Fortschr. Röntgenstr. 128, 2
237
Fortsehr. Rönrgenstr. 128,2 (1978) 237-238
Hemoperitoneum from spontaneous rupture of hemangioma of the liver, the value of angiographic diagnosis A case report By U. Nyman
Department of Diagnostic Radiology (Head Prof. Erik Bol smi Malmö General Hospital, S-214 01 Malmö, Sweden
Most hemangiomas of the liver are small, svmptomless and all
An abdominal paracentesis was performed and blood was aspira-
incidental finding on surgery, angiography or autopsy (Kato et al., 1975; Buurman et al., 1975). Large hemangiomas usually present
ted. During the subsequent laparotomy the peritoneal cavity
themselves as an abdominal mass with nonspecific abdominal
gioma on the lower border of the left lobe of the liver. The
symptoms. Rarely does spontaneous rupture of a liver hemangioma
hemorrhage was immediately controlled by suturing. The extension of the hernangioma within the liver could not be assesed during surgery. Hence no excision of the lesion was carried out.
with bleeding into the peritoneal cavity occur (Orihe, 1951 Matsuo, 1953; Sewell and Weiss, 1962; Dcssoff, 1967), a dramatic
event with a reported mortality of 70 per cent (Nieman and Penitschka, 1957). Successful treatment depends partly OIl a prompt diagnosis and knowledge of the extension of the lesion. As far as we know no case with spontaneous rupture of a liver hemangioma has been reported in the literature where angio-
graphy has been utilized among the diagnostic procedures. Such a case will be presented below and the application of angiography in unexplained intra-abdominal blood loss will be com-
was found filled with blood originating from a ruptured heman-
Two days later the patient was referred to the department of radiology for angiography. The exact site and extension of the hemangiorna was demonstrated (Fig. 1), thereby facilitating proper surgical removal of the bleeding source.
Comments intra- and retroperitoneal bleeding must be considered in patients
mented upon.
with unexplained blood loss indicated by falling hemoglobin levels and/or shock often in combination with sudden onset of
Case Report shock to the surgical clinic of the Malmö General Hospital.
abdominal plain. Hemoperitoneum is most commonly caused by gynecologic disorders and trauma (Ellis et al., 1958). In their clinical review of 129 consecutive cases during a six-year period there was only
Fig. la
Fig. I h
A 37-year-old man was admitted unconscious and in profound
Fig. la and b. At celiac angiography a well-defined hemangioma in the left lobe of the liver was demonstrated in arterial phase (Fig. la, right posterior oblique projection). In capillary phase (Fig. lb, anteroposrerior view) the hemangioma (-), its drainage into portal veins (>-s, and multiple small hemangiomatas (o) are observed. 0340-1618/78
0232
0237
$ 05.00 © 1978 Georg Thieme Publishers
Dieses Dokument wurde zum persönlichen Gebrauch heruntergeladen. Vervielfältigung nur mit Zustimmung des Verlages.
1 Figure
Fortschr. Röntgenstr. 128, 2
one fatality among 87 patients with bleeding of gynecologic origin, whereas 10 of the remaining 12 patients in the nontraumatic group succumbed. Among 14519 autopsies (six-year period) Steiner (1966) found 140 cases of massive hemoperitoneum.
In the non-traumatic group, comprising 65 cases, there was only
one case of gynecologic origin. Thus it seems as rupture of
Schaukasten
Experimental work in dogs also suggests a possible therapeutic role for hepanc artery embolization (Cho et al., 1976). In patients with intra-abdominal bleeding this method could be particularly valuable in the management of persistent bleeding when surgery fails and in patients who are poor surgical risks.
gynecologic disorders is a well-recognized clinical entity easily curable by prompt surgery. On the other hand, however, spontan-
Literatur
eous hemoperitoneum of non-gynecologic causes was seldom
Abrao, A., C. I. de Paula,
diagnosed before surgery and autopsy. In the latter group rupture of arterial aneurysms and pathologic conditions in the liver are the most common bleeding source. Massive bleeding from the liver is most frequently caused by hepatocellular carcinoma
(Herman and David, 1973), which also is the most common cause of hemoperitoneum among malignant diseases followed by malignancy in the ovaries and ectopic testes (Gribble and Blair, 1962). Hemangioendothelioma of the liver (Burke et al., 1972), hepatocellular adenoma (Davis et al., 1973), metastatic carcinoma (Abrao et al., 1974) and systemic disorders affecting the liver (Herman and David) as well as lesions in the spleen, pancreas, kidneys and intestine have been associated with inrraabdominal bleeding.
