Spontaneous Hemoperitoneum:
Causes and Significance
Brian C. Lucey, MD, Jose C. Varghese, MD, and Jorge A. Soto, MD
Spontaneous hemoperitoneum is an uncommon cause of
acute abdominal pain. When it occurs, it may be cata-
strophic. There are a myriad of causes for spontaneous
hemoperitoneum and an underlying cause should always
be looked for if the patient survives the initial event. This
article describes the imaging findings of spontaneous he-
moperitoneum and discusses the relative merits of multiple
imaging modalities used for the diagnosis of the hemoperi-
toneum and an underlying cause. In addition, we outline
the etiology of spontaneous hemoperitoneum, which in-
cludes hepatic, splenic, gynecologic, and vascular causes,
and bleeding disorders.
Spontaneous hemoperitoneum is a condition most
frequently diagnosed by the radiologist and is usually
unsuspected at the time of diagnosis. This is often a
catastrophic condition that may result in rapid death
and prompt diagnosis is required to institute potential
life-saving measures. Spontaneous hemoperitoneum is
defined as the presence of blood within the peritoneal
cavity that is unrelated to trauma. It may be idiopathic
or related to spontaneous rupture of either a known or
an unknown pathology. It is an uncommon condition
that is usually heralded by abdominal pain, often
severe. There may be associated abdominal distension,
hematocrit drop, and, occasionally, signs of hypovo-
lemic shock. Imaging performed to evaluate the cause
of the abdominal pain may then detect the hemoperi-
toneum. Imaging modalities available to make the
diagnosis include sonography, computed tomography
(CT), and magnetic resonance (MR) imaging. There is
frequently an underlying pathology that results in the
From the Division of Body Imaging, Department of Radiology, Boston
University Medical Center, Boston, MA.
Reprint requests: Brian C. Lucey, MD, Division of Body Imaging,
Department of Radiology, Boston University Medical Center, 88 East
Newton Street, Atrium 2, Boston, MA 02118. E-mail: brian.lucey@bmc.org.
Curr Probl Diagn Radiol 2005;34:182-95.
© 2005 Mosby, Inc. All rights reserved.
0363-0188/2005/$30.00 ⫹ 0
doi:10.1067/j.cpradiol.2005.06.001
182
hemoperitoneum, although spontaneous hemoperito-
neum may result from an unknown or undetectable
cause. Imaging plays a role, not only in the diagnosis
of spontaneous hemoperitoneum, but also in elucidat-
ing a cause. If the diagnostic imaging does not identify
an underlying cause, careful follow-up imaging is
required if the patient survives, to establish if a
treatable cause is present. The causes of spontaneous
hemoperitoneum may be grouped into hepatic causes,
splenic causes, gynecological causes, vascular causes,
and altered coagulation status. The purpose of this
article was to describe the imaging findings and review
the etiology of spontaneous hemoperitoneum.
Imaging Characteristics
The first goal of imaging is to detect the hemoperito-
neum. Localizing the source of the bleeding is the next
step. Elucidating a potential underlying cause is the
third requirement of imaging. CT is generally the first
line imaging modality in the evaluation of patients
presenting with abdominal pain. Sonography has a
role in this patient population, particularly in patients
presenting to the emergency room with severe abdom-
inal pain and signs suggesting hemodynamic instabil-
ity. Sonography is useful as it is a portable imaging
modality that may be performed quickly and may be
performed at the same time as resuscitation and
stabilization of critically ill patients. Sonography may
detect blood within the peritoneum. Although sonog-
raphy may not identify active extravasation or an
underlying cause of the bleeding, sonography is ex-
cellent at identifying blood within the pelvis and
around the solid parenchymal organs. Hemoperito-
neum appears as hypo-echoic fluid surrounding the
solid parenchymal organs or bowel. The fluid may
appear complex with multiple areas of increased
echogenicity within the fluid. It is the complex nature
of the fluid that may help to differentiate hemoperito-
Curr Probl Diagn Radiol, September/October 2005
FIG 1. (A) CT image of a 48-year-old male with a large volume of ascites. These ascites are hyperdense on CT imaging representing blood in this
patient with cirrhosis and spontaneous intraperitoneal hemorrhage. This patient presented with severe, acute abdominal pain. Note the dense
blood clot in the dependent portion of the right paracolic gutter (arrow). (B) Axial T1-weighted MR image of a 48-year-old male patient. This shows
the low signal ascites with a focus of high signal (arrow) representing the blood clot seen on the CT image. (C) Axial T2-weighted MR image with
fat saturation of a 48-year-old male patient. This shows the high signal ascites and mixed signal focus representing blood clot (arrow). (D) CT image
of a 48-year-old male patient obtained 4 weeks after the initial CT scan showing a heterogeneous mass within the liver that was a biopsy-proven
hepatocellular carcinoma (HCC) (arrow). This HCC bled to cause the spontaneous hemoperitoneum and was not as easily identified on the initial
CT scan due to the acute bleed.

