G a s t r o i n t e s t i n a l I m a g i n g • P i c t o r i a l E s s ay

Furlan et al.
CT of Spontaneous Abdominal Hemorrhage

Gastrointestinal Imaging
Pictorial Essay
Downloaded from www.ajronline.org by 1.52.235.218 on 11/22/21 from IP address 1.52.235.218. Copyright ARRS. For personal use only; all rights reserved

Spontaneous Abdominal
Hemorrhage: Causes, CT Findings,
and Clinical Implications
Alessandro Furlan1,2 OBJECTIVE. The purpose of this article is to present the most common causes of spon-
Saeed Fakhran1 taneous abdominal hemorrhage and to review the CT findings that are important in establish-
Michael P. Federle1,3 ing the correct diagnosis and in guiding appropriate therapy.
CONCLUSION. Knowledge of the common CT manifestations of various causes of
Furlan A, Fakhran S, Federle MP spontaneous abdominal hemorrhage allows their accurate diagnosis and has a direct impact
on clinical decision making.

Keywords: abdomen, CT, hemorrhage
DOI:10.2214/AJR.08.2231
Received December 10, 2008; accepted after revision
March 3, 2009.
1 Appearance of Hemorrhage on CT
Department of Radiology, University of Pittsburgh
Medical Center, Presbyterian Campus, 200 Lothrop St.,
Pittsburgh, PA.
2
Istituto di Radiologia, Azienda Ospedaliero-Universitaria
“Santa Maria della Misericordia” di Udine, Udine, Italy.
3
Department of Radiology, Stanford University, 300
Pasteur Dr., Stanford, CA 94305-5105. Address
correspondence to M. P. Federle (federle@stanford.edu).
CME
This article is available for CME credit.
See www.arrs.org for more information.
AJR 2009; 193:1077–1087
0361–803X/09/1934–1077
© American Roentgen Ray Society
S
pontaneous abdominal hemor-
rhage is defined as the presence of
intraabdominal hemorrhage from
a nontraumatic and noniatrogenic
cause. Common sources of spontaneous ab-
dominal hemorrhage are visceral (hepatic,
splenic, renal, and adrenal), gynecologic, co-
agulopathy-related, and vascular. The clinical
presentation is usually nonspecific; thus, fre-
quently the diagnosis is made on the basis of
radiologic findings. Because of its speed and
widespread availability, CT plays an important
role in the assessment of the presence, loca-
tion, and extent of hemorrhage and in the iden-
tification of the underlying cause [1–3]. This
article reviews the most common causes of
spontaneous abdominal hemorrhage and the
CT findings that are essential for prompt diag-
nosis and patient management.
The appearance of hemorrhage on CT de-
pends on its age and location. On unenhanced
images, acute bleeding has an attenuation of
30–45 HU because of its high protein con-
tent. In the first few hours after hemorrhage,
clotted blood appears hyperdense (HU > 60)
as the concentration of hemoglobin increas-
es, with geographic areas of high attenuation
(clot) surrounded by areas of lower attenua-
tion (serum) [1]. Clots tend to form first near
the site of bleeding; thus, the identification of
a heterogeneous and relatively higher attenua-
tion clot allows localization of the site of hem-
orrhage (sentinel clot sign) [2] (Fig. 1). With
time the clot decreases in size and density be-
cause of the progressive lysis of hemoglobin
[1]. The detection of active hemorrhage on
contrast-enhanced CT as high-attenuation foci
nearly isodense to adjacent vessels (Fig. 2) is
usually indicative of the need for emergency
embolization or surgical treatment [3].
Visceral Causes
Hepatic Causes
Spontaneous hepatic bleeding is a rare con-
dition that is mainly due to the rupture of an
underlying hypervascular tumor [4]. Rupture
of a hepatic adenoma usually occurs in young
women receiving long-term oral contracep-
tive therapy [4], whereas the highest inci-
dence of bleeding hepatocellular carcinoma
has been reported in Asian countries in cir-
rhotic patients with tumors located at the pe-
riphery of the liver [5]. Clinical concern for
a bleeding tumor (known liver disease, de-
crease in hematocrit, abdominal pain) should
be evaluated by unenhanced and contrast-
enhanced CT to clearly identify the hemato-
ma and the underlying hepatic lesion. On un-
enhanced CT images, the ruptured tumor is
usually hypoattenuating, but it may be com-
pletely obscured by the adjacent subcapsular
hematoma (Figs. 3A and 4A); thus, the senti-
nel clot sign is helpful to recognize the hepatic
source of hemorrhage. The IV administration
of contrast material helps to detect foci of ac-
tive extravasation and to identify the ruptured
hepatic tumor as a large spherical and partial-
ly exophytic enhancing mass contiguous with
the subcapsular hematoma [5] (Figs. 3B and
4B). Early diagnosis by CT directs the patient
to emergency treatment, such as transarterial
embolization or liver resection [4, 5].

