Background: Spontaneous rupture of omental vessels is an infrequent medical condition possibly causing severe intra-abdominal hemorrhage. Omental bleeding results from trauma associated injury and irritation, neoplasia, arterial aneurysm rupture, and anticoagulant treatment. Idiopathic omental bleeding rarely causes acute abdominal bleeding which has been reported to occur in previous studies. Here we reported a case with idiopathic omental hemorrhage due to vascular malformation. A systematic review of literature is provided. Case presentation: A 58-year-old Han Chinese man arrived at the emergency department with left upper quadrant abdominal pain for 1 day. He had no significant previous medical history. There was no history of fever, vomiting, nausea, or anorexia. He was a non-smoker and did not consume alcohol. On physical examination, blood pressure was 118/72 mmHg, for a temperature of 37.7 °C; heart and respiratory rates of 130 per/min and 20 per/min were obtained, respectively. Abdomen assessment showed only mild tenderness in the left upper quadrant. Complete 3 3 blood count (CBC) showed white cell and platelet counts of 16.69 × 10 /L and 196 × 10 /L, respectively. The haemoglobin value was 13.5 g/L at admission. Abdominal Computer Tomography (CT) was performed that showed peritoneal fluid appeared around the liver. Fresh blood was confirmed in the abdominocentesis. A hemoperitoneum was confirmed by abdominal enhanced CT, which presented a structural disorder in the left upper abdomen. The subject immediately underwent exploratory laparotomy. A massive hemoperitoneum originating from omental vessels was observed. The omental were partially removed. There was no evidence of malignancy or aneurysm upon palpation. Pathological assessment of the extracted tissue pointed to vascular malformation. The patient subsequently had an uneventful recovery; hospital discharge occurred at 7 days post-operation. Previous reports assessing idiopathic omental bleeding were systematically reviewed, summarizing published cases. A total of 12 hits were found in PubMed for idiopathic omental bleeding. Conclusion: Idiopathic omental bleeding is a rare condition that requires emergency treatment. Treatment strategies include surgical intervention and transcatheter arterial embolization (TAE). The surgical option is suitable in subjects with persistent hypotension and those with unconfirmed diagnosis. Keywords: Omental bleeding, Diagnosis, Computerd tomography, Surgery, Transcatheter arterial embolization Background . Idiopathic omental bleeding rarely causes acute ab- Spontaneous rupture of omental vessels is an infrequent dominal bleeding which has been reported to occur in medical condition which causes serious intra-abdominal previous studies. Here, we reported a case with idiopathic bleeding. Omental bleeding can result from trauma omental hemorrhage due to vascular malformation. In associated injury and irritation, neoplasia , arterial addition, previous reports were systematically reviewed. aneurysm rupture , and treatment with anticoagulants Case presentation A 58-year-old Han Chinese man arrived at the emer- * Correspondence: firstname.lastname@example.org Department of Hepatobiliary Surgery, Dongyang People’s Hospital, No. 60, gency department with left upper quadrant abdominal West Wuning Road, Dongyang, Jinhua, Zhejiang, China pain for 1 day. He had no significant previous medical Department of General Surgery, Dongyang People’s Hospital, No. 60, West history. There was no history of fever, vomiting, nausea, Wuning Road, Dongyang 322100, Zhejiang Province, China Full list of author information is available at the end of the article or anorexia. He was a non-smoker and did not consume © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Lyu et al. BMC Surgery (2018) 18:33 Page 2 of 4 alcohol. On physical examination, blood pressure was 118/72 mmHg, for a temperature of 37.7 °C; heart and re- spiratory rates of 130 per/min and 20 per/min were ob- tained, respectively. Abdomen assessment showed only mild tenderness in the left upper quadrant. Complete blood count (CBC) showed white cell and platelet counts 3 3 of 16.69 × 10 /L and 196 × 10 /L, respectively. The haemo- globin value was 13.5 g/L at admission. Abdominal Computer Tomography (CT) was performed that showed peritoneal fluid. In order to clarify the nature of peritoneal