neum from simple ascites. Sonography also plays a
large role in the diagnosis of spontaneous hemoperi-
toneum secondary to gynecologic causes. In patients
presenting with pelvic pain, sonography is frequently
the imaging modality of choice. Pelvic sonography is
excellent at detecting blood in the cul-de-sac. This also
appears as complex fluid with multiple areas of in-
creased echogenicity within the hypo-echoic fluid. A
gynecological cause for the hemoperitoneum may also
be detected using sonography.
On CT imaging, the appearance of blood within the
peritoneum varies depending on the site of origin of
the bleeding, the extent of the bleeding, and the age of
the blood. Hemoperitoneum generally appears as fluid
within the peritoneum that may surround the liver,
spleen, or small bowel loops. Blood may also collect
in either paracolic gutter, Morrison’s pouch, or the
dependent portion of the pelvis (Fig 1). If this time
interval between bleeding and imaging is several
hours, high attenuation clot may be seen. Over the next

Curr Probl Diagn Radiol, September/October 2005 183

few days, the attenuation of the blood decreases and is
usually similar to simple fluid after 2 to 3 weeks.
Acute blood may have a heterogeneous attenuation as
fresh blood mixes with the older blood and clot lysis
begins. High attenuation clots may appear at the site of
the bleeding and may give an indication as to the site
of origin of the bleeding. There may also be a
fluid–fluid level present in the abdomen. This repre-
sents the layering of the components of the blood with
the serum rising to the top, above the denser cellular
layer. This has the CT appearance of low attenuation
fluid lying above the higher attenuation cellular com-
ponent of blood. The line between these layers is
horizontal and identifying such a fluid–fluid level is
diagnostic of hemoperitoneum.
Once the diagnosis of hemoperitoneum has been
made, the first thing to consider is if there is continued
active bleeding present. This is identified as active
extravasation of contrast or blood seen on CT arising
from a vessel or organ. With the recent introduction of
multidetector CT scanners, particularly the 16- and
64-row detectors, CT should be able to identify active
extravasation more easily, if it is present. This has
prognostic implications as ongoing extravasation car-
ries a greater morbidity and mortality. The presence of
active extravasation also alters the management strat-
egy for these patients as extravasation mandates either
surgical or endovascular management to arrest the
bleeding.
Once the presence of hemoperitoneum has been
established and active extravasation is excluded, a
search should be made for an underlying cause. This
includes careful evaluation of the liver and spleen. If
the spontaneous hemoperitoneum results from a he-
patic or splenic cause, the peritoneal blood may be
centered around the lesion responsible. Therefore iden-
tifying a high attenuation hematoma in close proximity to
the liver or spleen may indicate an underlying cause.
MR imaging of spontaneous hemoperitoneum is
complementary to CT and is particularly useful in
equivocal cases. The distribution of intraperitoneal
blood on MR mirrors that of CT. The signal charac-
teristics of the blood may vary considerably and
depends on the age of the blood products in the
hemoperitoneum. At the time that most patients with
spontaneous hemoperitoneum get an MR scan, most of
the blood will appear as high signal on T1-weighted
imaging and of mixed or intermediate signal on
T2-weighted imaging (Fig 1). The value of MR in
evaluating patients with spontaneous hemoperitoneum
184
lies in the ability to characterize fluid, seen on CT, but
as yet uncharacterized, as blood. In addition, MR may
be able to identify an underlying lesion in the liver or
spleen that was not seen on CT due to the surrounding
hemorrhage. MR may also be able to characterize a
lesion seen in the liver on CT that is suspected of
causing the hemoperitoneum.
Hepatic Causes of Spontaneous
Hemoperitoneum
Spontaneous rupture of a previously undetected liver
lesion, although rare, is the most frequently reported
etiology of spontaneous hemoperitoneum. Occasion-
ally, minor trauma may be a precipitating factor.1
Pregnancy is also associated with an increased risk of
spontaneous rupture of some liver lesions.2 Hepatic
causes of spontaneous hemoperitoneum include rup-
ture of both benign and malignant hepatic masses.
Benign masses that may rupture include hepatic ade-
nomas1-4 and, rarely, giant hemangiomata5,6 and focal
nodular hyperplasia.7,8 Small hemangiomata almost
never rupture spontaneously.
Hepatic adenoma is the most common benign
hepatic mass that may rupture and rupture of a hepatic
adenoma is more frequently encountered in females.
There is an increased risk of rupture in patients with
prolonged oral contraceptive steroid use4 and also in
pregnancy.2 Hepatic adenomata may outgrow their
blood supply, leading to necrosis and, rarely, rupture.
Larger adenomata are at increased risk of rupture.
Given the potential for a hepatic adenoma to rupture,
surgical excision of these lesions is often recom-
mended. This is also advisable as there is potential for
adenomata to undergo malignant degeneration.
Hemangioma is the most common benign liver
lesion and is found more frequently in females. These
seldom cause symptoms and rupture of a hemangioma
is an extremely infrequent event. Hemangiomas are
more likely to rupture during pregnancy, likely related
to the overall increased intravascular volume when
pregnant. There have been in excess of 30 reported
cases of spontaneous rupture of hepatic hemangiomata
in the literature.6 Of those that could be characterized
by size, 84% were described as a giant hemangioma.
The potential catastrophic nature of spontaneous he-
moperitoneum is reflected in the statistic that the
reported mortality of these patients with rupture of a
benign hemangioma undergoing surgery is 36%.
Curr Probl Diagn Radiol, September/October 2005
FIG 2. (A) CT image of a 44-year-old male patient with cirrhosis showing a heterogeneous mass arising from the left lobe of the liver (arrow). Dense
ascites representing blood are seen around the liver and spleen. This mass is an HCC that ruptured spontaneously causing hemoperitoneum. (B)
Axial T1-weighted MR image of a 44-year-old male patient with cirrhosis obtained 10 days after the CT scan showing the low signal intensity mass
(arrow). There has been some interval resolution of some of the hemoperitoneum. (C) Axial T2-weighted MR image with fat saturation of a
44-year-old male patient with cirrhosis obtained 10 days after the CT scan showing the heterogeneous signal within the mass (arrow), suggesting
that this mass has undergone recent hemorrhage. Incidental note is made of a simple hepatic cyst (arrowhead).

