Laparoscopic Treatment of The Gastro-Omental Hemangioma Hemorrhage: 2 Cases Report And Review of The Literature

doi:10.21203/rs.3.rs-1251975/v1

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Laparoscopic Treatment of The Gastro-Omental Hemangioma Hemorrhage: 2 Cases Report And Review of The Literature

https://doi.org/10.21203/rs.3.rs-1251975/v1

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posted 18 Jan, 2022

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Background: Spontaneous hemorrhage of gastro-omental hemangioma is a rare disease. Such patients generally have no medical history of recent abdominal trauma, abdominal surgery, anticoagulation or systemic vascular disease. Treatment strategy of this disease variates along with its development. In the acute circumstances, surgery is somehow the first priority. Among them, laparoscopic treatment should be the most frequently considered option in the large general hospital, however, such cases are rarely reported until now.

Case presentation: The present report enrolled two cases admitted with upper abdominal pain. Subsequent abdominal computed tomography (CT) scan revealed masses alongside the greater curvature of the stomach. Laparoscopic surgeries were conducted immediately and the postoperative pathological examination suggested ruptured omental hemangioma with thrombosis. Both two patients recovered smoothly after surgery, and no obvious abnormalities were complained in the follow-up period.

Conclusions: Clinicians should consider the possibility of spontaneous rupture of gastro-omental hemangioma in patients with abdominal stroke. The center of medical institutions with mature technology and equipment can perform laparoscopic treatment to minimize surgical trauma and promote rapid recovery of the cases with abdominal apoplexy.

Surgery

Laparoscope

Gastro-omental hemangioma

Hemorrhage

Abdominal Apoplexy.

Spontaneous hemorrhage of gastro-omental hemangioma is a rare disease, and there may be no recent history of abdominal trauma, surgery, anticoagulant therapy, and/or systemic vascular disease in such patients. Clinical diagnosis should be identified with abdominal B-ultrasound, abdominal CT, abdominal puncture and/or other auxiliary examinations. The methods of treating this disease usually depend on its development and the the patient's conditions. In the onset or chronic phase, clinic observation and medical treatment are routine options, while in the advanced or acute phase, surgical treatment should be a better choice [1, 2]. Recently, there are some case reports on the gastro-omental hemangioma hemorrhage, however, few studies on its laparoscopic treatment [3]. In this article, we present two elderly cases with spontaneous gastro-omental hemangioma hemorrhage and huge intra-abdominal hematoma underwent laparoscopic surgery and both achieved a good treatment effect. The two cases recovered smoothly after operation, and there was no discomfort in the follow-up period.

Case 1: A 61-year-old female was admitted to our hospital on September 16, 2018 due to persistent dull pain in the middle and upper abdomen for > 2 months and aggravated for 1 day. According to the patient's self-report, there was no obvious inducement for the persistent dull pain before her admission, which was persistent dull pain accompanied by paroxysmal aggravation. The pain was relieved after taking an oral anodyne (the drug's specific name and dosage unknown) prescribed by one of the local physicians, and no further examination or treatment was given. One day before her admission to our hospital, the patient experienced persistent abdominal distension with sharp tingling pain and paroxysmal aggravation. The stool and body weight of the case were normal, but the urine became dark brown 1 day before her admission. Past medical history: denying history of hypertension, diabetes, hepatitis, tuberculosis, heart disease, abdominal trauma and operation.

