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DOI: 10.1148/rg.271065042
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Blood in the Belly: CT Findings of Hemoperitoneum1

Meghan Lubner, MD, Christine Menias, MD, Creed Rucker, MD, Sanjeev Bhalla, MD, Christine M. Peterson, MD, Lisa Wang, MD and Brett Gratz, MD

1 From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Box 8131, St Louis, MO 63110. Recipient of a Certificate of Merit award for an education exhibit at the 2003 RSNA Annual Meeting. Received March 27, 2006; revision requested May 3 and received June 2; accepted June 13. All authors have no financial relationships to disclose.

Figure 1
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  		Figure 1a.  Typical flow pattern of hemorrhage from a liver laceration. (a) Contrast material–enhanced CT image shows high-attenuation fluid (arrows) in perihepatic and perisplenic regions, the hepatorenal fossa, and the lesser sac. (b) Contrast-enhanced CT image at a lower level than a shows blood tracking laterally along the paracolic gutters (arrows).

 

Figure 1
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  		Figure 1b.  Typical flow pattern of hemorrhage from a liver laceration. (a) Contrast material–enhanced CT image shows high-attenuation fluid (arrows) in perihepatic and perisplenic regions, the hepatorenal fossa, and the lesser sac. (b) Contrast-enhanced CT image at a lower level than a shows blood tracking laterally along the paracolic gutters (arrows).

 

Figure 2
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  		Figure 2a.  Free intraperitoneal fluid after trauma. (a) Contrast-enhanced CT image shows a large volume of high-attenuation free intraperitoneal fluid. A subsequent CT cystogram revealed that most of the fluid was urine leaking from an injured bladder. (b) Contrast-enhanced CT image shows leakage of urine from a bladder rupture at the 1-o’clock position (arrow).

 

Figure 2
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  		Figure 2b.  Free intraperitoneal fluid after trauma. (a) Contrast-enhanced CT image shows a large volume of high-attenuation free intraperitoneal fluid. A subsequent CT cystogram revealed that most of the fluid was urine leaking from an injured bladder. (b) Contrast-enhanced CT image shows leakage of urine from a bladder rupture at the 1-o’clock position (arrow).

 

Figure 3
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  		Figure 3a.  Low-attenuation hemoperitoneum in a hemophiliac patient with a splenic rupture. (a, b) Contrast-enhanced CT images (b at a lower level than a) show much lower attenuation in the intraperitoneal hemorrhage than in the adjacent muscle. The patient’s hematocrit level was 0.24 at the time of CT.

 

Figure 3
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  		Figure 3b.  Low-attenuation hemoperitoneum in a hemophiliac patient with a splenic rupture. (a, b) Contrast-enhanced CT images (b at a lower level than a) show much lower attenuation in the intraperitoneal hemorrhage than in the adjacent muscle. The patient’s hematocrit level was 0.24 at the time of CT.

 

Figure 4
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  		Figure 4a.  Sentinel clot sign. (a) Contrast-enhanced CT image shows a sentinel clot secondary to laceration along the fissure for the ligamentum teres (arrow), in the perihepatic space and lesser sac. (b) Contrast-enhanced CT image obtained in a patient who was undergoing anticoagulation therapy for a protein C deficiency shows a sentinel clot (arrow) surrounding the spleen.

 

Figure 4
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  		Figure 4b.  Sentinel clot sign. (a) Contrast-enhanced CT image shows a sentinel clot secondary to laceration along the fissure for the ligamentum teres (arrow), in the perihepatic space and lesser sac. (b) Contrast-enhanced CT image obtained in a patient who was undergoing anticoagulation therapy for a protein C deficiency shows a sentinel clot (arrow) surrounding the spleen.

 

Figure 5
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  		Figure 5a.  Bleeding hepatoma. (a) Unenhanced CT image shows perihepatic and perisplenic fluid, with an area of slightly higher attenuation (arrow) indicative of a clot along the left hepatic lobe. (b) Contrast-enhanced CT image shows the origin of the clot, a ruptured mass (arrow) that subsequently was proved to be a hepatocellular carcinoma, as well as active extravasation (arrowhead).

