Objectives: To review existing data on the pathophysiology and clinical presentation of hemoperitoneum in patients with ascites and to familiarize practicing clinicians who take care of such patients with the therapeutic options currently available for management of this complication.
Methods: Relevant English-language articles published between January 1988 and November 1996 were identified through MEDLINE search, using the key words "hemoperitoneum" and "ascites." Articles cited in the bibliographies of these articles were searched manually. Published papers that contained data on hemoperitoneum in general and on hemoperitoneum developing in patients with ascites were reviewed.
Results: In patients with ascites, hemoperitoneum can develop spontaneously or can follow abdominal trauma and diagnostic or therapeutic procedures. Spontaneous bleeding into ascites usually develops insidiously and may 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 surgical treatment. Acute hemoperitoneum develops in 5-15% of patients with hepatocellular carcinoma requiring transcatheter arterial embolization. Metastatic liver tumors cause bloody ascites infrequently; however, this is a common complication of ovarian carcinoma.
Conclusions: Hemoperitoneum is a severe complication in patients with ascites. When it develops spontaneously, it is usually related to the same disease process that caused the formation of ascites. Massive bloody ascites develops acutely after the rupture of intra-abdominal varices or hepatocellular carcinoma and requires aggressive interventional management. Based on a review of published data and on personal experience with patients suffering from end-stage liver disease, I propose an algorithm for the evaluation and treatment of patients with cirrhosis and hemoperitoneum.