Spontaneous hemoperitoneum in cats_65 cases

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Spontaneous hemoperitoneum in cats: 65 cases (1994–2006) William T. N. Culp, vmd, dacvs; Chick Weisse, vmd, dacvs; Melissa E. Kellogg, dvm; Ira K. Gordon, dvm, dacvr; Dana L. Clarke, vmd; Lauren R. May, vmd, dacvs; Kenneth J. Drobatz, dvm, msce, dacvecc, dacvim

Objective—To describe the clinical signs, physical examination findings, clinical laboratory abnormalities, etiology, and outcome in cats with spontaneous hemoperitoneum.

Design—Retrospective case series.

Animals—65 client-owned cats with spontaneous hemoperitoneum.

Procedures—Medical records of cats with spontaneous hemoperitoneum at 7 large referral clinics were reviewed. Cats were included if a definitive diagnosis of spontaneous hemoperitoneum could be obtained from review of the medical records.

Results—65 cats met inclusion criteria. The most common historical findings were lethargy, anorexia, and vomiting. Common findings on physical examination included inadequate hydration status and hypothermia. The most common clinicopathologic abnormalities were high serum AST activity, anemia, prolonged prothrombin time, and prolonged partial thromboplastin time. Forty-six percent (30/65) of cats had abdominal neoplasia, and 54% (35/65) had nonneoplastic conditions. Hemangiosarcoma was the most often diagnosed neoplasm (18/30; 60%), and the spleen was the most common location for neoplasia (11/30; 37%). Eight cats survived to be discharged from the hospital. Cats with neoplasia were significantly older and had significantly lower PCVs than cats with nonneoplastic disease.

Conclusions and Clinical Relevance—Spontaneous hemoperitoneum in cats often results in debilitating clinical consequences. In contrast to dogs with hemoperitoneum, the cause of hemoperitoneum in cats is approximately evenly distributed between neoplastic and nonneoplastic diseases. Although only a few cats were treated in this study, the prognosis appears poor. (J Am Vet Med Assoc 2010;236:978–982)

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emoperitoneum in companion animals is categorized according to etiology, specifically being traumatic or spontaneous.1–3 Traumatic hemoperitoneum is further divided into blunt causes of trauma (ie, motor vehicle accidents and high-rise falls) and penetrating trauma (ie, gunshot wounds and bite wounds). Some recorded causes of spontaneous hemoperitoneum in the veterinary literature include neoplasia, hematoma rupture, gastrointestinal ulcer perforation, coagulopathy, vena caval syndrome, and intra-abdominal organ torsion.1,4 Spontaneous hemoperitoneum in cats is a rarely encountered but clinically important disease process. In 1 study1 of hemoperitoneum in cats, bleeding was of hepatic origin in 12 of 16 cats. Of the 16 cats reviewed in that study, 7 were bleeding from a tumor, including hemangiosarcoma, lymphosarcoma, and mast cell tumors. Hemoperitoneum secondary to ruptured splenic hemangiosarcoma in 4 cats has also been reported.5

Abbreviations ALP ALT AST

Alkaline phosphatase Alanine transaminase Aspartate transaminase

While spontaneous hemoperitoneum in cats is uncommon, it is a life-threatening condition that has been minimally characterized in the veterinary literature. The purpose of the study reported here was to describe the signalment, clinical signs, physical examination findings, clinical laboratory abnormalities, etiology, surgical treatment, and outcome in cats with spontaneous hemoperitoneum.

Materials and Methods Criteria for selection of cases—A retrospective, multiinstitutional study was performed. The medical records

From the Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104 (Culp, Weisse, Drobatz); the Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, Saint Paul, MN 55108 (Kellogg, May); the Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, CA 95616 (Gordon); and the Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, East Lansing, MI 48823 (Clarke). Dr. Culp’s present address is School of Veterinary Medicine, University of California-Davis, Davis, CA 95616. Dr. Weisse’s present address is Animal Medical Center, 510 East 62nd St, New York, NY 10065. Dr. Kellogg’s present address is Veterinary Surgical Associates, 1410 Monument Blvd, Concord, CA 94520. Dr. Gordon’s present address is Radiation Oncology Branch of the National Cancer Institute, 10 Center Dr, Bethesda, MD 20892. Dr. Clarke’s present address is the Veterinary Hospital of the University of Pennsylvania, 3800 Spruce St, Philadelphia, PA 19104. Dr. May’s present address is Veterinary Specialists of Rochester, 825 White Spruce Blvd, Rochester, NY 14623.