effusion,abdominocentesis was performed. Fresh blood was confirmed in the abdominocentesis. We could not identify the source of bleeding through abdominal CT. A hemoper- itoneum was confirmed by abdominal CT with contrast enhancement, which presented a structural disorder in the left upper abdomen (Fig. 1). The subject immedi- Fig. 2 Pathology examination. The pathology reveals the the ately underwent exploratory laparotomy. A massive vascular malformations of omental hemoperitoneum originating from omental vessels was observed. The omental were partially removed. There was no evidence of malignancy or aneurysm upon pal- Patient data, including age, diagnostic and treatment pro- pation. Pathological assessment of the extracted tissue cedures, were extracted. pointed to vascular malformation(Fig. 2). Our patholo- A total of 12 articles were found in PubMed for idio- gist found that it is venous malformation with the dam- pathic omental bleeding, including ours [4–15]. Relevant age of the venous wall continuity accompanied with the findings are summarized in Table 1. The patients included overflow of large number of red blood cells. The patient 11 males and 1 female, aged between 20 and 70 years. The subsequently had an uneventful recovery; hospital dis- diagnostic procedures included CT and laparotomy. The charge occurred at 7 days post-operation. patients underwent emergency surgery (n =8) or trans- Previous reports assessing idiopathic omental bleeding catheter arterial embolization(TAE) (n =4). were systematically reviewed, summarizing published cases. A total of 12 hits were found in PubMed for idio- Discussion and conclusions pathic omental bleeding. Idiopathic omental bleeding, although sparse in this part of the world, is considered one of the causes of spontan- eous hemoperitoneum. Spontaneous omental bleeding is Review of the literature a serious condition, with a mortality rate exceeding The PubMed (2000–2017) database was queried for case 30% . Several causes of spontaneous omental bleeding reports of idiopathic omental bleeding. The abstracts of all have been reported, including neoplasia, arterial aneurysm, articles published in the English language were screened. vasculitis, and anticoagulant therapy. A patient adminis- tered sildenafil citrate succumbed to the rupture of an omental varix . However, there are few reports of idio- pathic omental bleeding. The ages of patients with idio- pathic omental bleeding range between the 20s and the 80s; it has a male predominance. Acute intraabdominal hemorrhage, abdominal pain and distension, tachycardia, and hypotension, constitute typical signs of idiopathic omental bleeding; severe cases present with abdominal compartment syndrome . Some cases series assessing omental bleeding suspected appendicitis or peritonitis preoperatively [10, 18]. The diagnostic assessment of idio- pathic omental bleeding is essentially based on imaging procedures, especially ultrasonography (US) and CT. US facilitated hemoperitoneum detection in the current hemodynamically unstable subject. US is considered as an Fig. 1 Abdominal CT scan. The CT-scan receals structural disorder of effective method. However, in our hospital, US needs to the left upper abdominal and hemoperitoneum be done by a professional ultrasound-doctor. However, CT Lyu et al. BMC Surgery (2018) 18:33 Page 3 of 4 Table 1 Reports of idiopathic omental hemorrhag First of author Year Coutry F/M Age Chief complaint Post medical history Diagnostic Treatment procedure Kroot EJ  2003 Netherlands M 70y Abdominal pain NA CT Surgery Finely DS  2005 USA M 41y Abdominal pain Alcoholic cirrhosis Hemoglobin Ligate the omental varix Difficulty seeing (took a unkonwn drop dose of sidenafi) Ohno T  2005 Japan M 27y Intermittent abdominal Surgery for CT Partial omentalectomy pain cryptorchidism Jadav M  2004 USA M 60y Acute abdominal pain Hypertension laparotomy Surgery Nausea,voimiting and diarrha Nagaba Y  2005 Japan M 64y Acute abdominal pain Autosomal-dominant CT TAE hemorrhagic shock polycystic kidney disease Tsuchiya R  2009 Japan M 58y abdominal pain NA CT TAE Matsumoto T  2010 Japan M 25y Abdominal pain NA CT TAE Henry D  2012 USA F 24y malaise, myalgias, and NA laparotomy Surgery fatigue Takahashi M  2012 Japan M 27y abdominal pain. NA CT TAE temporary loss of consciousness Cheng VE  2014 Australia M 68y acutely hypotensive Inferior