Focal nodular hyperplasia (FNH) is a benign liver
lesion with no malignant potential found most com-
monly in females. Most FNH are asymptomatic and
are identified incidentally. Spontaneous rupture of an
FNH is extremely rare. Several case reports have been
published and FNH should be considered as a potential
cause when spontaneous hemoperitoneum is encoun-
tered.7,8
Pregnancy complicated by eclampsia or pre-
eclampsia may also result in spontaneous hepatic
rupture.9 This is usually seen in association with the
HELLP syndrome. This most frequently presents with
acute right upper quadrant pain and hepatic rupture is
identified as a subcapsular hematoma with or without
evidence of intraperitoneal hemorrhage.
Hepatic adenomatosis is a condition resulting in
multiple large hepatic adenomas without oral con-
traceptive use or exogenous androgenic steroid
ingestion. These hepatic adenomata may also rup-
ture on occasion.10 This hormonal-dependent in-
creased risk of rupture is also reflected in an
increased risk of rupture of hepatic adenoma in
males taking anabolic steroids.11 There have also
been case reports of spontaneous rupture of a
hepatic adenoma in male patients, one in association
with hyperthyroidism.12,13
Infiltrative disease of the liver may also result in
spontaneous hemoperitoneum. This may occur even in
the absence of a focal liver mass. There have been reports
of spontaneous rupture of the liver in patients with