A more frequent use of angiography could improve the therapeutic results in spontaneous hemoperironeum of non-gynecologic origin. If angiography is performed it is possible to determine the
site, extension and nature of the bleeding source. In Steiner's report there was a time interval between the onset of bleeding and death ranging from 70 minutes to 2 days. Thus, in several cases there is usually sufficient time to make an accurate preoperative diagnosis and to plan the surgical approach. The value of angiography has been illustrated in a few reports concerning rupture of arterial aneurysms (Baum et al., 1965; Fontaine et al., 1967; Boijsen et al., 1969; Tongio et al., 1972; Blumenberg et al.,
1974) and in a case of hepatocellular carcinoma as the causal factor (Herman and David).
Angiography is most valuable in cases such as rupture of liver tumors, since total removal of the tumor may be the only possible method to control hemorrhage and this is greatly facilitated if the tumor extension is known. If there is no rime for angiographie procedure prior to celiotomy because of the patients poor condi-
tion, these studies should be carried out as soon as possible in the postoperative period when the site of hemorrhage is not found and removed at surgery. When hemorrhage can be properly
controlled by suturing or packing with surgical gauze pads, angiography can be used for a more accurate evaluation of the
tore dramatique de l'artére splénique dans une poche de pseudokyste nécroJ.
B. da
Silva Neto, R. A. Possik, R. S. L
tique du pancréas. Presse méd. 75 (1967) 655
Capcilano, A. Luizi: Hemoperitonio aqudo espontaneo por ruptura de metastáscs hepáticas. Rev. Ass. méd. bras. 20 (1974) 431 Baum, S., R. H. Greenstein, M. Nushatim, W. S. Blakemorc: Diagnosis of ruptured, noncaicified splenic artery aneurysm by selective celiac arteriography. Arch. Surg. 91 (1965) 1026 Blumenberg, R. M., D. David, J. Sbyak: Abdominal apoplexy due to rupture of a superior meseiiteric artery aneurysm. Arch. Surg. los 1974) 223
Goldstein, H. M., S. Wallace, J. H. Anderson, R. L. Bree, C. Gianturco:
Boijsen, E., J. Göthlin, T. Hallböök,
liver. Diagnosis with combined use of laparoscopy and hepatic angio-
P. Sandblom: Preoperatise angiographic diagnosis of bleeding aneurysms of abdominal visceral arteries. Radiology 93 (1969) 781
Burke, J., D. B. Hamer, L. H. Blunsgart Haemangioendothelioma of the liver presenting as haenioperitoneum. Brit. J. clin. Pract. 26 (1972) 28i
Transcatheter occlusion of abdominal tumors. Radiology 120 (1976) 539 Gribble, M. G., J. S. G. Blair: Haemoperitoiseuin complicating malignant disease. Brit. J. Surg. 49 (1962) 432
Herman, R. E., T. E. David: Spontaneous rupture of the Ever caused by hepatomas. Surgery 74 (1973) 715 Kato, M., I. Sugawara, A. Okada, K. Kusvata, M. Satani, E. Okamoto, H. Manabe: Hemangioma of the graphy. Anier. J. Surg. 129 (1975) 698 Katzen, B. T., P. Rossi, R. Pasariello, G. Simonetti: Transcatheter therapeutic arterial embolization. Radiology 120 (1976) 523 Matojo, 1.: Hemangioma of the liver
Buurman, R., E. Biicheler,
complicated by with massive miraabdominal hemorrhage. Tokyo Med.
Fortschr. Röntgenstr. 123 (1975) 393 CEo, K. J., S. R. Reuter, R. Schmidt: Effects of experimental hepatic artery
J. 70 (1953) 104
I. Boldt: Das Leherhämangiom im Angiogramm.
enibolization
on
hepatic
function.
