UT Southwestern Medical Center Dallas, TX, United States
Elizabeth Harris, MD UT Southwestern Medical Center, Dallas, TX
Introduction: The differential diagnosis for acute abdominal pain in a young, healthy individual is extensive, but availability bias can often lead to misdiagnosis. This case of acute onset abdominal pain due to idiopathic spontaneous intraperitoneal hemorrhage highlights the importance of keeping a broad differential when approaching this common complaint in gastrointestinal medicine.
Case Description/Methods: A healthy 25-year-old hemodynamically stable male presented to the Emergency Department with a one-day history of severe abdominal pain followed by an episode of syncope. He denied abdominal trauma, fever, nausea, vomiting, diarrhea, or constipation. His abdominal exam was significant for distension and tenderness to palpation of the left upper quadrant. His hemoglobin was initially 13.2, though later in admission dropped to 10.7. CT abdomen/pelvis showed a large left upper quadrant mass-like lesion measuring 13.9 cm and a moderate amount of intermediate and hyperattenuating fluid in the abdomen and pelvis concerning for blood products. Subsequent MRI showed the mass to be most consistent with a hematoma. The GI service was consulted due to concern for hemorrhagic gastrointestinal stromal tumor (GIST) and performed EGD/EUS with fine needle aspiration that showed no malignant cells but demonstrated coagulated blood consistent with the diagnosis of a hematoma. The specific location of the hematoma in the lesser sac suggested a bleed from the left epiploic artery or short gastric artery. As his hemoglobin remained stable and CT angiography of his mesenteric vessels showed no evidence of ongoing bleeding, he was discharged without intervention and followed up in clinic, with eventual resolution of hematoma and abdominal pain.
Discussion: Idiopathic spontaneous intraperitoneal hemorrhage (ISIH), also termed “abdominal apoplexy,” is a rare but potentially fatal diagnosis. Since GIST can also develop in the mesentery, cause bleeding, and have a similar appearance as hematoma on imaging, it is important to rule out this malignancy even when ISIH is suspected. Only slightly over one hundred case reports of ISIH exist in the literature, with most cases occurring in individuals with chronic hypertension or vascular malformations. This case of ISIH in a healthy male with no predisposing conditions highlights an exceedingly rare diagnostic clinical entity, but one that is important to consider especially if acute onset abdominal pain is accompanied by syncope and new onset anemia.
Figure: Top: CT abdomen/pelvis with IV contrast, large left upper quadrant mesenteric mass-like lesion measuring up to 13.9 cm Bottom: MR abdomen/pelvis with IV contrast, large 8.6 x 8.0 x 13.1 cm lesion in the lesser sac, features most consistent with hematoma
Disclosures: Elizabeth Harris indicated no relevant financial relationships.
Elizabeth Harris, MD. P0658 - An Unusual Case of Idiopathic Spontaneous Intraperitoneal Hemorrhage in a Healthy 25-year-old Male, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.