 

Figure 5
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  		Figure 5b.  Bleeding hepatoma. (a) Unenhanced CT image shows perihepatic and perisplenic fluid, with an area of slightly higher attenuation (arrow) indicative of a clot along the left hepatic lobe. (b) Contrast-enhanced CT image shows the origin of the clot, a ruptured mass (arrow) that subsequently was proved to be a hepatocellular carcinoma, as well as active extravasation (arrowhead).

 

Figure 6
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  		Figure 6.  Hematocrit effect. Contrast-enhanced CT image shows an obvious layer of high attenuation produced by sedimented blood cells (arrow) in a pelvic hemoperitoneum.

 

Figure 7
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  		Figure 7a.  Active arterial extravasation. Note the sentinel clot sign produced by serpiginous areas of high attenuation surrounded by lower-attenuation areas of hematoma. (a) Contrast-enhanced CT image shows active bleeding from a branch of the internal iliac artery (arrow) in a patient with pelvic fractures. (b) Contrast-enhanced CT image shows active bleeding from a splenic rupture due to blunt trauma.

 

Figure 7
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  		Figure 7b.  Active arterial extravasation. Note the sentinel clot sign produced by serpiginous areas of high attenuation surrounded by lower-attenuation areas of hematoma. (a) Contrast-enhanced CT image shows active bleeding from a branch of the internal iliac artery (arrow) in a patient with pelvic fractures. (b) Contrast-enhanced CT image shows active bleeding from a splenic rupture due to blunt trauma.

 

Figure 8
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  		Figure 8.  Mesenteric tear. Contrast-enhanced CT image depicts high-attenuation triangular fluid collections (arrows) within the mesentery of the distal small bowel in a patient with a surgically proved ileal mesenteric tear.

 

Figure 9
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  		Figure 9a.  Spectrum of hepatic and splenic injuries due to trauma. (a) Contrast-enhanced CT image shows a large subcapsular hepatic hematoma with laceration and periportal edema and with a typical indentation in the fibrous capsule of the liver. (b) Contrast-enhanced CT image shows multiple irregular low-attenuation contusions in both hepatic lobes (arrows). (c) Contrast-enhanced CT image depicts a single hepatic laceration that extends alongside the fissure of the ligamentum teres (arrow). Lacerations commonly occur along the natural planes of hepatic vessels and fissures. (d) Contrast-enhanced CT image shows a single jagged laceration in the posterior tip of the spleen (arrow).

 

Figure 9
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  		Figure 9b.  Spectrum of hepatic and splenic injuries due to trauma. (a) Contrast-enhanced CT image shows a large subcapsular hepatic hematoma with laceration and periportal edema and with a typical indentation in the fibrous capsule of the liver. (b) Contrast-enhanced CT image shows multiple irregular low-attenuation contusions in both hepatic lobes (arrows). (c) Contrast-enhanced CT image depicts a single hepatic laceration that extends alongside the fissure of the ligamentum teres (arrow). Lacerations commonly occur along the natural planes of hepatic vessels and fissures. (d) Contrast-enhanced CT image shows a single jagged laceration in the posterior tip of the spleen (arrow).

 

Figure 9
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  		Figure 9c.  Spectrum of hepatic and splenic injuries due to trauma. (a) Contrast-enhanced CT image shows a large subcapsular hepatic hematoma with laceration and periportal edema and with a typical indentation in the fibrous capsule of the liver. (b) Contrast-enhanced CT image shows multiple irregular low-attenuation contusions in both hepatic lobes (arrows). (c) Contrast-enhanced CT image depicts a single hepatic laceration that extends alongside the fissure of the ligamentum teres (arrow). Lacerations commonly occur along the natural planes of hepatic vessels and fissures. (d) Contrast-enhanced CT image shows a single jagged laceration in the posterior tip of the spleen (arrow).

 

Figure 9
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  		Figure 9d.  Spectrum of hepatic and splenic injuries due to trauma. (a) Contrast-enhanced CT image shows a large subcapsular hepatic hematoma with laceration and periportal edema and with a typical indentation in the fibrous capsule of the liver. (b) Contrast-enhanced CT image shows multiple irregular low-attenuation contusions in both hepatic lobes (arrows). (c) Contrast-enhanced CT image depicts a single hepatic laceration that extends alongside the fissure of the ligamentum teres (arrow). Lacerations commonly occur along the natural planes of hepatic vessels and fissures. (d) Contrast-enhanced CT image shows a single jagged laceration in the posterior tip of the spleen (arrow).