AJR:193, October 2009 1077


HELLP (hemolysis, elevated liver enzymes,
low platelet count) syndrome is a severe vari-
ant of preeclampsia that should always be
considered in pregnant women with acute ab-
dominal pain and accompanying laboratory
abnormalities. This serious obstetric condi-
tion may be associated with hepatic necrosis
Downloaded from www.ajronline.org by 1.52.235.218 on 11/22/21 from IP address 1.52.235.218. Copyright ARRS. For personal use only; all rights reserved
and intrahepatic hemorrhagic infarction. In
these patients, CT is the study of choice to de-
tect hepatic subcapsular hematomas, intrahe-
patic liver hemorrhage, and infarcts (Fig. 5).
Treatment consists of expeditious delivery of
the neonate and emergency surgery or selec-
tive embolization of hepatic arteries in case of
liver rupture for the mother [4, 6].
Splenic Causes
Spontaneous splenic rupture is rare and
mainly occurs in cases of marked spleno­
megaly because of underlying hematologic
malignancies (acute leukemia or lymphoma)
or infectious causes such as mononucleosis
or Cytomegalovirus organisms in young pa-
tients [7]. Clinical presentation includes acute
abdominal and shoulder pain due to diaphrag-
matic irritation. Diagnosis at CT is suggest-
ed by the identification of a grossly abnormal
spleen with perisplenic hemorrhage and clot
in the organ (Figs. 1 and 6). Treatment may
be conservative, surgical, or transcatheter em-
bolization, depending on the grade of splenic
injury and the underlying disease [7].
Renal Causes
Spontaneous hemorrhage into the sub-
capsular or perinephric space is usually
the result of rupture of a renal tumor, such
as angiomyolipoma or renal cell carcinoma
(RCC) [8]. In most cases, CT permits the ra-
diologist to clearly differentiate a mass from
the surrounding hematoma. The diagnosis of
an underlying angiomyolipoma is based on
the identification of low-attenuation areas of
fat in a large heterogeneous mass (Fig. 7).
On contrast-enhanced CT, the presence of
a solid mass with less contrast enhancement
than the adjacent renal parenchyma suggests
RCC. However, small tumors may initially
be obscured by the hematoma; therefore, fol-
low-up imaging after resolution of the initial
hematoma is essential [8] (Fig. 8).
Spontaneous renal or perirenal hemor-
rhage may also result from coagulopathy or
vasculitis, such as polyarteritis nodosa and
Wegener’s granulomatosis (Fig. 9). Rarely,
the accumulation of blood in the perinephric
subcapsular space can compress the renal
parenchyma, leading to ischemia and sub-
1078 AJR:193, October 2009
Furlan et al.
sequent high renin hypertension (Page kid-
ney) [9].
Adrenal Causes
Spontaneous adrenal hemorrhage is an
uncommon condition that is usually bilater-
al and associated with anticoagulation ther-
apy, severe stress, or sepsis. Bilateral ad-
renal hemorrhage may be complicated by
life-threatening adrenal insufficiency. CT
reveals enlarged hyperdense adrenal glands
(Fig. 10A) without appreciable enhancement
after the IV administration of contrast mate-
rial [10] (Fig. 10B).
Gynecologic and Obstetric Causes
Rupture of an ectopic pregnancy or rup-
ture of an ovarian cyst are the most common
causes of spontaneous hemoperitoneum in
women of childbearing age [11, 12].
Ectopic pregnancy is a potentially life-
threatening condition that must be consid-
ered in every woman of reproductive age
with abdominal or pelvic pain, usually start-
ing with measuring the serum HCG and per-
forming pelvic sonography. In the emergency
setting, CT may be performed in these pa-
tients because of the presenting severe symp-
toms and a falsely negative urine pregnancy
test. Ectop­ic pregnancy commonly occurs in
the fallopian tube and presents as a ring-en-
hancing adnexal cystic mass surrounded by
hemoperitoneum [11] (Fig. 11). Correct diag-
nosis often leads to emergency laparotomy.
Spontaneous abdominal hemorrhage as-
sociated with toxemia is usually a manifesta-
tion of the HELLP syndrome, as previously
discussed.
Rupture of an ovarian cyst should be sus-
pected in young women presenting with pel-
vic pain and negative serum β-HCG. When
the source of bleeding cannot be localized at
sonography, CT better detects the ruptured
cyst as a mixed-attenuation mass in the con-
text of a high-density pelvic hematoma [12]
(Fig. 12).
Coagulopathy-Related Spontaneous
Abdominal Hemorrhage
Abdominal hemorrhage due to anticoagula-
tion or bleeding diatheses (e.g., hepatic failure,
hemophilia, idiopathic thrombocytopenic pur-
pura, systemic lupus erythematosus) common-
ly involves multiple sites, and especially the
body wall muscle compartments, such as the
rectus sheath or the iliopsoas muscle [13]. Ab-
dominal viscera are less commonly the sites
of coagulopathic hemorrhage, but perirenal
and intramural bowel hematomas are not rare.
On CT, the presence of a cellular–fluid lev-
el caused by the settling of cellular elements
in the dependent portion of a hematoma, the
so-called hematocrit sign, is a highly sensi-
tive (87%) and specific sign of coagulopath-
ic hemorrhage [14] (Fig. 13). When contrast-
enhanced CT detects coagulopathy-associated
active extravasation, this is more frequent-
ly venous than arterial, usually not requiring
surgery or embolization. Treatment is mainly
conservative and based on withholding of anti-
coagulant medications [14] (Fig. 14).
Vascular Causes
CT is usually performed in patients with
known abdominal aortic aneurysm (AAA)
presenting with abdominal pain to exclude
rupture or to identify other causes for the pa-
tient’s symptoms [15]. On unenhanced CT
images, findings associated with increased
risk of rupture include increasing diameter
of the aneurysm (> 5 cm), focal discontinuity
in circumferential wall calcifications, and
presence of a crescent-shaped area of high
attenuation in the mural thrombus or in the
aneurysmal wall, known as the hyperattenu-
ating crescent sign [16] (Fig. 15). An early con-
tained rupture may manifest with the “draped
aorta” sign (Fig. 16), which is considered
present when the posterior wall of the aorta
is not identifiable as distinct from adjacent
structures [17]. Rupture is usually associated
with a large retroperitoneal hematoma adja-
cent to the aneurysm [15] (Fig. 17). In pa-
tients with a concomitant coagulopathic con-
dition, it is critical to determine the cause of
the retroperitoneal hematoma because a rup-
tured AAA requires prompt treatment by
surgery or endovascular intervention, where-
as surgery is usually contraindicated in cases
of coagulopathic hemorrhage [14, 15]. The
presence of an aneurysm greater than 4 cm in
diameter with hemorrhage contiguous with
the aorta for a length of at least 3 cm and the
absence of the “hematocrit” sign are findings
suggestive of ruptured AAA [14].
Less common vascular causes of sponta-
neous abdominal hemorrhage include rupture
of a splanchnic artery aneurysm (mainly the
splenic and hepatic arteries) [18] and erosion
of a vessel by an adjacent neoplastic or in-
flammatory disorder (e.g., pancreatitis) [19].
Summary
Knowledge of the common CT manifes-
tations of various causes of spontaneous ab-
dominal hemorrhage allows their accurate
 CT of Spontaneous Abdominal Hemorrhage

