[Downloaded free from http://www.smjonline.org on Wednesday, October 7, 2020, IP: 105.112.76.

191]

CASE REPORT

Hemoperitoneum complicating venomous

snakebite: A case report
Abdulmumini Yakubu, Y. Musa, A. S. Maiyaki, S. H. Tambuwal
Department of Internal Medicine, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

A B S T R A C T
Herein, we report a case of hemoperitoneum complicating venomous snakebite from a carpet viper in a young Nigerian who survived
it. Review of the literature indicates that it is a rare presentation and from the available evidence, the first from Nigeria. A peculiar
feature was the late presentation. Management has been discussed while highlighting some of its limitations.

Keywords: Carpet viper, EchiTAB‑Plus, hemoperitoneum, venomous snakebite

INTRODUCTION In addition to abdominal ultrasonography scan (USS),

Snakebites are a relatively common occurrence
worldwide and are estimated to affect >2.5 million
humans annually, of whom more than 100,000 will
die.[1] It encompasses a major public health problem
among the sub‑Saharan African communities including
Nigeria.[2] Snakebites cause life‑threatening ailment
worldwide where its management sometimes requires
intensive care. Echis ocellatus , the predominant
envenoming species in Nigeria, has been found to
contain hemorrhagin, a prothrombin‑activating
procoagulant causing bleeding, shock, and local tissue
reactions or necrosis. Intra‑abdominal hemorrhage in
the form of hematomas, hemoperitoneum, or both is
rare but has been reported from India[3] and Korean[4,5]
and Benin[6] Republics.
high‑profile investigations such as computed
tomography (CT) scan and celiac angiography (CA)
to identify the source of bleeding can be very helpful
for invasive interventional treatments.[4] However, the
mainstay in the treatment of snakebites involves the use
of anti‑venom, clotting factors and other fractionated
blood products, tetanus prophylaxis, and sometimes
antibiotics. In developing nations, belief in traditional
treatment, scarcity, and high cost of anti‑venom have
led to late or nonpresentation to hospital with the
consequent increase in mortality and morbidity from
snakebites.[7]
In this article, we report the case of hemoperitoneum
in a young rural dweller with late presentation, who
was managed, discharged, and followed up in a
resource‑poor setting.

Corresponding Author: Dr. Abdulmumini Yakubu, CASE REPORT

Department of Internal Medicine, Usmanu Danfodiyo
University Teaching Hospital, Sokoto, Nigeria.
A  20‑year‑old  farmer referred from a general hospital
E‑mail: yakubuabdulmumini@gmail.com
on account of snakebite on the left toe of 2‑week
duration. The patient was bitten by a snake on the
Submitted: 12-Mar-2019 Revised: 25-Jan-2020 
Accepted: 01-Jun-2020 Published: 07-Oct-2020 This is an open access journal, and articles are distributed under the terms of
the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
Access this article online which allows others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are licensed under
Quick Response Code:
the identical terms.
Website:
www.smjonline.org
For reprints contact: wkhlrpmedknow_reprints@wolterskluwer.com

DOI: Cite this article as: Yakubu A, Musa Y, Maiyaki AS, Tambuwal SH.
10.4103/smj.smj_62_19 Hemoperitoneum complicating venomous snakebite: A case report. Sahel
Med J 2020;23:191-4.