Curr Probl Diagn Radiol, September/October 2005 185

FIG 3. (A) CT image of a 66-year-old male patient with a history of
lung cancer showing multiple low attenuation liver lesions representing
metastases. One of these spontaneously ruptured resulting in hemo-
peritoneum with a large volume of blood seen around the liver and
spleen (arrows). (B) CT image of a 66-year-old male patient with a
history of lung cancer showing blood tracking inferiorly along both
flanks following spontaneous rupture of one of the hepatic metastases.
amyloidosis, although this is an extremely rare phe-
nomenon.14,15
In addition to benign liver masses, spontaneous hemo-
peritoneum may result more frequently from rupture of
malignant liver lesions, either primary hepatocellular
carcinoma (HCC)16,17 or metastatic disease.18-24 HCC is
the most common malignant liver lesion to rupture
spontaneously (Fig 2). In one large report of 70 cases of
spontaneous hepatic rupture,25 HCC was the underlying
cause in 60 cases (85%). This has most frequently been
reported in the setting of cirrhosis secondary to alcohol or
chronic viral infection. HCC that ruptures has a higher
association with cirrhosis than HCC that has not rup-
tured. Rupture of an HCC usually presents with right
upper quadrant pain and is frequently seen with hypo-
186
FIG 4. (A) CT image of a 58-year-old male patient with chronic renal
failure. There is a large area of low attenuation within the spleen
representing evidence of a splenic bleed. There is a crescent-shaped
hematoma on the lateral aspect of the spleen (arrow) that is hyper-
dense. No mass was identified on this or follow-up imaging. Given the
history of chronic renal failure, it was thought that a platelet abnormal-
ity was the most likely underlying cause of the spontaneous splenic
rupture. (B) CT image of a 58-year-old male patient with chronic renal
failure. There is a crescent-shaped hematoma on the lateral aspect of
the spleen (arrow) that is hyperdense. This represents an acute bleed.
tension and hypovolemic shock. The exact cause of HCC
rupture is uncertain but proximity of large masses to the
hepatic surface without intervening normal liver paren-
chyma predisposes to hemoperitoneum. When hemoperi-
toneum is detected, HCC should be suspected if imaging
identifies a hepatic mass adjacent to the site of hemor-
rhage. The mass may be identified as an HCC if it shows
characteristic imaging findings on sonography, CT, or
MR imaging.
The mortality from ruptured HCC is extremely high.
Management consists primarily of supportive measures.
Curr Probl Diagn Radiol, September/October 2005

FIG 5. (A) CT image of a 42-year-old female showing a hyperdense
bleed into the spleen (arrow). No underlying cause was found. (B) CT
image of a 42-year-old female showing high-density fluid representing
blood tracking down the right paracolic gutter (arrow).
Surgical resection should be considered; however, many
patients are poor surgical candidates and hepatic arterial
embolization may be attempted in these patients.
Rupture of primary angiosarcoma of the liver has
also been reported as a cause of spontaneous hemo-
peritoneum, although this is a rare condition.26,27
Spontaneous rupture of metastatic lesions to the liver
is an unusual cause of spontaneous hemoperitoneum (Fig
3). In a large report of 70 patients with spontaneous
hemoperitoneum, metastatic disease was only responsi-
ble for one case.25 Metastatic lesions from a wide range
of primary malignancies resulting in spontaneous rupture
have been reported, most in the form of case reports.
These include metastatic colon, lung,20 renal cell carci-
noma,19 testicular,18 choriocarcinoma,21 and Wilm’s tu-
Curr Probl Diagn Radiol, September/October 2005
FIG 6. CT image of a 52-year-old male patient showing an extensive
area of mixed attenuation within the spleen. This represents a large
spontaneous splenic bleed with extra splenic blood. The areas of
higher attenuation represent fresh blood clot (arrows). This patient had
no history of trauma, no underlying risk factors, and no lesions found
on imaging follow-up. This represents a spontaneous splenic hemor-
rhage of unknown cause.
mor,22 among others. Despite the relative rarity of the
condition, when evaluating CT or MR imaging of pa-
tients presenting with spontaneous hemoperitoneum, a
search should also be made for evidence of a primary
tumor that may have metastasized to the liver. Rupture of
a hepatic metastasis results in massive hemoperitoneum
that is frequently a terminal event. The cause of the
rupture is often unknown, but as with HCC rupture, large
lesions adjacent to the capsule are at greatest risk.
Increased intra-abdominal pressure and coagulopathy
have also been postulated as causes.
On occasion, spontaneous rupture of the liver oc-
curs for no apparent cause, or at least, no underlying
cause is identified by imaging.
Splenic Causes of Spontaneous
Hemoperitoneum
Delayed splenic rupture may occur following blunt
abdominal trauma. Spontaneous rupture of the spleen,
however, is extremely rare (Fig 4). Many of the reports
in the literature on spontaneous splenic rupture are
indeed case reports. Unlike the liver, spontaneous
splenic rupture is rarely associated with parenchymal
splenic masses. When it occurs, it is most frequently
associated with splenic infection and these infections
include cytomegalovirus,28 malaria, and Epstein–Barr
virus. Disseminated infection with Bartonella henselae
187
FIG 7. (A) CT image of a 42-year-old male patient showing intravenous contrast within an aneurysm of a branch of the superior mesenteric artery
(SMA) (arrow). The abnormal artery ruptured spontaneously resulting in hemoperitoneum. (B) Image from the diagnostic digital subtraction
angiogram of a 42-year-old male following selective catheterization of the superior mesenteric artery. The aneurysm of one of the SMA branches
is clearly identified (arrow). (C) Axial T2-weighted image with fat saturation showing blood and thrombus within the SMA branch aneurysm
(arrows). (D) Axial T1-weighted image showing blood and thrombus within the SMA branch aneurysm (arrows).