diagnosis and has a direct impact on clinical
decision making.
References
1. Swensen SJ, McLeod RA, Stephens DH. CT of
extracranial hemorrhage and hematomas. AJR
1984; 143:907–912
Downloaded from www.ajronline.org by 1.52.235.218 on 11/22/21 from IP address 1.52.235.218. Copyright ARRS. For personal use only; all rights reserved
7. Gayer G, Zandman-Goddard G, Kosych E, Apter
S. Spontaneous rupture of the spleen detected on
CT as the initial manifestation of infectious
mononucleosis. Emerg Radiol 2003; 10:51–52
8. Belville JS, Morgentaler A, Loughlin KR, Tumeh
SS. Spontaneous perinephric and subcapsular re-
nal hemorrhage: evaluation with CT, US and an-
Semin Ultrasound CT MR 2006; 27:117–125
14. Federle MP, Pan KT, Pealer KM. CT criteria for
differentiating abdominal hemorrhage: anticoag-
ulation or aortic aneurysm rupture? AJR 2007;
188:1324–1330
15. Siegel CL, Cohan RH, Korobkin M, Alpern MB,
Courneya DL, Leder RA. Abdominal aortic aneu-

2. Orwig D, Federle MP. Localized clotted blood as
evidence of visceral trauma on CT: the sentinel
clot sign. AJR 1989; 153:747–749
3. Willmann JK, Roos JE, Platz A, et al. Multidetector
CT: detection of active hemorrhage in patients with
blunt abdominal trauma. AJR 2002; 179:437–444
4. Casillas VJ, Amendola MA, Gascue A, Pinnar N,
Levi JU, Perez JM. Imaging of nontraumatic hem-
orrhagic hepatic lesions. RadioGraphics 2000;
20:367–378
5. Kim HC, Yang DM, Jin W, Park SJ. The various
manifestations of ruptured hepatocellular carci-
noma: CT imaging findings. Abdom Imaging
2008; 33:633–642
6. Nunes JO, Turner MA, Fulcher AS. Abdominal
imaging features of HELLP syndrome: a 10-year
retrospective review. AJR 2005; 185:1205–1210
giography. Radiology 1989; 172:733–738
9. Pintar TJ, Zimmerman S. Hyperreninemic hyper-
tension secondary to a subcapsular perinephric
hematoma in a patient with polyarteritis nodosa.
Am J Kidney Dis 1998; 32:503–507
10. Kawashima A, Sandler CM, Ernst RD, et al. Im-
aging of nontraumatic hemorrhage of the adrenal
gland. RadioGraphics 1999; 19:949–963
11. Pham H, Lin EC. Adnexal ring of ectopic preg-
nancy detected by contrast-enhanced CT. Abdom
Imaging 2007; 32:56–58
12. Hertzberg BS, Kliewer MA, Paulson EK. Ovarian
cyst rupture causing hemoperitoneum: imaging
features and potential for misdiagnosis. Abdom
Imaging 1999; 24:304–308
13. Zissin R, Ellis M, Gayer G. The CT findings of
abdominal anticoagulant-related hematomas.
rysm morphology: CT features in patients with
ruptured and nonruptured aneurysms. AJR 1994;
163:1123–1129
16. Arita T, Matsunaga N, Takano K, et al. Abdomi-
nal aortic aneurysm: rupture associated with the
high-attenuating crescent sign. Radiology 1997;
204:765–768
17. Halliday KE, al-Kutoubi A. Draped aorta: CT
sign of contained leak of aortic aneurysms. Radi-
ology 1996; 199:41–43
18. Lambert CJ Jr, Williamson JW. Splenic artery an-
eurysm: a rare cause of upper gastrointestinal
bleeding. Am Surg 1990; 56:543–545
19. Carr JA, Cho JS, Shepard AD, Nypaver TJ, Reddy
DJ. Visceral pseudoaneurysm due to pancreatic
pseudocysts: rare but lethal complications of pan-
creatitis. J Vasc Surg 2000; 32:722–730

A B
Fig. 1—33-year-old man with AIDS and underlying infection with Cytomegalovirus organism causing spontaneous splenic rupture.
A and B, Axial unenhanced (A) and contrast-enhanced (B) CT sections obtained at slightly different levels show splenic laceration (arrow, B) with hyperdense sentinel
clot (ROI [region of interest] 1 = 52 HU, A) surrounding spleen, and relatively lower density lysed blood (ROI 2 = 35 HU, A) surrounding liver.

AJR:193, October 2009 1079

 Furlan et al.