Physical examination showed the patient had an acute facial features and pallid eyelid conjunctiva, and the skin was clammy and less elastic, with the body temperature (T) of 36.5℃, pulse frequency (P) of 80 beats/min, respiration frequency (R) of 20 beats/min and blood pressure (BP) of 126/80mmHg. The abdomen was flat, without damage, petechiae, bleeding point, varicose vein, gastrointestinal type and peristaltic wave. However, there was a deep tenderness in middle and upper abdomen with moderate rebound pain and muscle tension. Abdominal mass was not palpated, liver and spleen costal margin was not touched, Murphy's sign was negative, nevertheless, abdominal moving dullness was positive and non-coagulated blood was extracted by diagnostic abdomen puncture. Routine blood examination showed the following: white blood cell (WBC) of 9800/mm³ (normal range 4000–10000/mm³), red blood cell (RBC) of 3100/cm³ (normal range 3800–5100/cm³), platelet (PLT) of 130/cm³ (normal range 100–300/cm³), Hematocrit (HCT) of 0.283 (normal range 0.350–0.450), and the concentration of hemoglobin (HGB) of 91 g/dL (normal range 115-150 g/dL). No abnormality was found in coagulation function examination. The above results indicated that the patient had an intraperitoneal hemorrhage combined with moderate anemia. The results of abdominal B-ultrasound showed there was a medium amount of effusion in the abdominal cavity, including perihepatic effusion of about 3.9 cm, perisplenic effusion of about 2.2 cm, intestinal effusion of about 3.2 cm and pelvic effusion of about 2.8 cm in diameter. Abdominal enhanced computed tomography (CT) showed that there was effusion in the abdomen and pelvis, suspicious blood accumulation around the liver and spleen, and a slightly patchy high-density shadow on the side of the great curvature of the gastric body, about 9.8 × 6.9 × 6.5 cm in size (Figure. 1A). Emergency laparoscopic exploration was performed subsequently. During the procedure, about 1400ml of bloody fluid was found in the abdominal pelvic cavity, and an elliptical mass about 10.1 × 8.2 × 8.0 cm in size with surrounding blood clot was detected in the omentum of the greater curvature of the gastric body (Figure. 1B). The boundary of the mass was unclear, accompanied by active hemorrhage, which was hard to be separated from the greater curvature of the gastric body. Therefore, the mass and the attached wedge-shaped stomach wall were removed together by an endoscopic linear cutting stapler (EC60A, Ethicon) (Figure. 1C). Postoperative hemostasis, anti-infection and symptomatic treatment were given. Postoperative pathological examination showed a gastric omental hemangioma with hemorrhage (Figure. 1D), and the patient was discharged on postoperative Day 7. No complaints of special discomfort were mentioned in the 1 year followed-up period (data not shown).

Case 2: Another 81-year-old male was admitted on December 13, 2020 due to upper abdominal pain for 20 hours. According to the patient's readme, there was no obvious cause of paroxysmal abdominal cramps before admission, which was worsened after eating, without chills, fever, hematemesis, melena and other symptoms. The local physician considered the diagnosis of unexplained abdominal pain and gave him analgesic and symptomatic treatment. Not only the symptoms were not relieved, but also abdominal distension gradually appeared, so he came to our hospital. Past history includes hypertension for approximately 10 years, and the highest blood pressure can reach 180/110mmHg. Nifedipine was used to control blood pressure. The case also suffered from cerebral infarction for > 1 year, which caused a decrease in left limb muscle strength. Since then, he received long-term oral administration of aspirin enteric-coated tablets (90mg per day, AstraZeneca) and atorvastatin calcium tablets (20mg per day, Pfizer). Denies history of hepatitis, tuberculosis, heart disease, diabetes, trauma, surgery and blood transfusion.

