Intramural gastric hematoma with hemoperitoneum

Case contributed by Dr Haiying Chen

Presentation

Abdominal pain and hypotension; recent rectal bleeding on background of alcoholic cirrhosis and prior pancreatitis

Patient Data

Age: 30 years
Gender: Male

The non-contrast study demonstrates a heterogeneously hyperdense collection of the greater curvature of the stomach in keeping with hematoma. A large volume of intraperitoneal fluid is present, the majority of which is low density (25 HU), although smaller pockets (right sub-hepatic) are hyperdense in keeping with hemoperitoneum.

The arterial phase shows contrast extravasation in the left lateral and inferomedial margins of the collection consistent with active bleeding. The inferomedial bleed appears to be arising from an unnamed branch of the left hepatic artery. The portal venous phase shows pooling of contrast in the greater curvature wall. Also note medialisation of the enhancing gastric mucosa confirming the intramural location of the bleed. There is no intraluminal bleed. Prominent peri-splenic and mesenteric porto-systemic collaterals without active bleed. 

Note is also made of a nodular liver contour as well as extensive pancreatic pseudocysts in keeping with patient's history of cirrhosis and prior pancreatitis, respectively. 

Case Discussion

Initial emergency gastroscopy confirmed no active intraluminal bleed. However, large extrinsic compression of the greater curvature was noted during the scope. Patient proceeded to emergency laparotomy, which demonstrated large subserosal hematoma of the gastric body degloving the gastric serosa, resulting in large volume hemoperitoneum. Bleeding was controlled by ligating the short gastric artery and removal of the spleen. 

The exact cause of hemorrhage in this patient is not identified. However, the working diagnosis is of short gastric artery rupture from recent retching and vomiting. Variceal bleeding is considered much less likely in this case given the contrast extravasation in arterial phase. 

There have been several case reports of vomiting being the precursor of short gastric artery rupture 1,2. It is thought that vomiting causes gastric twisting and pulling on the gastro-splenic ligament that result in short gastric artery rupture 2

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