Fig. 2—55-year-old man with acute decrease in

hematocrit level 1 day after colon resection for
adenocarcinoma. Axial contrast-enhanced CT
section shows focus of active extravasation of
contrast material as serpiginous high-attenuation
(140 HU) area (arrow) in large mesenteric hematoma.
Downloaded from www.ajronline.org by 1.52.235.218 on 11/22/21 from IP address 1.52.235.218. Copyright ARRS. For personal use only; all rights reserved

A B
Fig. 3—29-year-old woman with surgically proven ruptured hepatic adenoma.
A, Axial unenhanced CT section shows subcapsular hematoma with higher density sentinel clot (arrow) along right posterior hepatic lobe.
B, Axial contrast-enhanced CT section, obtained at slightly different level from A, shows spherical heterogeneously hypervascular hepatic mass (arrow), adjacent to clot,
proven to be ruptured hepatic adenoma at resection.

A B
Fig. 4—54-year-old man with acute abdominal pain and surgically proven ruptured hepatocellular carcinoma (HCC).
A, Axial unenhanced CT section shows diffusely low-attenuation liver parenchyma and surrounding hyperattenuating perihepatic fluid (white arrows) with ill-defined
subtle mass in left hepatic lobe (black arrow), suggestive of underlying mass.
B, Axial contrast-enhanced CT section, obtained at same level as A, shows spherical heterogeneously hypervascular mass (arrow) in left hepatic lobe. Left hepatic
lobectomy proved bleeding HCC associated with hemoperitoneum.

1080 AJR:193, October 2009

 CT of Spontaneous Abdominal Hemorrhage
Downloaded from www.ajronline.org by 1.52.235.218 on 11/22/21 from IP address 1.52.235.218. Copyright ARRS. For personal use only; all rights reserved

Fig. 5—36-year-old woman with toxemia of pregnancy, right upper quadrant pain,
and falling hematocrit (HELLP [hemolysis, elevated liver enzymes, low platelet
count] syndrome). Axial contrast-enhanced CT section shows nonenhancing
hepatic foci (white asterisk) due to infarction and hematoma, foci of active
bleeding (white arrows), and subcapsular and perihepatic hemorrhage (black
asterisks).
Fig. 6—43-year-old man with underlying B cell lymphoma and spontaneous
splenic rupture. Axial contrast-enhanced CT section shows splenomegaly with
parenchymal laceration (straight white arrow) and large eccentric mass (black
arrows), proven to be tumor and hematoma, with foci of calcification (curved
arrow).

Fig. 7—25-year-old man with tuberous sclerosis and acute onset of right flank
pain due to spontaneous rupture of renal angiomyolipoma. Axial unenhanced CT
section shows large fat-containing mass (arrow) in right kidney with extensive
perirenal hemorrhage (asterisk).

AJR:193, October 2009 1081

 Furlan et al.
Downloaded from www.ajronline.org by 1.52.235.218 on 11/22/21 from IP address 1.52.235.218. Copyright ARRS. For personal use only; all rights reserved

A B

C
Fig. 8—50-year-old man with acute left flank pain due to spontaneous bleeding from renal cell carcinoma (RCC).
A, Axial unenhanced CT section through left kidney shows perirenal hemorrhage (white arrows) and subtle renal peripheral mass (black arrow) that is nearly isodense to
surrounding renal parenchyma. No IV contrast material was given because of prior anaphylactic reaction to its use.
B, Coronal unenhanced T1-weighted (TR/TE, 145/4.2) MR image shows left renal exophytic mass (black arrow) that is isointense to surrounding renal parenchyma and
hyperintense adjacent hematoma (white arrows).
C, Axial unenhanced CT section, obtained 4 weeks later than A, shows partial resolution of perirenal hemorrhage and detectable renal exophytic mass (arrow). RCC was
proven at partial nephrectomy.

1082 AJR:193, October 2009

 CT of Spontaneous Abdominal Hemorrhage
Downloaded from www.ajronline.org by 1.52.235.218 on 11/22/21 from IP address 1.52.235.218. Copyright ARRS. For personal use only; all rights reserved

Fig. 9—66-year-old man with bilateral renal bleeding from Wegener’s vasculitis
who presented with abdominal pain. Axial unenhanced CT section shows bilateral
perirenal hematomas (asterisks).

A B
Fig. 10—46-year-old woman with abdominal pain and hypotension after surgery for colon carcinoma, spontaneous adrenal hemorrhage, and insufficiency.
A and B, Axial unenhanced (A) and contrast-enhanced (B) CT sections obtained at same level show hyperattenuating (68–72 HU), enlarged bilateral adrenal glands
(arrows, A) with no significant enhancement (78–84 HU) (arrows, B) after injection of contrast material.

AJR:193, October 2009 1083

 Furlan et al.
Downloaded from www.ajronline.org by 1.52.235.218 on 11/22/21 from IP address 1.52.235.218. Copyright ARRS. For personal use only; all rights reserved

Fig. 11—42-year-old woman with increasing pelvic pain and negative urine
pregnancy test. Axial contrast-enhanced CT section shows pelvic hematoma
(black arrows) around ring-enhancing left adnexal mass (white arrow) and
adjacent high-attenuation foci indicative of active bleeding (curved arrow).
Rupture of ectopic pregnancy in left fallopian tube was confirmed at surgery.
Serum β-HCG test confirmed elevated levels after completion of CT scan.

A B
Fig. 12—23-year-old woman with sudden onset of pelvic pain due to ruptured corpus luteum with hemoperitoneum.
A and B, Axial contrast-enhanced CT sections through pelvis (A) and lower abdomen (B) show corpus luteum with enhancing wall and intracystic hemorrhagic
component (arrow, A) in left ovary, surrounded by pelvic hematoma (ROI [region of interest], A; mean attenuation, 77 HU; sentinel clot) and relatively lower density blood
in paracolic gutters (ROIs, B; mean attenuation, 34 HU).

