A. Blood loose in the peritoneal cavity is called hemoperitoneum (he-mo-peri-to-ne-um). Since peritoneal dialysis (PD) fluid is drained on a schedule, should there be blood loose inside the peritoneal cavity, it will appear in the drainage of the peritoneal dialysis fluid (effluent).

First and foremost, let me assure the reader that this phenomenon is not as bad as it looks.  An innocent peritoneal fluid drainage that comes out pink, or worse (red!), is frightening and shocking. About a thimbleful of blood will make the PD effluent look quite pink and two-to-three thimblefuls will have the entire drainage bag quite red. This is about the same amount of blood that is drawn for your monthly lab work. So at least relax regarding the amount of blood lost.

There are a number of causes for hemoperitoneum from trivial nuisances to very serious disorders. In females, there are varieties of gynecologic causes that explain more than 90 percent of all the episodes of hemoperitoneum in PD patients. First, the simple process of ovulation can result in blood loss in the peritoneal cavity as the egg separates from the ovary to find its way to the Fallopian tubes. That bleeding is quite temporary and may be gone within a few hours. It would most likely be without any symptoms. On the other hand, a ruptured ovarian cyst could cause bleeding in a similar manner but more likely is associated with pain.

During menses, there may be retrograde (backward) flow of blood from the uterus (womb) into the peritoneal cavity instead of or in addition to the vagina. This may be associated with menstrual cramps. Endometriosis is a disorder where biologically active cells lining the womb spread and grow outside the womb. These cells can cause bleeding in a variety of ways and this may be associated with pelvic pain independent of seeing any blood.

There may be cysts in other organs that rupture, such as liver or kidney cysts. Such ruptures may result in loose blood within the peritoneum. In addition, trauma can tear tissue within the abdomen and result in bleeding, especially in patients taking blood thinners. All of the above-mentioned entities can be so minor as to just be a frightening nuisance, but on occasion could lead to significant discomfort and blood loss.

More serious causes of hemoperitoneum include trauma severe enough to rupture the spleen, or spontaneous rupture of the spleen as might be seen in some hematologic or liver disorders. Cancers such as bowel, pancreas, liver, kidney, ovary or bladder could cause visible blood in PD fluid. A ruptured spleen would be associated with pain, but these other phenomenon may not be. Ischemic bowel (intestines not getting enough blood due to vascular disease) and pancreatits (often due to gallstones) can cause hemoperitoneum and are accompanied by pain and significant consequences. Peritoneal dialysis does not predispose a patient to have other disorders.

I try to warn women of child bearing age of these disorders because the gynecologic causes represent almost all the cases we see in PD patients. To be assured in training that such events can happen is somewhat of a comfort when the shock of a bloody bag occurs.

The treatment, of course, depends on the cause. Since most cases are short-lived phenomena, the initial treatment may be increasing the frequency of exchanges to wash out or prevent clots and/or the administration of the blood thinner, heparin, into the inflow PD fluid. This may seem strange, but the goal is to not let a blood clot clog up the PD catheter. The bleeding is self-limited and not prolonged by the local effect of the heparin. Occasionally, placing room temperature dialysate into the peritoneum to constrict bleeding vessels is recommended. This “cool” dialysate is like a cold compress, causing vessels to constrict, reducing bleeding.

If the medical history does not suggest an obvious cause, then a more definitive diagnostic evaluation is indicated.

Answer provided by Thomas Golper, MD. Dr. Golper is a professor of medicine at the Vanderbilt University Medical Center , Division of Nephrology and a member of the AAKP Medical Advisory Board.

The Dear Doctor column provides readers with an opportunity to submit renal related health questions to healthcare professionals who specialize in the area of concern. The answers are not to be construed as a diagnosis and therefore, altercations in current healthcare should not occur until the patient's physician is consulted.

This article originally appeared in aakpRENALIFE, May 2004 Volume 19 Number 6. 

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