The authors thank Drs. Aylin Attilla, Victoria Campbell, Craig Clifford, Mathieu Glassman, and Rebecca Risbon for assistance.

Address correspondence to Dr. Culp (wculp@ucdavis.edu).

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Procedures—Data were recorded in a commercially available spreadsheet program.a Data recorded from the medical records included signalment, historical findings, physical examination findings, clinical laboratory findings from CBC, serum biochemical analysis, coagulation profiles, and FeLV-FIV status. Clinical laboratory data were obtained from several clinics with different reference ranges, and comments about abnormalities of the data are specific to the individual laboratory. Findings of imaging studies, surgical treatments pursued, etiology, and outcome were also recorded.

Statistical analysis—Continuous variables were assessed for normality by use of the Shapiro-Wilk test.

Those variables that were not normally distributed are described with median (range), whereas normally distributed variables are described by use of mean ± SD. Proportions are expressed as percentages. Receiver operating curve analysis for PCV and age was used to determine optimal cutoffs (maximizing correct classification and determining sensitivity and specificity) for diagnosing neoplasia as the underlying cause of the hemoperitoneum. The trapezoid method was used to determine the area under the curve for receiver operating curve analysis. All statistical evaluations were performed by use of a statistical software program.b Values of P < 0.05 were considered significant.

Results Sixty-five cats were determined to have spontaneous hemoperitoneum during the study period. Of the 65 cats, 31 (48%) were males (30 castrated and 1 sexually intact) and 34 (52%) were females (30 spayed and 4 sexually intact). Cat breeds included domestic shorthair (41/65; 63%), domestic longhair (8/65; 12%), unknown breed (7/65; 11%), Abyssinian (2/65; 3%), Devon Rex (2/65; 3%), Siamese (2/65; 3%), Maine Coon JAVMA, Vol 236, No. 9, May 1, 2010

(1/65; 2%), Norwegian Forest (1/65; 2%), and Persian (1/65; 2%). Mean age was 9 ± 4.5 years.

The most common historical findings were lethargy (38/65; 58%), anorexia (33/65; 51%), and vomiting (19/65; 29%). On initial physical examination, 83% (54/65) of cats had diminished hydration status, and 42% (27/65) were considered either underweight or cachectic. Mean rectal temperature was 36.6 ± 1.8°C (97.9 ± 3.3°F). Sixty-eight percent (44/65) of cats had a low rectal temperature and 25% (16/65) had a high rectal temperature, compared with reference range values (38.1° to 39.2°C [100.5° to 102.5°F]). Mean heart rate was 172 ± 50.9 beats/min. A heart murmur was ausculted in 28% (18/65) of cats, pale mucous membranes were observed in 40% (26/65) of cats, and depressed mentation was observed in 40% (26/65) of cats. Mean respiratory rate was 46 ± 22 breaths/min. Clinical signs related to the respiratory system (open-mouth breathing, dull lung sounds, increased respiratory effort) were noted in 25% (16/65) of cats. Forty-six percent (30/65) of cats had an abnormal finding on abdominal palpation, including abdominal distension (18/65; 28%), signs of abdominal discomfort (7/65; 11%), and a palpable abdominal mass (5/65; 8%).

Results of CBC and serum biochemical analysis were not available for all cats (Table 1). Median PCV was 20% (range, 6% to 56%; reference range, 28% to 40%), and 83% (50/60) of cats were anemic. Median total protein concentration was 6.2 g/dL (range, 3.3 to 12.9 g/dL; reference range, 6 to 8.6 g/dL), and the median serum albumin concentration was 2.4 g/dL (range, 1.3 to 3.7 g/dL; reference range, 2.4 to 3.8 g/dL). Fiftyfive percent (23/42) of cats were hypoalbuminemic. All cats (n = 10) that were not anemic at the time of admission were hyperproteinemic. Median serum ALT activity was 79 U/L (range, 37 to 1,860 U/L; reference range, 33 to 152 U/L), median serum AST activity was 96 U/L (range, 23 to 2,647 U/L; reference range, 1 to 37 U/L), and the median serum ALP activity was 34 U/L (range, 3 to 399 U/L; reference range, 22 to 87 U/L). Serum activities of AST, ALT, and ALP were high in 57% (20/35), 50% (20/40), and 7% (3/41) of cats, respectively. Fifteen of 26 (58%) cats with liver disease had high serum liver enzyme activities, and 5% (2/39) of cats without liver disease had high serum liver enzyme activities. Median serum lactate concentration was 3.5 mg/dL (range, 1 to 13 mg/dL; reference range, 0 to 2 mg/dL). Seventy-nine percent (19/24) of cats were hyperlactatemic.