© 2020 Sahel Medical Journal | Published by Wolters Kluwer - Medknow 191

[Downloaded free from http://www.smjonline.org on Wednesday, October 7, 2020, IP: 105.112.76.191]
Yakubu, et al.: Haemoperitoneum complicating venomous snake bite
left toe while walking at night; it was a carpet viper
from the patient’s description. There was initial
minimal bleeding at the site of bite which stopped
spontaneously. However, after 2 days, the affected limb
became swollen, and bleeding started from the nostrils
as well as from an old wound sustained before the bite.
There was associated gum bleeding and hematemesis,
but no hematuria, hematochezia, or petechial rashes.
Bleeding initially subsided following some first‑aid
measures at home, but after 3 days, he developed
progressive abdominal swelling and pain. The patient
was then taken to a comprehensive health center
where he had two units of whole blood transfused and
anti‑venom; however, the type of anti‑venom could not
be ascertained. He was then sent to our facility due
to nonimprovement of clinical features. There was no
past history of bleeding disorder or features suggestive
of chronic liver disease, chronic kidney disease, or
peptic ulcer disease.
Examination revealed a severely pale young man with
epistaxis, anicteric and no peripheral lymphadenopathy.
He had a blood‑stained dressing over a bleeding ulcer on
the right Achilles tendon. The pulse rate was 118 beats
per/ min, small volume, regular. His blood pressure
was 95/45 mmHg. His abdomen was distended, with
generalized tenderness and moderate ascites, but no
organ was palpable. Diagnostic paracentesis yielded
bloody, nonclotting aspirate. Initial abdominal girth
on admission was 83 cm, which reduced to 78 cm, and
subsequently 75 cm before it finally settled at 73 cm by
the 3rd day of admission.
Assessment of snakebite with systemic envenomation
(coagulopathy) complicated by hemoperitoneum was
made. The following investigations were sought:
Admitting bedside whole‑blood clotting time (WBCT)
was in excess of 20 min.
Complete blood count showed hematocrit of 9%, white
cell count (WCC) of 15.2 × 109/L, and platelets of
192 × 109/L. Serum electrolytes were normal; however,
urea was 16.6 mmol/L, whereas serum creatinine was
2.0 mg/dl. Serum aspartate transaminase was 79 IU/L,
alanine transaminase was 50 IU/L, total serum bilirubin was
2.66 mg/dL, while total protein was 6.9 g/dL. Serology for
both hepatitis B virus surface antigen and anti‑hepatitis C
virus was nonreactive. The prothrombin time was 15 s with
an international normalized ratio of 1.08, and activated
partial thromboplastin time was 49 s (elevated).
192 Sahel Medical Journal | Volume 23 | Issue 3 / July-September 2020
Abdominal ultrasound scan showed intraperitoneal fluid
collection with mobile internal echoes. The left psoas
muscle appeared inflamed with three well‑encapsulated
echogenic masses in the left lumbar region presumably
organized hematomas.
Abdominal CT scan done on two occasions showed
huge, ovoid, well‑defined (thick walled), nonenhancing,
hypodense mass (HU 30–40) in the left hemi‑abdomen
inferior to the stomach, inferomedial to the spleen,
and anterior to the left kidney. It had an enhancing
wall with enhancing internal septation, as shown in
Figures 1 and 2.
Intravenous (IV) EchiTAB‑Plus 30 ml in 200 ml of normal
saline was started, which continued for about 2 h.
Four units of fresh whole blood was grouped and
cross‑matched and two pints were transfused
immediately, and then one pint daily for the subsequent
2 days.
Six‑hourly whole‑blood bedside clotting time was
checked for 48 h, while abdominal girth was monitored
daily throughout the 1 week of the patient’s stay in the
hospital, and subsequently on each clinic visit for 1
month.
After receiving three vials of EchiTAB‑Plus, the patient
improved significantly as evidenced by cessation of gum
bleeding with normalization of urine output. The WBCT
normalized after three prolonged values, and abdominal
distention regressed progressively. He also received IV
ciprofloxacin and metronidazole. A repeat abdominal
ultrasound scan revealed resolution of intraperitoneal
Figure 1: Precontrast abdominal computed tomography scan at the level of
kidneys
[Downloaded free from http://www.smjonline.org on Wednesday, October 7, 2020, IP: 105.112.76.191]
Yakubu, et al.: Haemoperitoneum complicating venomous snake bite
Figure  2: Postcontrast abdominal computed tomography scan at the level of
kidneys
fluid collection as well as the encapsulated echogenic