Nieman, F., W. Penitschka: Die kavernösen Hämangiome, Kavernoma" der Leber. Bruns' Bei. kim. Chie. 195 (1957) 257
Amer. J. Roentgenol. 127 (1976) 563 Davis, J. B., J. R. Schenken, O. Zimmerman: Massive hemoperitoneum from rupture of benign hepatocellular
Uribe, T.: Massive intraabdomival hemorrhage in a male. J. Therapy 33
adenoma. Surgery 73 (1973) 181 Dessoff, S.: Rtiptured cavernous hem-
rupture of hemangioma of the liver.
angioma of the liver. Med. Ann. D.C. 36 (1967) 538
Ellis, H., P. W. W. Griffiths, A. Macintyre: Haemoperitoneuns. A record of 129 consecutive patients svith notes on some unusual cases. Brit. J. Surg. 45 (1957) 606 Fontaine, J. L., J. Piétri, S. Bahin:
De l'utilité de l'angiographie sélective d'urgence pour le diagnostic des hémopéritoines. A propos d'un cas de rup-
(1951) 1101
Sewell, J. H., K. Weiss: Spontaneous A review of the literature and presentation of illustrative case. Arch. Surg. 83 (1961) 729 Steiner, H.: Das akute Häinoperl-
toneum. Bericht über 140 Fälle intraabdomineller Massenbiurung. Schweiz. Med. Wschr. 96 (1966) 875
Tongio, J., G. Fouchet, P. Fresnel, P. Warter: Rupture d'un anévrisme de
l'artère splénique. Diagnostique angiographique pré-opératoire. J. Radiol. Fiectrol. 53 (1972) 339
bleeding lesion, as in the present case, before surgical removal is carried out.
Recently, several reports have emphasized the value of transcatheter embolization by use of angiographie technique in cases of gastrointestinal bleeding and in treatment of tumors and vascu-
lar malformations (Goldstein et aI., 1976; Katzen et al., 1976).
Dr. U. Nyrnan, Department of Diagnostic Radiology, Malmö General Hospital, S-21402 Malmö
Dieses Dokument wurde zum persönlichen Gebrauch heruntergeladen. Vervielfältigung nur mit Zustimmung des Verlages.
238
237
Fortsehr. Rönrgenstr. 128,2 (1978) 237-238
Hemoperitoneum from spontaneous rupture of hemangioma of the liver, the value of angiographic diagnosis A case report By U. Nyman
Department of Diagnostic Radiology (Head Prof. Erik Bol smi Malmö General Hospital, S-214 01 Malmö, Sweden
Most hemangiomas of the liver are small, svmptomless and all
An abdominal paracentesis was performed and blood was aspira-
incidental finding on surgery, angiography or autopsy (Kato et al., 1975; Buurman et al., 1975). Large hemangiomas usually present
ted. During the subsequent laparotomy the peritoneal cavity
themselves as an abdominal mass with nonspecific abdominal
gioma on the lower border of the left lobe of the liver. The
symptoms. Rarely does spontaneous rupture of a liver hemangioma
hemorrhage was immediately controlled by suturing. The extension of the hernangioma within the liver could not be assesed during surgery. Hence no excision of the lesion was carried out.
with bleeding into the peritoneal cavity occur (Orihe, 1951 Matsuo, 1953; Sewell and Weiss, 1962; Dcssoff, 1967), a dramatic
event with a reported mortality of 70 per cent (Nieman and Penitschka, 1957). Successful treatment depends partly OIl a prompt diagnosis and knowledge of the extension of the lesion. As far as we know no case with spontaneous rupture of a liver hemangioma has been reported in the literature where angio-
graphy has been utilized among the diagnostic procedures. Such a case will be presented below and the application of angiography in unexplained intra-abdominal blood loss will be com-
was found filled with blood originating from a ruptured heman-
Two days later the patient was referred to the department of radiology for angiography. The exact site and extension of the hemangiorna was demonstrated (Fig. 1), thereby facilitating proper surgical removal of the bleeding source.