has also been reported.29 As with the liver, splenic
rupture may occur when the spleen is diffusely infil-
trated as is seen with amyloidosis30 or Gaucher’s
disease. Spontaneous rupture of the spleen may also
occur with no apparent underlying precipitating
cause31 (Figs 5 and 6). There have been several reports
of rupture of the spleen from an underlying splenic
mass. These are usually a splenic hamartoma that
undergoes spontaneous rupture. Spontaneous splenic
rupture from neoplastic disease is uncommon but may
occur with lymphoma, leukemia, or angiosarcoma.
Spontaneous rupture of a true splenic cyst has been
reported as a cause of hemoperitoneum.32
Vascular Causes of Spontaneous
Hemoperitoneum
There is a wide range of vascular causes of spontane-
ous hemoperitoneum. These may be divided into
arterial causes and venous causes. Arterial causes are

188 Curr Probl Diagn Radiol, September/October 2005

FIG 8. (A) CT image of a 62-year-old male with a history of acute pancreatitis showing splenic artery pseudo-aneurysm (arrow). This ruptured
spontaneously resulting in hemoperitoneum. Blood can be seen around the spleen. (B) CT image of a 62-year-old male with a history of acute
pancreatitis showing splenic artery pseudo-aneurysm that ruptured resulting in intraperitoneal hemorrhage. The blood is seen as mixed attenuation
soft tissue in the region of the pseudo-aneurysm.

FIG 9. (A) CT image of rupture of a mycotic aneurysm of the SMA leading to hemoperitoneum. (B) Note the gas in the ruptured aneurysm (arrow),
suggesting the diagnosis of infection.

FIG 10. (A) CT image of a 43-year-old male presenting with acute abdominal pain. Image shows spontaneous hemoperitoneum with a large
hematoma (arrows) in the mesentery. This patient had ulceration of the mesentery identified at the time of surgery. The underlying cause in this
patient is unknown. (B) CT image of a 43-year-old male presenting with acute abdominal pain. Image shows mixed attenuation fluid surrounding
the small bowel indicating that clot has formed within the mesentery. The clot indicates that the source of bleeding likely arises from the nearby
mesentery.
FIG 11. (A) CT image of a 55-year-old male patient with cirrhosis and portal hypertension. Extensive varices (arrows) and low attenuation ascites
are present. (B) CT image of a 55-year-old male patient with cirrhosis and portal hypertension obtained 3 months after the first CT obtained
following an episode of acute abdominal pain. This shows interval development of high attenuation hemoperitoneum from variceal rupture. A large
high attenuation hematoma is seen conforming to the contour of the lesser sac (arrows). (C) T1-weighted axial MR image obtained 1 month after
the second CT shows high signal from the lesser sac hematoma (arrows). (D) T2-weighted axial MR image obtained 1 month after the second CT
shows intermediate to low signal from the lesser sac hematoma (arrows).