masses initially seen in the left lumbar region. The
patient was discharged home after a week, and was seen
in the medical outpatient clinic after 1 week, 2 weeks,
and then 4 weeks with no significant complaints.
DISCUSSION
So far, there have been three reported cases of
snakebite‑related hemoperitoneum. All the cases were
as a result of viper envenoming. The first was from
India,[3] while the second and third were from Korean
republics.[4,5] Our index patient is a young sub‑Saharan
African subsistent farmer from a rural community,
which is consistent with the most common target group
for snakebite.[6] Victims often disturb or step on snakes
while working on the farm or walking back home under
poor visibility. The bite occurred on the foot in the
evening which is the most common time as reported by
Belonwu and Gwarzo.[8] The description of the snake and
the complication developed are consistent with carpet
viper (Echis ocellatus) which is one of the three most
common species in Nigeria.[2] Coagulopathy in the form
of gum bleeding, hematuria, hematochezia, epistaxis,
or bleeding into the third space is a well‑known and
clinically significant complication that follows carpet
viper bite with serious morbidity and mortality;[6,9] the
findings in our patient were in keeping with earlier
reports. One peculiar feature of our patient was his late
presentation, i.e., more than 2 weeks after the bite even
with features of significant systemic envenomation; this
has been well documented in resource‑poor settings
where very often, there is a strong belief in traditional
medication and poor accessibility due to poverty.[10,11]
In this instance, the onset of abdominal pain was what
Sahel Medical Journal | Volume 23 | Issue 3 / July-September 2020
prompted the initial presentation at a comprehensive
health center where he was kept for many days before
being referred to our center. In all the cases including
our case, abdominal pain which corresponded with the
onset of massive hemoperitoneum started 3–4 days
after the snakebite.[3‑5] Our patient’s age agrees with
the commonly affected age groups for envenoming.[7]
Viper venoms contain several toxins which act in
various ways to cause coagulopathy. Some viper
venoms act as anticoagulants by activating Protein
C with resultant antithombin III activity. Others are
enzymes with procoagulant/prothrombin and increased
platelet activation, causing widespread intravascular
coagulation and consumption of clotting factors. They
also contain disintegrins (Arginylglycylaspartic acid
(RGD)‑containing proteins) with antiplatelet and
fibrinolytic activators and hemorrhagins as well as
thrombocytopenic activity, resulting in decreased
fibrinogen concentration and increased fibrinogen
degradation products and D‑dimer levels.[12,13]
Although we could not assay his fibrinogen, fibrinogen
degradation products, protein C, and D‑dimer, he was
found to have elevated activated partial thromboplastin
time; the objective diagnosis of disseminated
intravascular coagulation was therefore difficult. The
origin of hemoperitoneum following snakebite may be
intestinal,[2] hepatic,[3] splenic,[4] and any or multiple
intra‑abdominal organs. Our patient showed CT evidence
of hematoma inferior to the stomach, inferomedial
to the spleen, and anterior to the left kidney. Also,
there was abdominal ultrasound scan findings of three
other distinct hematomas seen in the lumbar region
adjacent to the inflamed psoas muscle in addition to
hemoperitoneum. CA, which was not available in our
facility, was used to determine the hepatic origin of
necrosis and rupture in the second‑ever reported case
in 2007.[3] Sometimes, the location of hematoma is
used to anticipate the origin of the bleed. The organs
responsible for the intra‑abdominal bleed, which adjoin
the multiorgan hematoma in our patient, are unknown.
Our patient unlike the three previously reported cases,
had wound infection as evidenced by elevated white
cell count in addition to severe anemia.
Using CA,[3] hepatic artery embolization (HAE) as well
as splenic artery embolization (SAE) and splenectomy[4]
has been used to treat hemoperitoneum from snakebite.
While in the previosly reported Korean cases HAE was
hugely successful in one, SAE was not successful in the
other case. This was despite the infusion of six vials
193
[Downloaded free from http://www.smjonline.org on Wednesday, October 7, 2020, IP: 105.112.76.191]
Yakubu, et al.: Haemoperitoneum complicating venomous snake bite
of Korax freeze-dried anti-venom, three units of fresh