Comments intra- and retroperitoneal bleeding must be considered in patients
mented upon.
with unexplained blood loss indicated by falling hemoglobin levels and/or shock often in combination with sudden onset of
Case Report shock to the surgical clinic of the Malmö General Hospital.
abdominal plain. Hemoperitoneum is most commonly caused by gynecologic disorders and trauma (Ellis et al., 1958). In their clinical review of 129 consecutive cases during a six-year period there was only
Fig. la
Fig. I h
A 37-year-old man was admitted unconscious and in profound
Fig. la and b. At celiac angiography a well-defined hemangioma in the left lobe of the liver was demonstrated in arterial phase (Fig. la, right posterior oblique projection). In capillary phase (Fig. lb, anteroposrerior view) the hemangioma (-), its drainage into portal veins (>-s, and multiple small hemangiomatas (o) are observed. 0340-1618/78
0232
0237
$ 05.00 © 1978 Georg Thieme Publishers
Dieses Dokument wurde zum persönlichen Gebrauch heruntergeladen. Vervielfältigung nur mit Zustimmung des Verlages.
1 Figure
Fortschr. Röntgenstr. 128, 2
one fatality among 87 patients with bleeding of gynecologic origin, whereas 10 of the remaining 12 patients in the nontraumatic group succumbed. Among 14519 autopsies (six-year period) Steiner (1966) found 140 cases of massive hemoperitoneum.
In the non-traumatic group, comprising 65 cases, there was only
one case of gynecologic origin. Thus it seems as rupture of
Schaukasten
Experimental work in dogs also suggests a possible therapeutic role for hepanc artery embolization (Cho et al., 1976). In patients with intra-abdominal bleeding this method could be particularly valuable in the management of persistent bleeding when surgery fails and in patients who are poor surgical risks.
gynecologic disorders is a well-recognized clinical entity easily curable by prompt surgery. On the other hand, however, spontan-
Literatur
eous hemoperitoneum of non-gynecologic causes was seldom
Abrao, A., C. I. de Paula,
diagnosed before surgery and autopsy. In the latter group rupture of arterial aneurysms and pathologic conditions in the liver are the most common bleeding source. Massive bleeding from the liver is most frequently caused by hepatocellular carcinoma
(Herman and David, 1973), which also is the most common cause of hemoperitoneum among malignant diseases followed by malignancy in the ovaries and ectopic testes (Gribble and Blair, 1962). Hemangioendothelioma of the liver (Burke et al., 1972), hepatocellular adenoma (Davis et al., 1973), metastatic carcinoma (Abrao et al., 1974) and systemic disorders affecting the liver (Herman and David) as well as lesions in the spleen, pancreas, kidneys and intestine have been associated with inrraabdominal bleeding.
A more frequent use of angiography could improve the therapeutic results in spontaneous hemoperironeum of non-gynecologic origin. If angiography is performed it is possible to determine the
site, extension and nature of the bleeding source. In Steiner's report there was a time interval between the onset of bleeding and death ranging from 70 minutes to 2 days. Thus, in several cases there is usually sufficient time to make an accurate preoperative diagnosis and to plan the surgical approach. The value of angiography has been illustrated in a few reports concerning rupture of arterial aneurysms (Baum et al., 1965; Fontaine et al., 1967; Boijsen et al., 1969; Tongio et al., 1972; Blumenberg et al.,
1974) and in a case of hepatocellular carcinoma as the causal factor (Herman and David).
Angiography is most valuable in cases such as rupture of liver tumors, since total removal of the tumor may be the only possible method to control hemorrhage and this is greatly facilitated if the tumor extension is known. If there is no rime for angiographie procedure prior to celiotomy because of the patients poor condi-
tion, these studies should be carried out as soon as possible in the postoperative period when the site of hemorrhage is not found and removed at surgery. When hemorrhage can be properly
controlled by suturing or packing with surgical gauze pads, angiography can be used for a more accurate evaluation of the
tore dramatique de l'artére splénique dans une poche de pseudokyste nécroJ.
