Conservative Management of Idiopathic Spontaneous Intraperitoneal Hemorrhage

Idiopathic spontaneous intraperitoneal hemorrhage (ISIH), also known as abdominal apoplexy, is a rare and life-threatening cause of acute abdomen that typically requires surgical or endovascular intervention. Conservative treatment is rarely reported, particularly in the setting of hemorrhagic shock. We describe a 59-year-old postmenopausal woman with no anticoagulant use who initially presented with nonspecific gastrointestinal symptoms and then developed hypotension, lactic acidosis, and a significant drop in hemoglobin. Computed tomography (CT) angiography revealed a large mesenteric hematoma with moderate hemoperitoneum and a small focus concerning for extravasation. Follow-up imaging showed no active bleeding, and the patient remained without peritoneal signs. She was managed conservatively in the intensive care unit with fluid resuscitation, brief vasopressor support, and blood transfusion. Her condition stabilized, and she was discharged within a week. Repeat imaging at three months showed complete resolution. This case demonstrates that in carefully selected patients with ISIH, conservative management can be safe and effective. Key considerations include hemodynamic stabilization after resuscitation, absence of peritonitis, no active bleeding on repeat imaging, and availability of close inpatient monitoring. A multidisciplinary approach may support non-operative treatment in situations where surgical or endovascular intervention is not immediately necessary.