Intra-abdominal Bleeding: A Dangerous Condition Requiring Prompt Management

Intra-abdominal bleeding, also known as bleeding in the abdominal cavity, occurs when blood leaks into the space within the abdomen. This is a serious and potentially life-threatening condition that demands prompt medical attention. Intra-abdominal bleeding often arises from traumatic injuries or underlying diseases within the abdomen.

I. Clinical Manifestations:

1. Functional Symptoms:

• Abdominal Pain: This is the most common symptom. It may come on suddenly and intensely, be constant, and radiate outwards from the injured area.

• In the case of a ruptured spleen, the pain may radiate towards the left shoulder.

• Nausea and Vomiting: These symptoms are frequently encountered.

• Constipation: This is a specific sign that often appears when there’s significant bleeding.

• Shortness of Breath: Loss of blood leads to oxygen deprivation, causing difficulty breathing.

2. Systemic Symptoms:

• Blood Loss:

• Minor Blood Loss (<15% of blood volume): May not have obvious signs.

• Acute Blood Loss:

• Tachycardia: Rapid and weak heartbeat.

• Hypotension: Decreased blood pressure due to reduced blood volume.

• Pale Skin and Mucous Membranes: Due to blood deficiency.

• Excessive Sweating and Cold Extremities: The body’s attempt to conserve heat.

• Anxiety and Fear: Resulting from the critical situation.

3. Physical Examination:

• Inspection of the Abdomen:

• Distended Abdomen: Due to blood accumulation in the abdominal cavity.

• Bruising and Contusions: These can help pinpoint the injured area.

• Cullen’s Sign: Bluish discoloration around the umbilicus, frequently seen in cases of pancreatic rupture.

• Palpation, Percussion, and Auscultation:

• Tenderness Upon Palpation: Pain upon pressing on the abdomen (CUPM).

• Tympanic Percussion Sound: A high-pitched sound when percussing over fluid, a dull sound over blood clots.

• Dullness to Percussion Upon Light Palpation: PUTB (+) – indicating fluid in the abdominal cavity.

• Vaginal or Rectal Examination: A distended pouch of Douglas, tenderness upon palpation.

II. Diagnostic Tests:

1. Abdominal X-ray:

• Without Preparation:

• Abdominal Fluid: Blurring of the abdominal organs, intestines, and paravertebral margins.

• Ruptured Solid Organs: Shadowing of the liver, enlarged spleen/ Elevation of the diaphragm, lungs/ Increased space between the diaphragm and the stomach.

2. Abdominal Ultrasound:

• Advantages:

• Non-invasive, performed at the bedside.

• Identification of the quantity, nature, and location of abdominal fluid.

• Detection of rupture sites, blood clots, and tumors.

• Disadvantages:

• Cannot assess the extent of organ damage; requires combination with other tests.

• Classification of Fluid Location:

• Pericardial: Fluid around the heart.

• Right Subphrenic: Fluid in the liver and kidney region.

• Left Subphrenic: Fluid surrounding the spleen.

• Hypogastric: Fluid in the Douglas pouch.

3. Computed Tomography (CT) Scan:

• Advantages:

• Precise determination of intra-abdominal bleeding.

• Identification of hollow organ perforation.

• Location, nature, and size of the injury.

4. Other Tests:

• Abdominal Paracentesis and Lavage: Determines the presence of fluid in the abdominal cavity.

• Laparoscopy: Direct visualization of the peritoneal cavity, enabling blood clotting and treatment.

• Advantages: Effective blood clotting.

• Disadvantages: Difficult procedure, risk of abdominal perforation.

• Blood Tests:

• Blood Loss: Reduced red blood cell count, hemoglobin, and hematocrit.

• Liver Damage: Elevated liver enzymes (AST, ALT).

• Pancreatic Damage: Elevated amylase.

• Biliary Tract Damage: Elevated bilirubin.

III. Causes of Intra-abdominal Bleeding:

• Direct: Caused by direct trauma to the abdomen.

• Indirect: Resulting from indirect trauma impacting the body.

• Combined: Due to a combination of factors.

1. Direct Causes:

• Solid Organs Prone to Fracture or Rupture: Liver, spleen, kidneys, pancreas.

• Hollow Organs:

• Rupture When Significant Force is Applied with an Obstruction: Trauma to the ribs or spine.

• Organs Under Tension: Rupture of the intestines or stomach due to increased pressure within the organ.

2. Indirect Causes:

• Sudden and Abrupt Stop from High Velocity: Organs may be torn, ligaments may rupture, and blood vessels may tear.

3. Combined Causes:

• Sudden Pressure Increase: Due to explosions, forceful impacts to the abdomen.

• Pelvic Fractures and Rib Fractures: May puncture the bladder, liver, or spleen.

IV. Organs Susceptible to Injury:

• Liver: Blood collection within the parenchyma.

• Spleen: Blood collection beneath the splenic capsule, rupture of the splenic pedicle.

• Kidney:

• Retroperitoneal blood collection, bleeding into the abdominal cavity.

• Parenchymal contusion, renal pelvis or ureteral tear, hematuria (blood in the urine).

• Pancreas: Damage from trauma to the epigastric region, contusions.

• Blood Vessels: Mesenteric vessels, large vessel ruptures.

Note:

• Intra-abdominal bleeding is a perilous condition requiring prompt medical intervention.

• Promptly transport patients to the nearest medical facility for examination and treatment.

• Avoid prolonged transportation and prevent further trauma to the abdomen.

• Closely monitor the patient’s health after treatment.

Furthermore, it’s essential to remember:

• Intra-abdominal bleeding can be fatal if not managed promptly.

• Enhance awareness of injury and accident prevention.

• Equip everyone with basic first aid knowledge.