B. da
Silva Neto, R. A. Possik, R. S. L
tique du pancréas. Presse méd. 75 (1967) 655
Capcilano, A. Luizi: Hemoperitonio aqudo espontaneo por ruptura de metastáscs hepáticas. Rev. Ass. méd. bras. 20 (1974) 431 Baum, S., R. H. Greenstein, M. Nushatim, W. S. Blakemorc: Diagnosis of ruptured, noncaicified splenic artery aneurysm by selective celiac arteriography. Arch. Surg. 91 (1965) 1026 Blumenberg, R. M., D. David, J. Sbyak: Abdominal apoplexy due to rupture of a superior meseiiteric artery aneurysm. Arch. Surg. los 1974) 223
Goldstein, H. M., S. Wallace, J. H. Anderson, R. L. Bree, C. Gianturco:
Boijsen, E., J. Göthlin, T. Hallböök,
liver. Diagnosis with combined use of laparoscopy and hepatic angio-
P. Sandblom: Preoperatise angiographic diagnosis of bleeding aneurysms of abdominal visceral arteries. Radiology 93 (1969) 781
Burke, J., D. B. Hamer, L. H. Blunsgart Haemangioendothelioma of the liver presenting as haenioperitoneum. Brit. J. clin. Pract. 26 (1972) 28i
Transcatheter occlusion of abdominal tumors. Radiology 120 (1976) 539 Gribble, M. G., J. S. G. Blair: Haemoperitoiseuin complicating malignant disease. Brit. J. Surg. 49 (1962) 432
Herman, R. E., T. E. David: Spontaneous rupture of the Ever caused by hepatomas. Surgery 74 (1973) 715 Kato, M., I. Sugawara, A. Okada, K. Kusvata, M. Satani, E. Okamoto, H. Manabe: Hemangioma of the graphy. Anier. J. Surg. 129 (1975) 698 Katzen, B. T., P. Rossi, R. Pasariello, G. Simonetti: Transcatheter therapeutic arterial embolization. Radiology 120 (1976) 523 Matojo, 1.: Hemangioma of the liver
Buurman, R., E. Biicheler,
complicated by with massive miraabdominal hemorrhage. Tokyo Med.
Fortschr. Röntgenstr. 123 (1975) 393 CEo, K. J., S. R. Reuter, R. Schmidt: Effects of experimental hepatic artery
J. 70 (1953) 104
I. Boldt: Das Leherhämangiom im Angiogramm.
enibolization
on
hepatic
function.
Nieman, F., W. Penitschka: Die kavernösen Hämangiome, Kavernoma" der Leber. Bruns' Bei. kim. Chie. 195 (1957) 257
Amer. J. Roentgenol. 127 (1976) 563 Davis, J. B., J. R. Schenken, O. Zimmerman: Massive hemoperitoneum from rupture of benign hepatocellular
Uribe, T.: Massive intraabdomival hemorrhage in a male. J. Therapy 33
adenoma. Surgery 73 (1973) 181 Dessoff, S.: Rtiptured cavernous hem-
rupture of hemangioma of the liver.
angioma of the liver. Med. Ann. D.C. 36 (1967) 538
Ellis, H., P. W. W. Griffiths, A. Macintyre: Haemoperitoneuns. A record of 129 consecutive patients svith notes on some unusual cases. Brit. J. Surg. 45 (1957) 606 Fontaine, J. L., J. Piétri, S. Bahin:
De l'utilité de l'angiographie sélective d'urgence pour le diagnostic des hémopéritoines. A propos d'un cas de rup-
(1951) 1101
Sewell, J. H., K. Weiss: Spontaneous A review of the literature and presentation of illustrative case. Arch. Surg. 83 (1961) 729 Steiner, H.: Das akute Häinoperl-
toneum. Bericht über 140 Fälle intraabdomineller Massenbiurung. Schweiz. Med. Wschr. 96 (1966) 875
Tongio, J., G. Fouchet, P. Fresnel, P. Warter: Rupture d'un anévrisme de
l'artère splénique. Diagnostique angiographique pré-opératoire. J. Radiol. Fiectrol. 53 (1972) 339
bleeding lesion, as in the present case, before surgical removal is carried out.
Recently, several reports have emphasized the value of transcatheter embolization by use of angiographie technique in cases of gastrointestinal bleeding and in treatment of tumors and vascu-
lar malformations (Goldstein et aI., 1976; Katzen et al., 1976).
Dr. U. Nyrnan, Department of Diagnostic Radiology, Malmö General Hospital, S-21402 Malmö
Dieses Dokument wurde zum persönlichen Gebrauch heruntergeladen. Vervielfältigung nur mit Zustimmung des Verlages.
238