1084 AJR:193, October 2009

 CT of Spontaneous Abdominal Hemorrhage
Downloaded from www.ajronline.org by 1.52.235.218 on 11/22/21 from IP address 1.52.235.218. Copyright ARRS. For personal use only; all rights reserved

A B
Fig. 13—Coagulopathic hemorrhage.
A, 80-year-old man undergoing chronic warfarin therapy with acute onset of abdominal pain and palpable abdominal wall mass due to spontaneous coagulopathic
hemorrhage. Axial unenhanced CT section shows enlargement of right rectus abdominal muscle with cellular–fluid level (“hematocrit” sign, arrow), which is diagnostic
of coagulopathic rectus sheath hematoma.
B, 45-year-old woman with hemophilia and back pain due to spontaneous coagulopathic hemorrhage. Axial contrast-enhanced CT section shows multi-compartment
hemorrhage including left perirenal (asterisk) and right iliopsoas with hematocrit sign (straight arrow) and active extravasation of contrast material (curved arrow).

A B
Fig. 14—50-year-old man undergoing heparin therapy for prevention of deep venous thrombosis with spontaneous perirenal hemorrhage.
A, Axial unenhanced CT section shows large hyperdense clot (asterisk) in right perirenal space.
B, Axial unenhanced CT section obtained at same level as A, 14 days after heparin was withheld, shows slow resolution of hematoma (asterisk) and decrease in size and
attenuation.

AJR:193, October 2009 1085

 Furlan et al.
Downloaded from www.ajronline.org by 1.52.235.218 on 11/22/21 from IP address 1.52.235.218. Copyright ARRS. For personal use only; all rights reserved

Fig. 15—74-year-old man with back pain and impending or early rupture of
known abdominal aortic aneurysm (AAA). Axial unenhanced CT section shows
large AAA with crescent-shaped area of high attenuation in mural thrombus
(hyperattenuating crescent sign, arrow), which is associated with increased risk
of rupture.

A B
Fig. 16—70-year-old man with abdominal pain and hypotension due to rupture of abdominal aortic aneurysm (AAA).
A and B, Axial contrast-enhanced CT sections obtained at slightly different levels show large AAA (arrow, A) with eccentric posterior bulge (“draped aorta” sign) and
indistinct margins with iliopsoas compartment (arrows, B).

1086 AJR:193, October 2009

 CT of Spontaneous Abdominal Hemorrhage
Downloaded from www.ajronline.org by 1.52.235.218 on 11/22/21 from IP address 1.52.235.218. Copyright ARRS. For personal use only; all rights reserved

A B
Fig. 17—62-year-old woman with ruptured abdominal aortic aneurysm (AAA).
A and B, Axial unenhanced (A) and contrast-enhanced (B) CT sections obtained at same level show AAA with large adjacent hemorrhage involving multiple right
retroperitoneal compartments (asterisks, A) and periaortic extravasation (arrow, B).

F O R YO U R I N F O R M AT I O N
This article is available for CME credit. See www.arrs.org for more information.

AJR:193, October 2009 1087

 This article has been cited by:

1. Erin Gomez, Karen Horton, Elliot K. Fishman, Pamela T. Johnson. 2021. CT of acute abdominopelvic hemorrhage: protocols,
pearls, and pitfalls. Abdominal Radiology 96. . [Crossref]
2. Adriel Guang Wei Goh, Yi Xiu Chua. 2021. Idiopathic spontaneous lesser sac haemorrhage possibly due to endometrioma.
ANZ Journal of Surgery 2017. . [Crossref]
3. Quinn Dunlap, William M. Mitchell, James Reed Gardner, Deanne King, Rohan Samant, Mauricio Moreno, Emre Vural. 2021.
Downloaded from www.ajronline.org by 1.52.235.218 on 11/22/21 from IP address 1.52.235.218. Copyright ARRS. For personal use only; all rights reserved

