Letter to the Editor
An uncommon cause of spontaneous hemoperitoneum in a peritoneal dialysis patient
Una causa infrecuente de hemoperitoneo espontáneo en un paciente en diálisis peritoneal
Carlos Hidalgo-Ordoñez, Emilio Sánchez-Alvarez
, Carmen Rodríguez-Suárez
Corresponding author
Unidad de Gestión Clínica de Nefrología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
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She began haemodialysis in May 2004. In November 2004, she received a cadaveric renal transplant; due to recurrence of underlying disease there was a progressive deterioration in renal function. In October 2010 she re-started a dialysis programme in the form of automated peritoneal dialysis (APD).</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient presented to the emergency department after few hours of sudden-onset epigastric pain, radiating to the back, and with associated nausea. A peritoneal exchange was performed, in which significant haemoperitoneum was observed. It was therefore decided perform further test to investigate the cause of haemoperitoneum.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Blood tests showed a Hb of 9.4<span class="elsevierStyleHsp" style=""></span>g/dL, leukocytes of 11<span class="elsevierStyleHsp" style=""></span>400/μl, normal platelet count, urea of 133<span class="elsevierStyleHsp" style=""></span>mg/dL, creatinine of 9.95<span class="elsevierStyleHsp" style=""></span>mg/dL, and sodium and potassium within normal range. There were no coagulation abnormalities. In the peritoneal fluid analysis, the red cell count was 135<span class="elsevierStyleHsp" style=""></span>000/mm<span class="elsevierStyleSup">3</span> and leukocytes were 369/mm<span class="elsevierStyleSup">3</span> (79.9% PMNs).</p><p id="par0020" class="elsevierStylePara elsevierViewall">Following review of all the findings, it was decided to perform axial computed tomography (CT) with contrast. This revealed the presence of a hyperdense nodule in the posterior region of the gastric fundus compatible with pseudoaneurysm of the left gastric artery, with an underlying haematoma (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Percutaneous transcatheter embolization of the pseudoaneurysm was performed with the use of coils, with satisfactory control of bleeding as per angiography (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The patient was subsequently admitted for haemodynamic monitoring; patient had an inguinal haematoma as a complication of the procedure and,required the transfusion of 2 units packed red cells.</p><p id="par0030" class="elsevierStylePara elsevierViewall">She was kept on peritoneal rest, with frequent peritoneal lavage until peritoneal fluid became clear. During this time, haemodialysis was performed via a temporary jugular venous catheter.</p><p id="par0035" class="elsevierStylePara elsevierViewall">She had a low-grade fever related to the haematoma, with negative blood cultures. After one week the patient re-started peritoneal exchanges with no signs of bleeding in the peritoneal fluid. She has had no further complications since this episode.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Haemoperitoneum is an uncommon complication of peritoneal dialysis, and can vary from minimal bleeding to frank haemorrhage causing shock.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–3</span></a> The most common cause of bleeding is related to menstruation or ovulation. Less common causes include sclerosing peritonitis, pseudoaneurysm of the splenic artery, polycystic kidneys, laceration of an abdominal organ, acute pancreatitis, and coagulation abnormalities.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Our patient presented to the emergency department with epigastric pain of sudden onset. The bloody peritoneal fluid gave us a clue as to the cause of the pain, which led to a CT. With percutaneous embolization, the bleeding was stopped.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Peritoneal dialysis is an established renal replacement therapy technique, but among its advantages is the rarely-mentioned possibility of early detection of abdominal bleeding, revealing blood loss that would otherwise go unnoticed.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> In other cases, previously reported, immediate angiography and percutaneous transcatheter embolization helped to control bleeding and avoid laparotomy.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> In our case, due to the peritoneal dialysis technique, we were able to suspect the cause of epigastric pain and treat it appropriately.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Hidalgo-Ordoñez C, Sánchez-Alvarez E, Rodríguez-Suárez C. Una causa infrecuente de hemoperitoneo espontáneo en un paciente en diálisis peritoneal. Nefrologia. 2016;36:80–81.