Physical examination indicated that the case had an acute facial features, clammy and weakened elastic skin, with T 36.7℃, P 90 beats/min, R 25 beats/min and BP 138/90mmHg. The abdomen was flat, without damage, scar, petechiae, bleeding point, varicose vein, gastrointestinal type and peristalsis wave. Middle and upper abdomen dad a moderate tenderness and rebound pain, without muscle tension. Abdominal mass was not touched, and the costal margin of liver and spleen costal margin were not reached, Murphy's sign was negative, and no percussion pain was existed in the area of liver and kidney area, however, abdominal moving dullness was strongly positive and non-coagulated blood was obtained by diagnostic abdominal puncture. Routine blood examination showed the following: WBC 9800/mm³, RBC 3200/cm³ (normal range 4300–5800/cm³), PLT 91/cm³, HCT 0.311 (normal range 0.400–0.500), HGB: 107g/L (normal range 130-175 g/dL), and the coagulation index was normal. The above results confirmed that the patient had an intraperitoneal hemorrhage combined with moderate anemia. Abdominal enhanced CT scan: 1. Obvious local lumen stenosis at the beginning of the Celiac axis, with a few calcifications on the wall, which was considered as atherosclerosis. Calcified plaques were formed in abdominal aorta, bilateral common iliac artery, bilateral internal iliac artery, and right external iliac artery, partially accompanied by mural thrombosis(Figure. 2A). 2. Hematoma was formed in the upper left abdominal cavity. The boundary between hematoma and the greater curvature of the gastric wall was unclear, and the abdominal pelvic fluid/blood was detected (Figure. 2B). The hematoma was 10.2 × 9.5 × 3.3 cm in size and located in the greater curvature of the stomach. Their boundary was not clear. The procedure was conducted by removing the mass and partly attached gastric wall with an endoscopic linear cutting stapler (EC60A, Ethicon) (Figure. 2C). Postoperative pathological result confirmed the diagnosis of ruptured omental hemangioma accompanied by thrombosis ( Figure. 2D). The patient was discharged on postoperative Day 8 and no obvious abnormalities were reported in the 6-month outpatient visit follow-up period (data not shown).

The pathogenesis of intraperitoneal bleeding variates with many causes, including trauma, iatrogenic, ruptured aneurysm, gynecological disease, malignant tumor, and inflammatory or autoimmune processes, but spontaneous or idiopathic bleeding is rare. Abdominal apoplexy is a type of acute abdomen, which usually caused by unknown factors, along with intra-abdominal vascular spontaneous rupture and retroperitoneal hemorrhage. Until now, the pathogenesis of abdominal apoplexy is still unclear, but according to a few reports domestically and abroad, the possible cause are as follows: 1. Abdominal organ vascular malformation, visceral tumor, abnormal coagulation function, liver cirrhosis, hypertension, arteriosclerosis, rheumatism, immune system diseases and so on. It has been documented that that visceral vascular rupture can lead to abdominal bleeding. Kumari J et al.[3] reported the occurrence of a case of spontaneous intraperitoneal bleeding without obvious inducement during pregnancy. Pancreatic tumor fibroma has also been reported as one of the rare causes of abdominal bleeding [4]. In addition, the rupture of large liver cancer and female uterine fibroids can also lead to the possibility of accidental bleeding in the abdominal cavity [5-7]. Aseni P et al. [8] observed that spontaneous intraperitoneal bleeding occurred in patients with cirrhotic portal hypertension without traumatic cause. Xu Y et al. [9] reported that patients with arteriosclerosis also have the possibility of spontaneous abdominal bleeding. Merichal M et al. [10] presented that acute abdomen with abdominal bleeding as the main manifestation caused by gastric torsion. Lin HH et al. [11] reported that some abdominal varicose veins can lead to spontaneous abdominal bleeding. 2. A small number of young people with no definite cause may also have the risk of abdominal apoplexy [1]. 3. Gastro-omental hemangioma rupture is another infrequent cause of intraperitoneal hemorrhage as reported in this paper.

It has been presented that the case with abdominal apoplexy should underwent auxiliary examination, including blood routine examination, abdominal B-ultrasound, abdominal X-ray, abdominal CT, computed tomography angiography (CTA), angiography, intervention, etc [3-11]. Surgeons often choose different treatment measures for abdominal apoplexy, as follows: 1. Conservative treatment: thrombin, blood transfusion and rehydration are selectively given to the patients with unclear diagnosis, small amount of bleeding or stable vital signs [19]; 2. Surgical treatment: For those with clear surgical indications, who suffered from large amount of blood loss, poor or ineffective conservative treatment, exploratory laparotomy is strongly recommended. The surgical treatment can be roughly divided into two types: laparoscopic exploration and open laparotomy [20]. 3. Interventional therapy: Patient with definite bleeding sites who has stable hemodynamics could underwent if the bleeding site is special or with high risk of surgical methods [21].This article reported 2 cases of gastro-omental angioma with spontaneous rupture and bleeding. As one of the rare causes of abdominal apoplexy, there are currently few literature reports. The specific pathogenesis of this disease is still unclear, but the following high-risk factors need to be considered when coming to the diagnosis: 1. The elderly patients with cardiovascular disease, such as Hypertension, arteriosclerosis, hyperlipidemia, coronary heart disease, etc, who take long-term oral anticoagulant medicine should be considered the possibility of gastro-omental angioma rupture [17]. For instance, the second case in this paper suffered from primary hypertension, with a blood pressure of up to 180/110mmHg occasionally, and had a past history of cerebral infarction and a long-term oral aspirin anticoagulation therapy subsequently. 2. This disease can also occur in some patients without high-risk factors and no obvious triggers [14]. 3. Patients with congenital vascular malformations can also have abdominal apoplexy, especially in the case of overeating, alcoholism, etc. It is more likely to cause abdominal apoplexy after severe vomiting [15, 16].

