A 19-year-old helmeted motorcyclist is brought to the emergency department by ambulance after a crash at approximately 55 miles per hour. He is combative, pale, and diaphoretic. An endotracheal tube is placed, and his blood pressure is 85/40 mm Hg while receiving crystalloid resuscitation. A focused assessment with sonography for trauma (FAST) examination of the abdomen demonstrates fluid in Morison’s pouch.
Abdominal hemorrhage can be intraperitoneal or extraperitoneal (e.g., retroperitoneal or within the abdominal wall), and secondary to either a primary or secondary process (e.g., after trauma).
Intraperitoneal hemorrhage can be life threatening and can arise secondary to trauma, spontaneously, or as a complication of anticoagulant medication, infection, or malignancy. Most intraperitoneal bleeding is related to traumatic solid organ injury. Splenic injury constitutes up to 49% of visceral injury after blunt trauma.1 Liver injury can be present in up to 10% of blunt abdominal traumas, but occurs in isolation much less commonly than the spleen.2
Extraperitoneal hemorrhage can occur between leaves of the mesentery, in the retroperitoneum, or in the abdominal wall. Retroperitoneal hemorrhage arises after trauma, ruptured aortic aneurysm, malignancy, pancreatitis, or as a complication of anticoagulant medication or endovascular procedures (e.g., coronary catheterization). Abdominal wall and muscular hematomas can likewise be a complication of anticoagulation or trauma, but also can be seen after forceful coughing or during pregnancy.3
Sudden deceleration injury or transmission of blunt force directly to the spleen or liver is responsible for most cases of intraperitoneal hemorrhage after trauma. Deceleration forces can cause capsular disruption and avulsion of ligamentous attachments, causing linear and stellate fractures of varying depths. Associated lesions are common and include ipsilateral rib fractures, hemothorax or pneumothorax, lung lacerations, and renal or adrenal injuries.
Abdominal wall and retroperitoneal hemorrhage can be related to intramuscular injections, or to anticoagulant medications, with or without antecedent trauma. Retroperitoneal hemorrhage can also be associated with major vascular injuries or malignancy and can be spontaneous.
Splenic injury presents with abdominal pain, with referred pain to the left shoulder (Kehr sign), while the pain after a liver injury can radiate to the right shoulder. Diffuse hemorrhage can lead to abdominal distention and shock with associated ileus. Intraperitoneal blood is a minor peritoneal irritant and so may be missed on physical examination. The diagnosis becomes more difficult in the presence of multiple injuries and can be complicated by closed head injury, drugs, or spinal cord injury.
Retroperitoneal hematomas present with generalized or localized pain. The larger the lesion, the more likely the pain is to be generalized.3 Physical examination tends to be nonspecific, but Cullen’s (peri-umbilical) or Grey-Turner’s (flank) ecchymosis has been described. Flank pain and pain radiating to the thighs are common.