either due to rupture of an abnormal vessel or a normal
vessel undergoing stress. Causes of arterial hemoperi-
toneum due to abnormal vessels include aneurysm
(Fig 7), pseudo-aneurysm (Fig 8), or mycotic aneu-
rysm (Fig 9) with rupture and arterial dissection with
rupture. These are not necessarily large vessels as
would be expected in patients with extensive athero-
sclerotic disease but frequently involve smaller vessels
and those vessels not commonly involved in athero-
sclerotic disease. Vessels most commonly implicated
are the splenic and renal arteries. Reported vessels also
include the left gastroepiploic artery,33 hepatic ar-
tery,34 and gastric artery.35 Mesenteric arteries may
also be involved and spontaneous rupture carries a
reported mortality of approximately 30%. Vasculitides
result in abnormal vessels that may also spontaneously
rupture. There are a vast number of such disease entities
that may result in abnormal vessels but spontaneous
rupture is an unusual event and resultant hemoperito-
neum is infrequently encountered.
As an example of a normal vessel undergoing
stress, there have been reports of septic thrombosis
leading to vascular rupture and thus spontaneous
hemoperitoneum.36 Erosion of a vessel by an adjacent
pathology such as tumor, inflammation (Fig 10), or
endometrioma37 may also result in spontaneous vas-
cular rupture. Occasionally, normal vessels may rup-
ture with no underlying stress or abnormality.

190 Curr Probl Diagn Radiol, September/October 2005

FIG 12. CT image of a 43-year-old female with end-stage renal
disease on hemodialysis that shows both intra- and extraperitoneal
blood with blood in the psoas muscles and around the loops of small
bowel. This patient was being anticoagulated with intravenous heparin
before developing spontaneous hemorrhage.
Spontaneous hemoperitoneum resulting from ve-
nous rupture occurs in a very different patient popu-
lation to arterial rupture. Venous rupture is usually
secondary to rupture of abdominal varices, most fre-
quently resulting from cirrhosis and portal hyperten-
sion.38-41 Rupture of varices may follow an episode of
elevated intraabdominal pressure. Spontaneous hemo-
peritoneum due to variceal rupture carries a mortality
of approximately 75%.41 Imaging these patients will
usually demonstrate signs suggesting portal hyperten-
sion. Portal vein thrombosis may be apparent with
cavernous transformation of the portal vein. Multiple
varices may also be present including recanalization of
the umbilical vein. The liver may have a nodular edge
with enlargement of the caudate lobe and atrophy of
the right lobe, suggesting cirrhosis. Splenomegaly may
be present. In these cirrhotic patients with portal
hypertension, ascites are commonly present. It is
important to differentiate simple ascites from hemo-
peritoneum as described previously. An episode of
increased intra-abdominal pressure may precipitate the
spontaneous rupture of the varices resulting in sudden,
massive hemoperitoneum (Fig 11).
Venous rupture leading to spontaneous hemoperi-
toneum may also result from the increased intra-
abdominal pressure associated with labor. There is
proliferation of the pelvic veins during the later stages
of pregnancy and the increased intra-abdominal pres-
sure may lead to rupture of a utero– ovarian vessel
Curr Probl Diagn Radiol, September/October 2005
FIG 13. (A) CT scan of a 52-year-old male patient who presented with
abdominal pain and vomiting showing a collection of blood at the tip
of the right lobe of the liver (arrow). This patient was anticoagulated
with coumadin for a valve replacement and had an INR of 13 on
admission. (B) CT scan of a 52-year-old male patient who presented
with abdominal pain and vomiting. There is also thickening of the wall
of a small bowel loop (arrow) reflecting hemorrhage into the small
bowel wall.
leading to hemoperitoneum. This has a high rate of
both fetal and maternal loss.
Most arteriovenous malformations of the gastroin-
testinal tract are found in the mucosa or submucosa of
the bowel wall and the vast majority does not cause
any symptoms. Arteriovenous malformation on the
serosal surface of the bowel is rare; however, an
arteriovenous malformation on the serosal surface of
the transverse colon has been reported as a vascular
cause of spontaneous hemoperitoneum.42
Coagulopathic Causes of Spontaneous
Hemoperitoneum
Spontaneous hemorrhage is a risk of anticoagulation.
This most frequently results in spontaneous hemor-
191
FIG 14. (A) CT scan of a 28-year-old male patient with hemophilia presenting with acute abdominal pain. The image shows a massive
hemoperitoneum with blood around the liver and gallbladder. A clear hematocrit level is present (arrows). (B) CT scan of a 28-year-old male patient
with hemophilia presenting with acute abdominal pain shows active bleeding from an omental vessel extending to the level of the hematocrit
(arrow). (C) CT scan of a 28-year-old male patient with hemophilia presenting with acute abdominal pain shows the extent of the hemoperitoneum
inferiorly extending into the pelvis. The denser cellular elements of the blood are seen as higher attenuation in the more dependent parts of the
abdomen (arrows).