Seventy-seven percent (20/26) of cats tested had a prolongation of the prothrombin time, and 76% (19/25) of cats tested had a prolongation of the partial thromboplastin time. Of the 18 cats tested for FeLV or FIV, no positive results were noted.

Of the 65 cats, 34 (52%) had a diagnosis of hemoperitoneum on the basis of findings on abdominocentesis, 29 (45%) on the basis of necropsy findings, and 2 (3%) on the basis of surgical findings. The PCV and the total protein concentration of the peritoneal effusion were recorded for 17 cats. Mean PCV of the peritoneal effusion was 21 ± 10%, and mean PCV of peripheral blood in the same 17 cats was 22 ± 10%. Mean total protein concentration of the peritoneal effusion was 4.9 ± 1.7 g/dL, and mean peripheral blood total protein in the same 17 cats was 6.6 ± 2.1 g/dL. Scientific Reports

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databases of the following clinics from the years 1994 through 2006 were searched: University of Pennsylvania School of Veterinary Medicine, University of Minnesota College of Veterinary Medicine, University of California-Davis School of Veterinary Medicine, Michigan State University College of Veterinary Medicine, University of Georgia College of Veterinary Medicine, Colorado State University College of Veterinary Medicine, and Red Bank Veterinary Hospital. Keywords included in the database search were cat, cats, feline, hemoperitoneum, and hemoabdomen.

Hemoperitoneum was defined as a hemorrhagic effusion (lesion resulting in bleeding was identified during surgery or necropsy) within the peritoneal cavity,4,6–8 and cats were diagnosed with hemoperitoneum either by abdominocentesis, during surgery, or at necropsy. Exclusion criteria included a recent surgery, confirmed external trauma, or lack of definitive diagnosis via histologic examination of tissue specimens obtained by surgical biopsy or necropsy.

Ninety-five cats with hemoperitoneum were initially identified from the medical record database review. Of those cats, 5 had postsurgical hemoperitoneum and 5 had hemoperitoneum secondary to trauma, and a definitive diagnosis of the cause of hemoperitoneum was not obtained in 20 cats; this left medical records of 65 cats with spontaneous hemoperitoneum to be analyzed.

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Table 1—Clinical laboratory data for cats with spontaneous hemoperitoneum.

Variable

No. of cats

Median

Range

Reference range

Cats with Cats with values  RR (%) values  RR (%)

PCV (%) TP (g/dL) WBC (/µL) Platelets (/µL) Lactate (mg/dL) Glucose (mg/dL)

60 58 43 32 24 51

20 6.2 13,250 216,000 3.5 147

6–56 3.3–12.9 2,500–33,600 13,000–353,000 1–13 46–613

28–40 6–8.6 4,004–18,700 175,000–500,000 0–2 67–168

83 36 7 66 0 2

3 15 28 0 79 35

0.025† 0.722 0.230 0.459 0.323 0.891

BUN (mg/dL) Creatinine (mg/dL) Albumin (g/dL) Globulin (g/dL) ALT (U/L) AST (U/L)

47 44 42 31 40 35

34 1.7 2.4 3.2 79 96

10–308 0.3–19.6 1.3–3.7 1.8–9.7 37–1,860 23–2,647

15–32 0–2 2.4–3.8 3.1–5 33–152 1–37

4 0 55 29 0 0

57 41 0 10 50 57

0.939 0.233 0.803 0.513 0.132 0.129

ALP (U/L) GGT (U/L) Cholesterol (mg/dL) Bilirubin (mg/dL) Sodium (mg/dL) Potassium (mmol/L)

41 27 39 39 49 49

34 5 114 0.4 147 4

3–399 0–19 65–269 0.1–7.3 136–164 2.6–8.5

22–87 5–19 96–248 0.1–0.8 146–157 3.5–4.8

2 4 28 0 18 14

7 0 3 15 6 12

0.175 0.566 0.395 0.174 0.307 0.470

Chloride (mmol/L) Magnesium (mmol/L) Phosphorus (mmol/L) PT (s) PTT (s)

46 24 41 26 25

116 2.3 4.8 12.3 26.5

105–151 0.4–5.4 2.6–23.9 8.3–120 9.4–133

116–126 0.1–1.5 3–6.6 6.8–10.2 10.7–16.4

43 0 5 0 4

6 29 24 77 76

0.370 0.520 0.239 0.459 0.215

P value*

*P value for the comparison of neoplastic versus nonneoplastic causes of hemoperitoneum. †Significantly (P  0.05) different.