frozen plasma, packed cells, and eight units of platelet
concentrate in the latter (unsuccessful) case. The patient
had to undergo splenectomy. Our patient’s dramatic
response to a single vial of EchiTAB‑Plus (a specialized
anti‑snake venom developed for the three most common
snakes in Nigeria) is consistent with the experiences of
excellent efficacy of this locally designed anti‑venom.[14]
At the time, the anti‑venom was supplied free of charge
by the Federal Ministry of Health; this easy accessibility
devoid of cost had a significant impact on the patient’s
outcome, which agrees with the previous report.[7] Initial
nonresponse to ineffective anti‑venoms circulating in
the country has been previously highlighted.[7]
In a prospective cross‑sectional study from the
Benin Republic,[6] all patients admitted to a tertiary
hospital with snakebite envenoming were subjected to
ultrasonography as indicated by clinical signs including
abdomen, lungs, and pericardium. The presence of
intestinal parietal hematoma was sought. The results
showed the presence of abdominal hematoma in 44%
of the patients with evidence of external bleeding,
while 13% of the patients had ultrasound evidence of
internal bleeding in the absence of external bleeding.
This suggests that hemoperitoneum may be grossly
underreported.
CONCLUSION
Hemoperitoneum is a rarely reported but serious
complication of viper envenomation requiring
multidisciplinary approach to management,
which could be quite challenging in resource‑poor
settings. A high index of suspicion with early serial
abdominal Ultrasound scan (USS) starting from the
2nd day of the incident will go a long way to diagnose
and mitigate potentially fatal outcomes. Strengthening
of hematologic and radiological services will improve
diagnostic accuracy in the management of bleeding due
to viper envenoming.
Declaration of patient consent
The authors certify that they have obtained all
appropriate patient consent forms. In the form the
patient has given his consent for his/her/their images
194 Sahel Medical Journal | Volume 23 | Issue 3 / July-September 2020
and other clinical information to be reported in the
journal. The patients understand that his names and
initials will not be published and due efforts will be
made to conceal their identity, but anonymity cannot
be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Chippaux JP. Snake‑bites: Appraisal of the global situation. Bull
World Health Organ 1998;76:515‑24.
2. Habib AG. Public health aspects of snake bite care in West Africa:
perspectives from Nigeria. Venom Anim Toxins Incl Trop Dis
2013;19:1‑7.
3. Rothold K, Shelth R, Chayhan G, Asrani A, Raut A. Haemoperitoneum
complicating snake bite: Rare CT features. Abdom Imaging
2003;28:820‑1.
4. Ahn JH, Yoo DG, Choi SJ, Lee JH, Park MS, Kwak JH, et al.
Hemoperitoneum caused by hepatic necrosis and rupture following
a snakebite: A case report with rare CT findings and successful
embolization. Korean J Radiol 2007;8:556‑60.
5. KangC, Kim DH, Kim SC, Kim DS, Jeong CY. Atraumatic splenic
rupture after coagulopathy owing to a snake bite. Wilderness and
Env Med 2014: 25, 325‑8.
6. Tchaou BA, Tové KS De, Tové YS De, Djomga ATC, Aguemon A,
Massougbodji A, et al. Contribution of ultrasonography to the
diagnosis of internal bleeding in snake bite envenomation. J Venom
Anim Toxins Incl Trop Dis 2016;22:1‑7.
7. Habib AG, Abubakar SB. Factors affecting snake bite mortality in
north‑eastern Nigeria. Int Health 2011;3:50‑5.
8. Belonwu RO, Gwarzo GD. Envenomation secondary to facial
snake bite:Report of a rare occurrence. Niger J Paediatr.
2015;42:162‑4.
9. Kim JS, Yang JW, Kim MS, Han ST, Kim BR, Shin MS, et al.
Coagulopathy in patients who experience snakebite. Korean J Intern
Med 2008;23:94‑9.
10. Njoku CH, Isezuo SA, Makusidi MA. An audit of snake bite injuries
seen at the Usmanu Danfodiyo University Teaching Hospital, Sokoto,
Nigeria. Nig Pg Med J 2008;15:112‑5.
11. Habib AG, Gebi UI, Onyemelukwe GC. Snake bite in Nigeria. Afr J.
Sci 2001;30:171‑8.
12. Marsh N, Williams V. Practical application of snake venom toxins in
haemostasis. Toxicon 2005;45:1171‑81.
13. W h i t e   J . S n a k e v e n o m s a n d c o a g u l o p a t h y. Tox i c o n
2005;45:951‑67.
14. Meyer WP, Habib AG, Onayade AA, Yakubu A, Smith DC, Nasidi A,
et al. First clinical experience with new ovine Fab Echis ocellatus
snake bites antivenom in Nigeria. Randomised comparative trial
with institute Pasteur Serum (IPSer) Africa antivenom. Am J Trop
Med Hyg 1997;56:292‑300.