 

Figure 10
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  		Figure 10a.  Contrast-enhanced CT images at progressively lower levels show a liver laceration extending to the level of the inferior vena cava, with evidence of active extravasation and hemoperitoneum, in a patient after a motor vehicle collision. At surgery, the liver was found to be totally avulsed from the inferior vena cava, leaving the latter open at the level of the diaphragm.

 

Figure 10
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  		Figure 10b.  Contrast-enhanced CT images at progressively lower levels show a liver laceration extending to the level of the inferior vena cava, with evidence of active extravasation and hemoperitoneum, in a patient after a motor vehicle collision. At surgery, the liver was found to be totally avulsed from the inferior vena cava, leaving the latter open at the level of the diaphragm.

 

Figure 10
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  		Figure 10c.  Contrast-enhanced CT images at progressively lower levels show a liver laceration extending to the level of the inferior vena cava, with evidence of active extravasation and hemoperitoneum, in a patient after a motor vehicle collision. At surgery, the liver was found to be totally avulsed from the inferior vena cava, leaving the latter open at the level of the diaphragm.

 

Figure 11
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  		Figure 11a.  Liver laceration with pseudoaneurysm formation. (a) Contrast-enhanced CT image shows a large liver laceration with internal pooling of high-attenuation material (arrow), a finding suggestive of an aneurysm or pseudo-aneurysm. (b) Angiogram shows a pseudoaneurysm (arrow).

 

Figure 11
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  		Figure 11b.  Liver laceration with pseudoaneurysm formation. (a) Contrast-enhanced CT image shows a large liver laceration with internal pooling of high-attenuation material (arrow), a finding suggestive of an aneurysm or pseudo-aneurysm. (b) Angiogram shows a pseudoaneurysm (arrow).

 

Figure 12
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  		Figure 12.  Mesenteric tear. Contrast-enhanced CT image shows active extravasation from jejunal mesenteric vessels with associated jejunal injury and mesenteric hemorrhage indicated by a triangular region of hemoperitoneum (arrow).

 

Figure 13
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  		Figure 13.  Hematoma after a pancreatoduodenectomy (Whipple operation). Contrast-enhanced CT image shows a large abdominal hematoma that involves the left perihepatic and perisplenic space, with evidence of active extravasation (arrow).

 

Figure 14
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  		Figure 14.  Hematoma after interventional procedures. Contrast-enhanced CT image shows a hematoma within the lesser sac after a laparoscopic Nissen fundoplication.

 

Figure 15
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  		Figure 15.  Hematoma after interventional procedures. Contrast-enhanced CT image in another patient depicts a large perigastric hematoma (arrow) after a percutaneous gastrostomy tube placement.

 

Figure 16
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  		Figure 16a.  Splenic rupture. (a) Contrast-enhanced CT image shows a splenic rupture and pooling of contrast material in a patient with splenomegaly due to polycythemia vera. (b) Angiogram reveals multiple splenic pseudoaneurysms that were subsequently treated with embolization.

 

Figure 16
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  		Figure 16b.  Splenic rupture. (a) Contrast-enhanced CT image shows a splenic rupture and pooling of contrast material in a patient with splenomegaly due to polycythemia vera. (b) Angiogram reveals multiple splenic pseudoaneurysms that were subsequently treated with embolization.

 

Figure 17
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  		Figure 17a.  Ruptured hepatic angiosarcoma. (a, b) Contrast-enhanced CT images (a at a higher level than b) show a heterogeneous low-attenuation lesion in the left hepatic lobe, with evidence of increased vascularity, active extravasation, and hemoperitoneum. At pathologic analysis, the lesion was found to be a hepatic angiosarcoma. The high-attenuation material adjacent to the lesion represents perihepatic blood secondary to a capsular rupture.

 

Figure 17
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  		Figure 17b.  Ruptured hepatic angiosarcoma. (a, b) Contrast-enhanced CT images (a at a higher level than b) show a heterogeneous low-attenuation lesion in the left hepatic lobe, with evidence of increased vascularity, active extravasation, and hemoperitoneum. At pathologic analysis, the lesion was found to be a hepatic angiosarcoma. The high-attenuation material adjacent to the lesion represents perihepatic blood secondary to a capsular rupture.