Vascularity Outcomes of Lingual Artery Ligation in Transoral Robotic Base of Tongue Resections. Otolaryngology–Head and
Neck Surgery 7, 019459982110174. [Crossref]
4. Leona Hessen, Marie Roumet, Martin Helmut Maurer, Naomi Lange, Helen Reeves, Jean‐François Dufour, Pompilia Radu.
2021. High subcutaneous adipose tissue density correlates negatively with survival in patients with hepatocellular carcinoma.
Liver International 41:4, 828-836. [Crossref]
5. I. V. Shrainer, E. S. Pershina, K. D. Dalgatov, M. V. Kozodaeva. 2021. Computed tomography in planning of the treatment of
complications after pancreatic surgery. Annaly khirurgicheskoy gepatologii = Annals of HPB Surgery 26:1, 48-58. [Crossref]
6. Vasiliki Chatzaraki, Michael J. Thali, Garyfalia Ampanozi. 2021. Diagnostic accuracy of postmortem computed tomography
for bleeding source determination in cases with hemoperitoneum. International Journal of Legal Medicine 27. . [Crossref]
7. Nishita Parmar, Jonathan Langdon, Krithica Kaliannan, Mahan Mathur, Yang Guo, Sowmya Mahalingam. 2021. Wunderlich
Syndrome: Wonder What It Is. Current Problems in Diagnostic Radiology . [Crossref]
8. Meir H. Scheinfeld, Carly Schwartz, Vineet R. Jain, Inessa A. Goldman. 2020. Non-traumatic hemoperitoneum in the ED
setting: causes, characteristics, prevalence and sex differences. Abdominal Radiology 148. . [Crossref]
9. Manabu Nakayama, Kenichi Kato, Kunihiro Yoshioka, Hirotaka Sato. 2020. Coagulopathy-related soft tissue hematoma:
a comparison between computed tomography findings and clinical severity. Acta Radiologica Open 9:5, 205846012092326.
[Crossref]
10. Curtis Tilves, Joseph M. Zmuda, Allison L. Kuipers, J. Jeffrey Carr, James G. Terry, Victor Wheeler, Shyamal D. Peddada,
Sangeeta Nair, Iva Miljkovic. 2020. Associations of Thigh and Abdominal Adipose Tissue Radiodensity with Glucose and
Insulin in Nondiabetic African‐Ancestry Men. Obesity 28:2, 404-411. [Crossref]
11. Haris Chrysikopoulos. Expertise and Competence 41-57. [Crossref]
12. Rajeev Sandal, Atul Saroch, Kundan Mishra, Aditya Jandial, Mohan Kumar, Alka Khadwal, Pankaj Malhotra. 2019. Half and
Half Abdomen. The Journal of Emergency Medicine 57:6, e187-e188. [Crossref]
13. Aaron J. Thomas, Christine O. Menias, Perry J. Pickhardt, Akram M. Shaaban, Ayman H. Gaballah, Sireesha Yedururi, Khaled
M. Elsayes. 2019. Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management. American
Journal of Roentgenology 213:1, 8-16. [Abstract] [Full Text] [PDF] [PDF Plus] [Supplemental Material]
14. Yoshihide Inayama, Eiji Kondoh, Yoshitsugu Chigusa, Shingo Io, Takeshi Funaki, Noriomi Matsumura, Susumu Miyamoto,
Masaki Mandai. 2019. Moyamoya Disease in Pregnancy: A 20-Year Single-Center Experience and Literature Review. World
Neurosurgery 122, 684-691.e2. [Crossref]
15. Khalid W. Shaqdan, Anushri Parakh, Avinash R. Kambadakone, Dushyant V. Sahani. 2019. Role of dual energy CT to improve
diagnosis of non-traumatic abdominal vascular emergencies. Abdominal Radiology 44:2, 406-421. [Crossref]
16. Massimo Tonolini, Anna Maria Ierardi, Gianpaolo Carrafiello. 2018. Elucidating early CT after pancreatico-duodenectomy: a
primer for radiologists. Insights into Imaging 9:4, 425-436. [Crossref]
17. Fabio Garofalo, Radu Pescarus, Ronald Denis, Henri Atlas, Pierre Garneau, Michel Philie, Karl Sayegh. 2018. Laparoscopic
Sleeve Gastrectomy: A Radiological Guide to Common Postsurgical Failure. Canadian Association of Radiologists Journal 69:2,
184-196. [Crossref]
18. Ahmed M. Abbas, Reda S. Hussein, Mustafa Nasr Ali, Mohamed A. Shahat, Abdel-Rahman Mahmoud. 2018. Spontaneous
first trimester posterior uterine rupture in a multiparous woman with scarred uterus: A case report. Middle East Fertility Society
Journal 23:1, 81-83. [Crossref]
19. Ahmed M. Abbas, Armia Michael, Fady Nasif, Shymaa S. Ali. 2018. Spontaneous Rupture of Subserous Uterine Vein in a 35-
Weeks Pregnant Woman Who Presented with Massive Hemoperitoneum. Journal of Gynecologic Surgery 34:1, 46-48. [Crossref]
20. Ahmed M. Abbas, Armia Michael, Shymaa S. Ali, Osama S. Abdalmageed. 2018. Placenta percreta presenting with marked
hemoperitoneum in the first trimester of pregnancy: A case report. Middle East Fertility Society Journal 23:3, 251. [Crossref]
21. Goran Augustin. 505. [Crossref]
 22. Dale E. Hansen, Sridhar Shankar, Mohammad Mansouri, Ajay Singh. Acute Nontraumatic Imaging in the Liver and Spleen
151-163. [Crossref]
23. Mitchell Tublin, Joel B. Nelson, Amir A. Borhani, Alessandro Furlan, Matthew T. Heller, Judy Squires. Coagulopathic
(Retroperitoneal) Hemorrhage 22-23. [Crossref]
24. Rami M. Abazid, Osama A. Smettei, Mohammad Obadah Kattea, Sawsan Sayed, Hanaa Saqqah, Adel M. Widyan, Maksymilian
P. Opolski. 2017. Relation Between Epicardial Fat and Subclinical Atherosclerosis in Asymptomatic Individuals. Journal of
Thoracic Imaging 32:6, 378-382. [Crossref]
Downloaded from www.ajronline.org by 1.52.235.218 on 11/22/21 from IP address 1.52.235.218. Copyright ARRS. For personal use only; all rights reserved