According to a few reports that the mortality was up to 100% of the patients with abdominal apoplexy who treated with conservative methods [1, 12, 13]. If the bleeding site could be found by exploratory laparotomy and the bleeding can be controlled effectively, the mortality can be reduced down to around 8.6%, however, it will go up to 54.8% while the bleeding site could not be detected eventually, and the main causes of death were hemorrhagic shock and its corresponding complications [12]. In this article, although the vital signs and hemodynamics were relatively stable for the two cases as we presented, we choose operation due to the cases were both with advanced ages and their tolerance to bleeding was poor, moreover, the abdominal B-ultrasound and CT examination all confirmed hevy amount of intra-abdominal bleeding and the bleeding sites were undefined, therefore, laparoscopic laparotomy was performed for the patients. In the 6 months and 12 months outpatient follow-up respectively, no obvious abnormalities were reported in the 2 cases, which indicated a good prognostic effect. It is well-known that the laparoscopic technology has developed rapidly in recent years and the laparoscopic surgery has the advantages of less trauma and quick recovery. The both two patients recovered smoothly and were discharged from the hospital about 1 week after the operation. Therefore, for patients with abdominal stroke, especially for elderly patients, laparoscopic treatment in non-emergency situations might be the first choice for treatment.

In summary, clinicians should consider the possibility of spontaneous rupture of gastro-omental hemangioma when facing patients with high-risk factors for abdominal apoplexy, and laparoscopic exploration should be conducted in medical institutions with rich experience in laparoscopic treatment, which would largely reduce the surgical trauma of the patients and help them to recover quickly. Although, laparoscopic treatment of abdominal apoplexy achieved good therapeutic effect in our present report, but patients with difficulty in laparoscopic surgery could be converted to open laparotomy or direct exploratory laparotomy.

Consent

Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor of this journal.

CT: Computed Tomography; T: Body Temperature; P: Pulse Frequency; R: Respiration Frequency; BP: Blood Pressure; WBC: White Blood Cell; RBC: Red Blood Cell; PLT: Platelet; HCT: Hematocrit; HGB: Concentration of Hemoglobin.

Authors’ contributions: Yin LK and Liu JJ contributed equally to this work. Yin LK, Liu JJ and Wang P wrote the manuscript; Yin LK, Liu JJ, Feng YG, Yuan HY and Wang P diagnosed and treated; all authors discussed the results and commented on the manuscript.

Supported by the program of strategic cooperation in science and technology of Nanchong City of China (No. 18SXHZ0110)

Informed consent statement: This is a retrospective study and informed consent is not required.

Telephone: +86-817-2598151 Fax:+86-817-2598151

Acknowledgements

Not applicable.

Competing interests

All authors declare that they have no competing interests.

Funding

This work was supported by the program of strategic cooperation in science and technology of Nanchong City of China(18SXHZ0110).

Availability of data and materials

Not applicable.

Ethics approval and consent to participate

The need for ethic approval is not subject to the hospital ethics committee due to simple case reporting. The patient provided informed consent for this paper.

Author details

Department of Gastrointestinal surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000, China.

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No competing interests reported.

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Laparoscopic Treatment of The Gastro-Omental Hemangioma Hemorrhage: 2 Cases Report And Review of The Literature

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Abstract

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Case Presentation

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