 

Figure 18
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  		Figure 18.  Hemorrhagic metastases. Contrast-enhanced CT image shows marked hemoperitoneum with active extravasation in a patient with metastatic peritoneal melanoma. Note the sentinel clot that surrounds the tumor implant, and the subcutaneous melanotic nodule (arrowhead) in the left posterior region.

 

Figure 19
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  		Figure 19.  Hemorrhagic metastases. Contrast-enhanced CT image depicts multiple hemorrhagic hepatic lesions with central high attenuation in a patient with known metastatic testicular choriocarcinoma. Hemoperitoneum (arrow) is seen adjacent to the largest lesion.

 

Figure 20
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  		Figure 20a.  Ruptured hepatocellular adenoma. (a) Contrast-enhanced CT image shows a large heterogeneous low-attenuation mass (arrow) in the right hepatic lobe, and a loss of liver capsule integrity anterolaterally. (b) Coronal volume-rendered CT image shows the peripherally enhancing mass, ruptured liver capsule, and perihepatic hemorrhage (arrow).

 

Figure 20
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  		Figure 20b.  Ruptured hepatocellular adenoma. (a) Contrast-enhanced CT image shows a large heterogeneous low-attenuation mass (arrow) in the right hepatic lobe, and a loss of liver capsule integrity anterolaterally. (b) Coronal volume-rendered CT image shows the peripherally enhancing mass, ruptured liver capsule, and perihepatic hemorrhage (arrow).

 

Figure 21
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  		Figure 21.  Splenic rupture. Unenhanced CT image shows an enlarged spleen with a perisplenic sentinel clot in a patient with lymphoma and thrombocytopenia who was evaluated for flank pain.

 

Figure 22
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  		Figure 22.  Splenic rupture. Contrast-enhanced CT image shows a hemoperitoneum that surrounds an enlarged ruptured spleen in a patient with malaria. (Fig 22 courtesy of Howard J. Harvin, MD, Scottsdale, Ariz.)

 

Figure 23
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  		Figure 23a.  Ruptured hemorrhagic ovarian cyst. (a) Contrast-enhanced CT image shows an adnexal cyst with an internal hematocrit level (arrow), surrounded by a pelvic hemorrhage. A curvilinear focus of extravasation (arrowhead) visible posterior to the cyst was found at surgery to represent active bleeding from an internal iliac artery branch. (b) Contrast-enhanced CT image from a different patient shows an ovarian cyst (arrow) and surrounding hemorrhage with a hematocrit effect.

 

Figure 23
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  		Figure 23b.  Ruptured hemorrhagic ovarian cyst. (a) Contrast-enhanced CT image shows an adnexal cyst with an internal hematocrit level (arrow), surrounded by a pelvic hemorrhage. A curvilinear focus of extravasation (arrowhead) visible posterior to the cyst was found at surgery to represent active bleeding from an internal iliac artery branch. (b) Contrast-enhanced CT image from a different patient shows an ovarian cyst (arrow) and surrounding hemorrhage with a hematocrit effect.

 

Figure 24
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  		Figure 24.  Adnexal rupture due to an ectopic pregnancy. CT image shows a hemorrhagic right adnexal mass that corresponds to an ectopic gestational sac with associated active extravasation (arrow) and blood in the cul-de-sac (arrowhead). Ectopic pregnancy and rupture were proved at surgery. (Courtesy of Alvaro Huete, MD, Santiago, Chile.)

 

Figure 25
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  		Figure 25.  HELLP syndrome. Coronal CT image demonstrates a subcapsular hematoma (arrow) in a recent postpartum patient with a history of HELLP syndrome. Note the hypervascularity of the postpartum uterus.

 

Figure 26
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  		Figure 26.  Hemorrhagic pancreatitis. Contrast-enhanced CT image shows a hematoma in the gastrocolic ligament, with a focus of active extravasation (arrow). At angiography, the bleeding vessel was found to be a pancreatic branch of the splenic artery. Subsequent embolization was successful.

 




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