Abdominal Bleeding: A Surgical Emergency

Abdominal Bleeding: A Surgical Emergency

Abdominal bleeding is a critical surgical emergency.

1. Anatomy of the Abdomen:

• Boundaries:

• Posterior: Spine, lumbar vertebrae, lower ribs, lumbar muscles.

• Superior: Diaphragm on both sides.

• Inferior: Pelvic region.

• Anterior and lateral: Abdominal wall: rectus abdominis muscle, pyramidalis muscle, external oblique muscle.

• Role of structures:

• The lumbar muscle mass protects the posterior abdominal organs from minor injuries.

• The strong pelvic region protects the lower abdominal organs from minor injuries.

• Anatomical characteristics: Blood and fluid in the abdomen will accumulate in the lower part (where there are cul-de-sacs).

• Vulnerable areas: The anterior and lateral abdomen is vulnerable to organ damage due to pressure from anterior to posterior.

2. Abdominal wall injuries:

• Injuries that easily lead to herniation: Muscle rupture.

• Injuries that require surgical intervention: Large hematomas.

3. Organ injuries:

• Two clinical presentations:

• Immediate bleeding: Due to organ rupture.

• Secondary bleeding: Due to contusion or laceration of the organ parenchyma, blood accumulation under the organ capsule, and subsequent rupture into the abdomen.

• Mechanism: Blood in the abdomen stimulates the visceral plexus, causing gastric and intestinal dilation, distension, and decreased motility.

• Blood in the abdomen:

• Envelopes the injured organ.

• Spreads between intestinal loops.

• Follows the grooves of the colon on both sides.

• Accumulates in low positions: Morrison’s pouch, Douglas’s pouch, and two pelvic fossae.

4. Causes:

• Most common: Blunt abdominal trauma.

• Others: Penetrating abdominal wounds, gynecological conditions, rupture of pathological organs.

5. Blunt Abdominal Trauma:

• Easily injured organs: Solid organs.

• Hollow organs: Usually only injured when trapped between the impact force and a hard surface (spine) or when distended.

• Mechanism of action:

• Direct: It is very difficult to observe abrasions and bruises on the abdominal wall.

• Indirect: When the body is moving at high speed and stops abruptly, creating a tearing force between the organs.

• Common injuries: Laceration of the peritoneum, organ capsules around the attachments of ligaments and vessels.

• Kidney injury: Often causes retroperitoneal hematoma but can rupture into the abdomen.

6. Penetrating Abdominal Wounds:

• Definition: Creates a communication with the external environment through a peritoneal injury.

7. Gynecological Conditions:

• Causes:

• Ruptured ectopic pregnancy.

• Ruptured Graafian follicle.

8. Rupture of Pathological Organs:

• Liver: Liver cancer rupture, liver hemangioma rupture, subcapsular hematoma, vascular malformation.

• Spleen: Enlarged spleen (malaria), subcapsular hematoma, vascular malformation.

• Pancreas: Acute hemorrhagic pancreatitis.

• Blood vessels: Aortic aneurysm rupture, mesenteric artery occlusion, mesenteric hemangioma, vascular malformation.

• Tumors: GIST rupture, ovarian tumor rupture.

• Medical conditions: Disseminated intravascular coagulation (DIC), use of anticoagulants.

9. Symptoms:

• Functional:

• Abdominal pain: sudden, severe, constant pain, throughout the abdomen or spreading throughout the abdomen.

• Vomiting.

• Constipation.

• Difficulty breathing.

• Specific: Constipation.

• Physical:

• Abdominal distention: uniform, entire, gradually increasing.

• Pain on palpation of the pelvic region.

• Edema of the abdominal wall is evident at the location of the injured organ.

• Dull percussion in the lower region, tympany in the upper region.

• Injury on the abdominal wall.

• Cullen’s sign (ecchymosis around the umbilicus).

• Douglas’s pouch is distended and painful on rectal-vaginal examination.

• Kehr’s sign: Pain radiating to the left shoulder (splenic rupture).

• Acute blood loss: Rapid pulse, low blood pressure, pale skin, cold extremities, sweating, anxiety, agitation, coma.

10. Diagnosis:

• Clinical: Assess shock signs, assess abdominal wall injury, rectal examination, abdominal ultrasound.

• Laboratory tests:

• Abdominal X-ray: Image of fluid in the abdomen, indirectly indicates solid organ injury.

• Abdominal ultrasound: Detects fluid, hematoma, injured organ, mass.

• Abdominal CT: Gold standard, detects blood in the abdomen, organ injury, hollow organs, retroperitoneal organs.

• Paracentesis, peritoneal lavage: Indicated in cases where ultrasound or CT are unavailable.

• Laparoscopic procedure: Indicated in cases where diagnosis is difficult using other methods.

• Blood tests: Red blood cells, hemoglobin, hematocrit decrease, blood chemistry (bilirubin, AST, ALT, amylase, lipase, beta hCG), blood type, coagulation.

11. Clinical Classification:

• Fulminant form: Large vessel injury, severe hemorrhagic shock, needs immediate surgery.

• Typical form: Clear and complete clinical signs.

• Atypical form: Poor clinical signs, difficult to diagnose.

• Secondary bleeding: Blood accumulation under the organ capsule ruptures into the abdomen.

• Abdominal bleeding in polytrauma patients: Signs of abdominal bleeding are often masked by shock or coma.

12. Treatment:

• Resuscitation:

• Establish intravenous lines, fluid resuscitation, blood transfusion.

• Oxygen therapy, endotracheal intubation and mechanical ventilation if necessary.

• Insert nasogastric tube, urinary catheter.

• Emergency blood tests.

• Keep the patient warm.

• Use vasopressors if necessary.

• Conservative treatment:

• Arterial ligation to control bleeding.

• Conservative treatment with monitoring.

• Surgery:

• Severe bleeding, severe shock, resuscitation is ineffective.

• Bleeding injury that cannot be ligated.

• Associated injuries requiring surgery.

• Laparoscopic surgery: Indicated in cases where the patient is stable, with moderate bleeding.

13. Complications:

• Hemorrhagic shock: Pathological vicious cycle leading to death.

• Surgical complications: Infection, bleeding, intestinal obstruction.

14. Prognosis:

• Depends on the cause, severity of injury, patient’s condition, treatment capabilities.

• High mortality rate if not treated promptly.

15. Prevention:

• Reduce traffic accidents, occupational accidents.

• Equip with first aid knowledge.

• Early diagnosis and prompt treatment of diseases that can cause abdominal bleeding.