Dx: Significant Free Fluid, Likely Blood

The ultrasound shows free fluid. In the absence of trauma or cirrhosis, this is likely blood, and in a young female it is most likely from a gynecologic source. The blood is acute and therefore appears anechoic (black). It can be seen posterior to the uterus on the pelvic view. There is also a significant amount of fluid in and around Morrison’s pouch between the liver and right kidney; this means there is a large amount of blood present. This finding could explain all the mysteries in this case: multifocal abdominal pain, non-specific bloating, and a little vomiting and diarrhea, plus even the elevated D-dimer and the pleuritic chest pain and arm pain from irritation of the underside of the diaphragm. To proceed, you:

• Cancel the VQ scan of her chest
• Order a comprehensive pelvic ultrasound and a repeat CBC, and
• Consult the gynecologist on-call

You learn the next day that the repeat hemoglobin was 2 grams lower, and the pelvic ultrasound showed only moderated free fluid and no source of bleeding. Your colleague decided to consult surgery and, of course, the surgeon requested a CT scan, which showed a 3.5cm splenic artery aneurysm that was bleeding. The vascular surgeon ended up taking her to the OR for repair of the aneurysm, and although her hemoglobin eventually dipped below 8, she fortunately she got away without needing a blood transfusion.

Spontaneous Hemoperitoneum
from Quick Essentials: Emergency Medicine, EMresource.org
Symptoms: Pain may radiate to chest or shoulder/arm & be pleuritic, bloating, weakness
Causes: Ovarian cyst, endometrioma, ectopic, uterine rupture. AAA, splenic artery aneurysm, Pancreatitis, ruptured hepatic cyst, ruptured neoplasm, DIC, spontaneous splenic rupture

Splenic Artery Aneurysm
from Quick Essentials: Emergency Medicine, EMresource.org
Risks: pregnancy, tobacco, female, HTN.
Complications: rupture if >2-3cm or pregnant (mortality 10-25%)
Treatment: refer, surgery, embolization, stent

Facts About Splenic Artery Aneurysm:

• Incidence is 0.7% - 10%, and in females is four times the rate in males
• It is the second most common intra-abdominal aneurysm after aortic and iliac
• The peak time of detection is in the sixth decade of life
• Half of ruptures occur during pregnancy
• The mortality of a ruptured splenic artery aneurysm is ~80%
• Rupture risk is highest for symptomatic aneurysms, those more than 30mm in size, and those detected in women who plan to become pregnant
• 50% of all ruptures occur in pregnant patients
• Fetal mortality is as high as 97%

Continue Next for Pearls for Using Ultrasound to Scan for Free Fluid