192 Curr Probl Diagn Radiol, September/October 2005


FIG 15. Sonographic image of a 24-year-old female with a positive
beta HCG and no intrauterine pregnancy identified. The image shows
a large volume of complex fluid in the pouch of Douglas (arrows). This
represents blood from a ruptured ectopic pregnancy.
rhage into the psoas or rectus abdominis muscles even
in the absence of trauma, usually in the first few weeks
of anticoagulant therapy. Anticoagulation, however,
may occasionally result in spontaneous hemoperito-
neum. This may be directly into the peritoneum or
result in hemorrhage into the bowel wall with second-
ary hemoperitoneum. The event may be associated
with either heparin (Fig 12) or coumadin (Fig 13)
therapy. There have been reports of hemoperitoneum
resulting from gallbladder rupture in a patient on
anticoagulation43 and also spontaneous rupture of the
spleen in a patient on heparin.44 In addition to medi-
cally indicated anticoagulation, spontaneous hemo-
peritoneum may result from blood dyscrasias. All such
disorders expose the patient to an increased risk of
spontaneous hemoperitoneum. The most common he-
matological disorder that may result in hemoperito-
neum is hemophilia (Fig 14). Although minor trauma
may precipitate the hemoperitoneum, this has occurred
in the absence of even minor trauma. Congenital factor
X deficiency has also been reported as resulting in
spontaneous hemoperitoneum following rupture of
luteal cysts.45
Gynecologic Causes of Spontaneous
Hemoperitoneum
Spontaneous hemoperitoneum occurs more fre-
quently in pregnancy than in the nonpregnant pop-
ulation. In addition to pregnancy, there are a variety
of gynecologic conditions that may result in hemo-
Curr Probl Diagn Radiol, September/October 2005
peritoneum. Ovarian cyst rupture may result in
hemoperitoneum.46 This is the most common cause
of hemoperitoneum in young females. Sonography
can usually identify fluid in the peritoneal cavity but
it may be difficult to determine if the fluid is blood.
In addition, sonography may not identify the cyst
responsible for the hemoperitoneum nor identify
evidence of cyst rupture. CT may be useful to
identify the hemoperitoneum by differing attenua-
tion values and may also identify an ovarian cyst
with irregular opacification of the wall, suggesting
rupture.47 Despite using multiple imaging modali-
ties, it may be difficult to differentiate a ruptured
ovarian cyst from an ectopic pregnancy and a serum
HCG level should always be obtained in a female
patient presenting with pelvic pain. Hemoperito-
neum may indeed be the only sign of an ectopic
pregnancy and should always be considered in a
female patient with hemoperitoneum (Fig 15). The
presence of hemoperitoneum in the setting of an
ectopic pregnancy does not always imply tubal
rupture; however, a large volume of blood in the
peritoneum is highly suspicious for tubal rupture.
Other gynecologic conditions reported to result in
spontaneous hemoperitoneum include hemorrhagic
corpus luteum cyst torsion.48,49 This is an infrequent
event as torsion of a cyst usually causes significant
pain and is diagnosed and treated before rupturing.
Leiomyosarcoma has been reported as a cause of
spontaneous hemoperitoneum.50 These uterine tumors
may be difficult to distinguish from the benign form,
fibroids. Rapid growth over a short timeframe is the
only imaging characteristic that separates malignant
lesions from benign in the absence of overt signs on
invasion.
Conclusions
Spontaneous hemoperitoneum, although overall an
uncommon entity, may result from a wide variety of
causes. The role of imaging is to detect the hemo-
peritoneum, identify if active extravasation is
present, and, where possible, identify the underlying
cause. CT is the imaging modality of choice in the
investigation of most causes of spontaneous hemo-
peritoneum. Sonography has a role in detecting
gynecological causes and in the acutely unstable
patient. MR is complementary to CT and is useful in
both confirming the diagnosis in equivocal cases
and identifying an underlying cause. Spontaneous
193
hemoperitoneum may be a life-threatening presen-
tation and the responsibility for diagnosis frequently
rests with the radiologist. The management of spon-
taneous hemoperitoneum may primarily be support-
ive measures; however, surgical or endovascular
intervention may be required.
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