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1627 "Ancho" => 1495 "Tamanyo" => 362110 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CT imaging of a hyperdense nodule in the posterior region of the gastric fundus, compatible with pseudoaneurysm of the left gastric artery, with an underlying haematoma.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1156 "Ancho" => 1667 "Tamanyo" => 208108 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Angiography after percutaneous transcatheter embolization of the pseudoaneurysm.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Percutaneous embolization of splenic artery pseudoaneurysm as a treatment of hemoperitoneum in a CAPD patient" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. 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Fernández" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/ndt/gfi298" "Revista" => array:6 [ "tituloSerie" => "Nephrol Dial Transplant" "fecha" => "2006" "volumen" => "21" "paginaInicial" => "789" "paginaFinal" => "791" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16368703" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hemoperitoneum due to carcinomatosis in the liver of a CAPD patient" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Fine" 1 => "C. Novak" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Perit Dial Int" "fecha" => "1996" "volumen" => "16" "paginaInicial" => "181" "paginaFinal" => "183" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9147556" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0735109710019583" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hemoperitoneum in CAPD patients with hepatic tumors" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.J. Peng" 1 => "C.S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 9 | 13 |
| 2024 October | 44 | 42 | 86 |
| 2024 September | 54 | 30 | 84 |
| 2024 August | 67 | 57 | 124 |
| 2024 July | 52 | 35 | 87 |
| 2024 June | 72 | 41 | 113 |
| 2024 May | 75 | 52 | 127 |
| 2024 April | 57 | 26 | 83 |
| 2024 March | 59 | 25 | 84 |
| 2024 February | 60 | 35 | 95 |
| 2024 January | 42 | 29 | 71 |
| 2023 December | 70 | 33 | 103 |
| 2023 November | 59 | 32 | 91 |
| 2023 October | 63 | 42 | 105 |
| 2023 September | 49 | 26 | 75 |
| 2023 August | 46 | 34 | 80 |
| 2023 July | 52 | 25 | 77 |
| 2023 June | 64 | 23 | 87 |
| 2023 May | 61 | 32 | 93 |
| 2023 April | 39 | 16 | 55 |
| 2023 March | 68 | 31 | 99 |
| 2023 February | 47 | 19 | 66 |
| 2023 January | 70 | 23 | 93 |
| 2022 December | 75 | 42 | 117 |
| 2022 November | 66 | 32 | 98 |
| 2022 October | 76 | 58 | 134 |
| 2022 September | 58 | 32 | 90 |
| 2022 August | 70 | 56 | 126 |
| 2022 July | 40 | 38 | 78 |
| 2022 June | 69 | 38 | 107 |
| 2022 May | 70 | 37 | 107 |
| 2022 April | 71 | 51 | 122 |
| 2022 March | 68 | 42 | 110 |
| 2022 February | 60 | 47 | 107 |
| 2022 January | 71 | 32 | 103 |
| 2021 December | 52 | 43 | 95 |
| 2021 November | 61 | 39 | 100 |
| 2021 October | 99 | 42 | 141 |
| 2021 September | 62 | 28 | 90 |
| 2021 August | 67 | 36 | 103 |
| 2021 July | 103 | 36 | 139 |
| 2021 June | 63 | 24 | 87 |
| 2021 May | 89 | 42 | 131 |
| 2021 April | 180 | 46 | 226 |
| 2021 March | 106 | 34 | 140 |
| 2021 February | 120 | 30 | 150 |
| 2021 January | 64 | 22 | 86 |
| 2020 December | 76 | 15 | 91 |
| 2020 November | 80 | 21 | 101 |
| 2020 October | 46 | 19 | 65 |
| 2020 September | 52 | 16 | 68 |
| 2020 August | 61 | 15 | 76 |
| 2020 July | 48 | 17 | 65 |
| 2020 June | 53 | 13 | 66 |
| 2020 May | 49 | 9 | 58 |
| 2020 April | 40 | 20 | 60 |
| 2020 March | 53 | 16 | 69 |
| 2020 February | 61 | 21 | 82 |
| 2020 January | 72 | 16 | 88 |
| 2019 December | 62 | 21 | 83 |
| 2019 November | 63 | 23 | 86 |
| 2019 October | 50 | 19 | 69 |
| 2019 September | 69 | 15 | 84 |
| 2019 August | 47 | 13 | 60 |
| 2019 July | 34 | 25 | 59 |
| 2019 June | 31 | 11 | 42 |
| 2019 May | 36 | 15 | 51 |
| 2019 April | 76 | 23 | 99 |
| 2019 March | 65 | 18 | 83 |
| 2019 February | 29 | 20 | 49 |
| 2019 January | 44 | 18 | 62 |
| 2018 December | 141 | 39 | 180 |
| 2018 November | 152 | 16 | 168 |
| 2018 October | 146 | 12 | 158 |
| 2018 September | 88 | 10 | 98 |
| 2018 August | 55 | 18 | 73 |
| 2018 July | 45 | 11 | 56 |
| 2018 June | 71 | 14 | 85 |
| 2018 May | 67 | 13 | 80 |
| 2018 April | 86 | 11 | 97 |
| 2018 March | 78 | 12 | 90 |
| 2018 February | 88 | 8 | 96 |
| 2018 January | 58 | 6 | 64 |
| 2017 December | 91 | 7 | 98 |
| 2017 November | 51 | 11 | 62 |
| 2017 October | 34 | 9 | 43 |
| 2017 September | 40 | 6 | 46 |
| 2017 August | 29 | 5 | 34 |
| 2017 July | 33 | 10 | 43 |
| 2017 June | 46 | 12 | 58 |
| 2017 May | 41 | 10 | 51 |
| 2017 April | 41 | 16 | 57 |
| 2017 March | 26 | 5 | 31 |
| 2017 February | 34 | 12 | 46 |
| 2017 January | 19 | 11 | 30 |
| 2016 December | 41 | 11 | 52 |
| 2016 November | 67 | 21 | 88 |
| 2016 October | 63 | 10 | 73 |
| 2016 September | 104 | 5 | 109 |
| 2016 August | 82 | 0 | 82 |
| 2016 July | 138 | 3 | 141 |
| 2016 June | 95 | 0 | 95 |
| 2016 May | 128 | 0 | 128 |
| 2016 April | 79 | 0 | 79 |
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