable to clinicians. Here, we report a 19-year-old man who initially presented left upper quadrant pain and diaphoresis followed by vomiting after ingesting alcohol. He was diagnosed with diffuse hemoperitoneum and large amount of hematoma in left side of lesser sac due to spontaneous rupture of left gastroepiploic vessel. The patient underwent emergency exploratory laparoscopy. Bleeding was controlled by clipping the teared vessel.

Spontaneous left gastroepiploic vessel rupture after forceful retching is extremely rare. This kind of idiopathic spontaneous intraperitoneal hemorrhage is known as abdominal apoplexy. Short gastric rupture after vomiting has been commonly reported in abdominal apoplexy. We experienced a case of a young man with abdominal apoplexy due to rupture of the left gastroepiploic vessel. He was managed with a laparoscopic approach.

A 19-year-old man presented to the emergency department (ED) with diffuse abdominal pain for 10 hours followed by vomiting and diarrhea after ingesting alcohol. He also complained of shortness of breath and chills. He denied having any trauma history. His abdominal pain got worse in both lateral decubitus positions. On physical examina- tion, he had localized tenderness in the left upper quadrant. Neither abdominal distension nor peritoneal irritation sign was seen.

On arrival to the ED, he showed tachycardia with heart rate of 107 beats per minute. His blood pressure was 150/100 mm Hg with respiratory rate of 20 breaths per minute. Laboratory results revealed hemoglobin level of 14.5 g/dL, platelets of 233000/uL, and white cell count of 11.42 x 10⁹/L. All were within reference ranges. initial impression for him was acute gastritis with dehydration. Therefore, he was treated with intravenous hydration and observed in the ED.

Two hours later, the patient still had abdominal pain. He developed peritoneal irrigation sign including whole abdominal muscle guarding. Contrast-enhanced abdominal computer tomography (CT) revealed a large hematoma between the body of stomach and the spleen with extravasation of contrast media (Fig. 1). He was immediately taken to the operation room for an exploratory laparoscopy. During the opera- tion, approximately 1000 mL of hemoperitoneum was found in the

? Disclosure information: Nothing to disclose.

peritoneal cavity. After dividing the greater omentum, huge hematoma was found in the left side of lesser sac (Fig. 2A). While removing the hematoma gently, bleeding foci were seen at the left gastroepiploic pedicle (Fig. 2B). Injured vessel was ligated by surgical clips at the proximal and distal part from the tearing site. Massive irrigation was carried out to confirm that there was no other Bleeding focus. The operation was completed with totally laparoscopic approach. After the surgery, his postoperative Hb level was 12.0 g/dL, reflecting earlier blood loss. Two units of Packed red blood cells was given. Afterward, the patient was discharged 3 days after the operation.

Idiopathic spontaneous intraperitoneal hemorrhage was first reported by Barber in 1901 [1]. It was later termed abdominal apoplexy by Green and Powers in 1931 [2]. Its definition is the presence of free blood within the peritoneal cavity from a nonTraumatic cause. The left Gastric artery, Superior mesenteric artery, and splenic artery are the most common sites of rupture in an order of decreasing frequency [3]. The etiology of abdominal apoplexy is not well understood. It usually results from an episode of elevated intra-abdominal pressure. Vomiting has been reported as a common antecedent event. Hayes et al [4] have proposed that retching may cause partial volvulus because it might pull gastrosplenic ligament. Shearing force may result in a tear of the

short gastric artery [4].

Acute blood loss may not yield hypovolemic shock in early phase. Patients usually present vague abdominal pain without peritoneal

Fig. 1. Computer tomography showing large hematoma between stomach and spleen with bleeding foci (red arrow).

0735-6757/(C) 2015

Fig. 2. A, Large amount of hematoma was seen at the left side of lesser sac. B, Bleeding focus at the left gastroepiploic vessel clamped with grasper.

irritation sign. Cool extremeties, chilling, tachycardia, or tachypnea may be seen. Symptom and sign can be developed as a result of blood loss and mass effect of hematoma. Hypotension and decrease in Hb level indicate more blood loss in the circulatory system, which can worsen the clinical outcome of patient.

contrast-enhanced CT scan can easily reveal the presence of intra-abdominal hematoma with its location and approximate amount. Extravasation means ongoing blood loss directly from vessel [5]. If CT scan is not available due to hemodynamic instability, Focused assessment with sonography in trauma examination can be helpful to find the hematoma [6]. Although the exact location or ongoing blood loss is difficult to determine, large amount of intra-abdominal hematoma necessitates prompt surgical intervention. Therefore, knowledge of this kind of situation and suspicion are cornerstones to reach Prompt diagnosis.

As general surgeons, we encounter plenty of patients presen- ting abdominal pain caused by various problems. We need to be aware of common diseases as well as potentially life-threatening diseases. Although the incidence of spontaneous hemoperitoneum is very low, delayed diagnosis can be fatal. When treating patients with atypical abdominal pain, we should also take abdominal apo- plexy into account. Immediate evaluation is necessary for early therapeutic management so that we can greatly improve patient’s clinical outcome.

Young Sun Choi, MD Dong Jin Kim, MD? Wook Kim, MD, PhD

Department of Surgery, Yeouido St Mary’s Hospital, College of Medicine The Catholic University of Korea, Seoul, Republic of Korea

?Corresponding author. Division of Gastrointestinal Surgery Department of Surgery, Yeouido St Mary’s Hospital, College of Medicine The Catholic University of Korea, #62 Yeouido-dong, Yeongdeungpo-gu Seoul, 150-713, Republic of Korea. Tel.: +82 2 3779 2165

fax: +82 2 786 0802

E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.08.034

References

1. Barber MC. Intra-abdominal haemorrhage associated with labour. Br Med J 1909;2:203-4.
2. Green WT, Powers JH. Intra-abdominal apoplexy. Ann Surg 1931;93:1070-4.
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4. Hayes N, Waterworth PD, Griffin SM. Avulsion of short gastric arteries caused by vomiting. Gut 1994;35:1137-8.
5. Birjawi GA, Nassar LJ, Atweh LA, Akel S, Haddad MC. Emergency abdominal radiology: the acute abdomen. J Med Liban 2009;57:178-212.
6. Badri F, Packirisamy K, Aryasinghe L, Al Suwaidi M. Abdominal apoplexy: a rare case of spontaneous rupture of the superior mesenteric artery in a Hypertensive patient. Int J Surg Case Rep 2012;3:614-7.