HEMOPERITONEUM IN PATIENTS WITH ASCITES

Objectives: To review existing data on the pathophysiology and clinica l presentation of hemoperitoneum in patients with ascites and to famil iarize practicing clinicians who take care of such patients with the t herapeutic options currently available for management of this complica tion. Methods: Relevant English-language articles published between Ja nuary 1988 and November 1996 were identified through MEDLINE search, u sing the key words ''hemoperitoneum'' and ''ascites.'' Articles cited in the bibliographies of these articles were searched manually. Publis hed papers that contained data on hemoperitoneum in general and on hem operitoneum developing in patients with ascites were reviewed. Results : In patients with ascites, hemoperitoneum can develop spontaneously o r can follow abdominal trauma and diagnostic or therapeutic procedures . Spontaneous bleeding into ascites usually develops insidiously and m ay not cause hemodynamic instability, even in patients with cirrhosis. Massive acute hemoperitoneum from a ruptured intraperitoneal varix is an unusual complication of portal hypertension requiring prompt surgi cal treatment. Acute hemoperitoneum develops in 5-15% of patients with hepatocellular carcinoma requiring transcatheter arterial embolizatio n. Metastatic liver tumors cause bloody ascites infrequently; however, this is a common complication of ovarian carcinoma. Conclusions: Hemo peritoneum is a severe complication in patients with ascites, When it develops spontaneously, it is usually related to the same disease proc ess that caused the formation of ascites. Massive bloody ascites devel ops acutely after the rupture of intra-abdominal varices or hepatocell ular carcinoma and requires aggressive interventional management. Base d on a review of published data and on personal experience with patien ts suffering from end-stage liver disease, I propose an algorithm for the evaluation and treatment of patients with cirrhosis and hemoperito neum.