# The Delayed Presentation of Abdominal Apoplexy Following Initial Negative Imaging: A Diagnostic Challenge

## TL;DR

A rare case of delayed abdominal bleeding highlights the diagnostic challenge of abdominal apoplexy and the importance of timely intervention.

## Contribution

This case report emphasizes the diagnostic difficulty and management of idiopathic spontaneous intraperitoneal hemorrhage with delayed presentation.

## Key findings

- Initial imaging failed to detect bleeding, delaying diagnosis until hemodynamic deterioration occurred.
- Damage control laparotomy and middle colic artery ligation were necessary for treatment.
- CT angiography and angioembolization are recommended diagnostic and therapeutic options.

## Abstract

Abdominal apoplexy, or idiopathic spontaneous intraperitoneal hemorrhage (ISIH), is a rare and life-threatening condition caused by the rupture of a mesenteric vessel, leading to massive abdominal bleeding and potential hemodynamic shock. This report presents the case of a 62-year-old patient with hypertension and anticoagulant use who arrived at the emergency department with abdominal and unusual chest pain. Initial imaging did not show signs of bleeding, delaying diagnosis until significant hemodynamic deterioration occurred, necessitating a damage control exploratory laparotomy to evacuate hemoperitoneum and ligate the middle colic artery. The double rupture phenomenon can complicate diagnosis, highlighting the importance of vigilance in patients with risk factors. CT angiography (CTA) is the preferred diagnostic method, while angioembolization is suitable for hemodynamically stable patients. Immediate resuscitation and surgical intervention are critical in unstable patients.