25. Joseph A. Graves, Tarek N. Hanna, Keith D. Herr. 2017. Pearls and pitfalls of hepatobiliary and splenic trauma: what every
trauma radiologist needs to know. Emergency Radiology 24:5, 557-568. [Crossref]
26. Y. Mao, I.S. De Oliveira, S. Hedgire, D. Prapruttam, M. Harisinghani. 2017. Aetiology, imaging features, and evolution of
spontaneous perirenal haemorrhage. Clinical Radiology 72:2, 175.e19-175.e26. [Crossref]
27. . Retroperitoneal Hemorrhage 468-469. [Crossref]
28. Jane J. Lee, Alison Pedley, Udo Hoffmann, Joseph M. Massaro, Caroline S. Fox. 2016. Association of Changes in Abdominal
Fat  Quantity and Quality With Incident Cardiovascular Disease Risk Factors. Journal of the American College of Cardiology
68:14, 1509-1521. [Crossref]
29. Massimo Tonolini, Anna Maria Ierardi, Gianpaolo Carrafiello. 2016. Atraumatic splenic rupture, an underrated cause of acute
abdomen. Insights into Imaging 7:4, 641-646. [Crossref]
30. T. M. Beachler, C. S. Bailey, K. A. McKelvey, J. L. Davis, A. Edwards, M. Diaw, J. M. Vasgaard, M. D. Whitacre. 2016.
Haemoperitoneum in a pregnant mare with an ovarian haematoma. Equine Veterinary Education 28:7, 359-363. [Crossref]
31. Jane J. Lee, Alison Pedley, Udo Hoffmann, Joseph M. Massaro, John F. Keaney, Ramachandran S. Vasan, Caroline S. Fox.
2016. Cross‐Sectional Associations of Computed Tomography (CT)‐Derived Adipose Tissue Density and Adipokines: The
Framingham Heart Study. Journal of the American Heart Association 5:3. . [Crossref]
32. . Coagulopathic (Retroperitoneal) Hemorrhage 26-29. [Crossref]
33. Nicholas A. Bodmer, Kiran H. Thakrar. 2015. Evaluating the Patient with Left Lower Quadrant Abdominal Pain. Radiologic
Clinics of North America 53:6, 1171-1188. [Crossref]
34. Suzanne T. Chong, James H. Ellis, Richard H. Cohan, Ursula S. Knoepp, Travis J. Langley, Darryl Lau, Shokoufeh Khalatbari.
2015. Abdominopelvic hemorrhage: correlation of CT positivity with the subsequent decision to perform blood transfusion.
Abdominal Imaging 40:8, 3348-3353. [Crossref]
35. Amada Sánchez-González, Leyre Riancho-Zarrabeitia, Zaida Salmón-González, José Antonio Riancho, Carmen Valero. 2015.
Clinical spectrum of patients with spontaneous retroperitoneal hematomas. Medicina Clínica (English Edition) 145:7, 301-304.
[Crossref]
36. Nancy A. Hammond, Antonella Lostumbo, Sharon Z. Adam, Erick M. Remer, Paul Nikolaidis, Vahid Yaghmai, Senta M.
Berggruen, Frank H. Miller. 2015. Imaging of adrenal and renal hemorrhage. Abdominal Imaging 40:7, 2747-2760. [Crossref]
37. Amada Sánchez-González, Leyre Riancho-Zarrabeitia, Zaida Salmón-González, José Antonio Riancho, Carmen Valero. 2015.
Perfil clínico de los pacientes con hematomas retroperitoneales espontáneos. Medicina Clínica 145:7, 301-304. [Crossref]
38. Piyush Gupta, Lanka Praveen Kumar, Vipon Kumar. 2015. Spontaneous intra-abdominal bleed following oral anticoagulant
therapy. Medical Journal Armed Forces India 71, S202-S204. [Crossref]
39. Jennifer W. Uyeda, Bradley S. Gans, Aaron Sodickson. 2015. Imaging of Acute and Emergent Genitourinary Conditions: What
the Radiologist Needs to Know. American Journal of Roentgenology 204:6, W631-W639. [Abstract] [Full Text] [PDF] [PDF
Plus]
40. G. Espil, N. Larrañaga, N. Díaz Villarroel, A. Oyarzun, G. Matzke, S. Kozima. 2015. Hemorragia abdominal espontánea:
evaluación por imágenes. Revista Argentina de Radiología 79:2, 86-94. [Crossref]
41. Gabriella Carnevale-Maffé, Pietro Amedeo Modesti. 2015. Out of the blue: the Grey-Turner's sign. Internal and Emergency
Medicine 10:3, 387-388. [Crossref]
42. Oliviero Caleo, Giorgio Bocchini, Sonia Paoletta, Anna Maria Ierardi, Alessandra Scionti, Michele Tonerini, Franco Guida,
Giacomo Sica, Alessandra Perillo, Gianpaolo Carrafiello, Mariano Scaglione. 2015. Spontaneous non-aortic retroperitoneal
hemorrhage: etiology, imaging characterization and impact of MDCT on management. A multicentric study. La radiologia
medica 120:1, 133. [Crossref]
 43. Anna Maria Ierardi, Chiara Floridi, Carlo Pellegrino, Mario Petrillo, Antonio Pinto, Isabella Iadevito, Erica Golia, Alessandra
Perillo, Roberto Grassi, Antonio Rotondo, Gianpaolo Carrafiello. 2015. Role of percutaneous transcatheter embolization (PTE)
in the treatment of spontaneous bleeding associated with anticoagulant therapy. La radiologia medica 120:1, 149-157. [Crossref]
44. Abdullah Alabousi, Michael N. Patlas, Mariano Scaglione, Luigia Romano, Jorge A. Soto. 2014. Cross-Sectional Imaging of
Nontraumatic Emergencies of the Spleen. Current Problems in Diagnostic Radiology 43:5, 254-267. [Crossref]
45. Bhavik N. Patel, Gabriela Gayer. 2014. Imaging of Iatrogenic Complications of the Urinary Tract. Radiologic Clinics of North
America 52:5, 1101-1116. [Crossref]
Downloaded from www.ajronline.org by 1.52.235.218 on 11/22/21 from IP address 1.52.235.218. Copyright ARRS. For personal use only; all rights reserved