STEMI CT Partial omentectomy with severe left sided ticagrelor and abdominal pain aspirin Aumann V  2016 Germany M 20 NA Hemophilia A NA Surgery Kimura J  2016 Japan M 29 Abdominal pain NA CT Partial omentectomy NA not avaliable, CT computer tomography, TAE transcatheter arterial embolization (especially enhanced CT) is the most effective imaging tool scheme is proposed for the treatment of idiopathic omental since signals corresponding to hemoperitoneum, active ar- bleeding in this study. terial extravasation, and mesenteric fluid might help radiol- In summary, idiopathic omental bleeding is an infre- ogists determine the origin of hemorrhage and guide quent condition requiring emergency treatment; typical treatment . Abdominocentesis can be a useful diagnos- manifestations include acute intraperitoneal hemorrhage. tic tool in distinguishing the characteristic of peritoneal US and CT scan are useful for its diagnosis. Treatment fluid. However, abdominocentesis is an invasive pro- strategies include surgical intervention and TAE. In sub- cedure which can be lead to intestinal perforation jects with persistent hypotension or cases with uncon- and abdominal wall abscess. When the patient’scon- firmed diagnosis, surgery might be suitable. dition is unstable, it may be appropriate to have a Abbreviations laparotomy or a laparoscopy. CT: Computed Tomography; TAE: Transcatheter arterial embolization; Regardless of the underlying etiology of idiopathic US: Ultrasound omental bleeding, aggressive treatment is preferable. Acknowledgements Idiopathic omental is routinely treated by surgical proce- The authors thanks Kang-Fei San who povided the medical images on behalf dures, including ligation or omentectomy. In most cases of the Derpartment of Radiology,Department of General Surgery, Dongyang reported, however, an emergency surgery was performed. people’s Hospital. The surgical option is suitable in subjects with persistent Authors’ contributions hypotension and those with unconfirmed diagnosis. Surgery Author contributions: YXL and TL searched the literature. YXL conceived of the is often carried out because few cases are correctly diag- study, participated in its design and drafted the manuscript, and final revision of the manuscript. YXC participated in the collection of the clinical data and nosed pre-treatment. However, TAE for idiopathic omental design of the study All authors read and approved the final manuscript. bleeding has been reported previously [8, 9, 11, 12]. TAE is a safeand minimallyinvasiveprocedure,withthe advan- Ethics approval and consent to participate tages of simultaneous diagnosis and treatment. Therefore, Not applicable. TAE might represent the best therapeutic option for idio- Consent for publication pathic omental bleeding. It should be carried out with cau- Written informed consent was obtained from the patient for publication of tion in patients with proximal embolization due to risk of this Case report and any accompanying images. A copy of the written rebleeding via the collateral circulation. A therapeutic consent form is available for review by the Editor of this journal. Lyu et al. BMC Surgery (2018) 18:33 Page 4 of 4 Competing interests The authors declare that they have no competing interests. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details Department of Hepatobiliary Surgery, Dongyang People’s Hospital, No. 60, West Wuning Road, Dongyang, Jinhua, Zhejiang, China. Dongyang People’s Hospital, No. 60, West Wuning Road, Dongyang, Jinhua, Zhejiang, China. Department of General Surgery, Dongyang People’s Hospital, No. 60, West Wuning Road, Dongyang 322100, Zhejiang Province, China. Received: 6 September 2017 Accepted: 22 May 2018 References 1. Dixon AY, Reed JS, Dow N, Lee SH. Primary omental leiomyosarcoma masquerading as hemorrhagic ascites. Hum Pathol. 1984;15(3):233–7. 2. Borioni R, Garofalo M, Innocenti P, Fittipaldi D, Tempesta P, Colagrande L, Seddio F, Pace A. Hemoperitoneum due to spontaneous rupture of an aneurysm of the left gastroepiploic artery. J Cardiovasc Surg. 1999;40(1):63–4. 3. Adelman MI, Gishen P, Dubbins P, Mibashan RS. Localised intramesenteric haemorrhage–a recognisable syndrome in haemophilia? Br Med J. 1979; 2(6191):642–3. 4. Cheng VE, Oppermen A, Natarajan D, Haikerwal D, Pereira J. 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Published: May 30, 2018