46. Nicholas J. Alvey, Alison Pedley, Klara J. Rosenquist, Joseph M. Massaro, Christopher J. O'Donnell, Udo Hoffmann, Caroline
S. Fox. 2014. Association of Fat Density With Subclinical Atherosclerosis. Journal of the American Heart Association 3:4. .
[Crossref]
47. Rodrigo B. Interiano, Regan F. Williams, Elizabeth Paton, Ulrike M. Reiss, Ashok Srinivasan, Claudette Shephard, Eunice
Y. Huang. 2014. Spontaneous Massive Hemoperitoneum From Hemorrhagic Corpus Luteum Cyst As Initial Presentation of
Aplastic Anemia (<100 characters). Journal of Pediatric Surgery Case Reports . [Crossref]
48. Linda Y. Kao, Meir H. Scheinfeld, Victoria Chernyak, Alla M. Rozenblit, Sarah Oh, R. Joshua Dym. 2014. Beyond Ultrasound:
CT and MRI of Ectopic Pregnancy. American Journal of Roentgenology 202:4, 904-911. [Abstract] [Full Text] [PDF] [PDF
Plus]
49. Adam S Wang, J Webster Stayman, Yoshito Otake, Gerhard Kleinszig, Sebastian Vogt, Gary L Gallia, A Jay Khanna, Jeffrey
H Siewerdsen. 2014. Soft-tissue imaging with C-arm cone-beam CT using statistical reconstruction. Physics in Medicine and
Biology 59:4, 1005-1026. [Crossref]
50. George Kasotakis. 2014. Spontaneous Hemoperitoneum. Surgical Clinics of North America 94:1, 65-69. [Crossref]
51. Goran Augustin. Ruptured Ectopic Pregnancy 473-494. [Crossref]
52. Goran Augustin. Miscellaneous Conditions 401-444. [Crossref]
53. Man-Ling Kao, Ping-Yi Lin, Chia-En Heish, Chen-Te Chou, Kuo-Hua Lin, Chih-Jan Ko, Chia-Cheng Lin, Yao-Li Chen.
2013. Predictors of intra-abdominal coagulopathic hemorrhage after living donor liver transplantation. International Journal of
Surgery 11:10, 1073-1077. [Crossref]
54. Massimo Tonolini, Federica Villa, Roberto Bianco. 2013. Multidetector CT imaging of post-robot-assisted laparoscopic radical
prostatectomy complications. Insights into Imaging 4:5, 711-721. [Crossref]
55. Massimo Tonolini, Roberto Bianco. 2013. Nontraumatic splenic emergencies: cross-sectional imaging findings and triage.
Emergency Radiology 20:4, 323-332. [Crossref]
56. Massimo Tonolini, Roberto Bianco. 2013. Mesenterial, omental, and peritoneal disorders in antiretroviral-treated HIV/AIDS
patients: spectrum of cross-sectional imaging findings. Clinical Imaging 37:3, 427-439. [Crossref]
57. Klara J. Rosenquist, Alison Pedley, Joseph M. Massaro, Kate E. Therkelsen, Joanne M. Murabito, Udo Hoffmann, Caroline
S. Fox. 2013. Visceral and Subcutaneous Fat Quality and Cardiometabolic Risk. JACC: Cardiovascular Imaging . [Crossref]
58. Michael N. Patlas, Abdullah Alabousi, Mariano Scaglione, Luigia Romano, Jorge A. Soto. 2013. Cross-Sectional Imaging of
Nontraumatic Peritoneal and Mesenteric Emergencies. Canadian Association of Radiologists Journal 64:2, 148-153. [Crossref]
59. Dale E. Hansen, Sridhar Shankar, Ajay Singh. Acute Nontraumatic Imaging in the Liver and Spleen 125-135. [Crossref]
60. Massimo Tonolini, Sonia Ippolito, Francesca Patella, Marina Petullà, Roberto Bianco. 2012. Hemorrhagic Complications of
Anticoagulant Therapy: Role of Multidetector Computed Tomography and Spectrum of Imaging Findings From Head to Toe.
Current Problems in Diagnostic Radiology 41:6, 233-247. [Crossref]
61. Eduardo Miguel Febronio, George de Queiroz Rosas, Patrícia Prando Cardia, Giuseppe D'Ippolito. 2012. Gravidez ectópica:
ensaio iconográfico com enfoque em achados de tomografia computadorizada e ressonância magnética. Radiologia Brasileira
45:5, 279-282. [Crossref]
62. Afshin Mohammadi, Jalal Porghasem, Arefeh Esmaeili, Mohammad Ghasemi-rad. 2012. Spontaneous rupture of a pancreatic
acinar cell carcinoma presenting as an acute abdomen. International Journal of Surgery Case Reports 3:7, 293-295. [Crossref]
63. Pavani Davuluri, Jie Wu, Yang Tang, Charles H. Cockrell, Kevin R. Ward, Kayvan Najarian, Rosalyn H. Hargraves. 2012.
Hemorrhage Detection and Segmentation in Traumatic Pelvic Injuries. Computational and Mathematical Methods in Medicine
2012, 1-12. [Crossref]
64. C. O’Donnell, P. Bedford, M. Burke. 2011. Massive hemoperitoneum due to ruptured ectopic gestation: Postmortem CT
findings in a deeply frozen deceased person. Legal Medicine 13:5, 245-249. [Crossref]
65. Daniel Bell, Yuranga Weerakkody. HELLP syndrome . [Crossref]
Downloaded from www.ajronline.org by 1.52.235.218 on 11/22/21 from IP address 1.52.235.218. Copyright ARRS. For personal use only; all rights reserved

66. Eric Delabrousse. Key CT Findings 31-61. [Crossref]