GGT = g-Glutamyltransferase. PT = Prothrombin time. PTT = Partial thromboplastin time. RR = Reference range. TP = Total protein.

Thoracic radiography was performed in 28 of 65 (43%) cats, and abnormal findings included pleural effusion (7/28; 25%), sternal lymphadenopathy (6/28; 21%), and pulmonary nodules (2/28; 7%). Pleural effusion was determined to be blood after thoracocentesis in all 7 cats.

Abdominal radiography and abdominal ultrasonography were performed in 17 (26%) and 30 (46%) of 65 cats, respectively. Of the 17 cats that underwent abdominal radiography, 15 had radiographic images with poor serosal detail, 4 had radiographic evidence of hepatomegaly, and 3 had radiographic evidence of an abdominal mass. Abdominal effusion was detected on ultrasonographic examinations of all 30 cats. A hyperechoic liver was observed in 6 of 30 (20%) cats, and a hypoechoic liver was observed in 5 of 30 (17%) cats. Abdominal masses were detected on ultrasonographic examination in 13 of 30 (43%) cats and included 5 hepatic masses (4 hyperechoic and 1 hypoechoic), 3 splenic masses (1 hyperechoic and 2 hypoechoic), and a pancreatic mass (hypoechoic) as well as 4 masses that could not be isolated to a particular organ (2 hyperechoic and 2 hypoechoic). Four cats had multifocal masses identified by abdominal ultrasonography. Abdominal surgery was performed on 14 of 65 (22%) cats and included splenectomy (n = 2), liver lobectomy (2), and abdominal exploratory with collection of specimens (10).

Neoplasia was the cause of hemoperitoneum in 46% (30/65) of cats. Of these 30 cats, 18 cats had hemangiosarcoma including a tumor in the spleen (n = 9), liver (4), small intestine (2), large intestine (1), omentum (1), and ureter (1). Other neoplasms included hepatocellular carcinoma (4) and 1 each of hepatic cholangiocarcinoma, splenic lymphoma, splenic histiocytic sarcoma, nephroblastoma, pancreatic adenocarcinoma, renal adenocarcinoma, biliary cystadenoma, and metastatic squamous cell carcinoma to the liver. The spleen was the most common location for neoplasia (11/30; 37%).

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Nonneoplastic causes of hemoperitoneum occurred in 54% (35/65) of cats. Coagulopathies (8/35; 23%) and hepatic necrosis (8/35; 23%) were the most common causes of nonneoplastic hemoperitoneum.

Of the 8 cats with coagulopathies, 4 had sepsis, 2 had anticoagulant rodenticide toxicosis, and 2 had pancreatitis. Other nonneoplastic causes of hemoperitoneum included ruptured bladder (n = 5), hepatic rupture secondary to hepatic amyloidosis (4), gastric ulcer (2), hepatic hematoma (2), hepatitis (2), duodenal ulcer (1), perinephric pseudocyst (1), feline infectious peritonitis–induced liver rupture (1), and feline infectious peritonitis–induced nephritis (1). Liver disease (both neoplastic and nonneoplastic) was the most common cause of hemoperitoneum (26/65; 40%). Of the 33 cats with mass lesions (neoplasia, 30 cats; hepatic hematomas, 2 cats; perinephric pseudocyst, 1 cat), a mass was palpated in 5 cats (15%).

Eight of 65 (12%) cats survived to be discharged from the hospital. Of the discharged cats, 4 were eventually euthanized (1 for recurrence of hemoperitoneum, 1 for metastatic disease to the liver, and 2 for unknown reasons), and 4 died (1 with recurrence of hemoperitoneum and 3 for unknown reasons). Of the 65 cats, 50 (77%) were euthanized and 15 (23%) cats died by the end of the study period. Median time of hospitalization for cats that were not discharged was 2 days (range, 1 to 21 days), and median survival time for cats that were discharged was 54 days (range, 5 to 1,825 days). Median survival time for cats with neoplasia was 11 days (range, 1 to 162 days), and median survival time for cats with nonneoplastic disease was 61 days (range, 1 to 1,825 days).

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Discussion Hemoperitoneum has been diagnosed in 0.3% of cats over a 7-year period at a large tertiary referral facility.1 However, most of those cats developed hemperitoneum secondary to trauma, and the rate of spontaneous hemoperitoneum in cats was only 0.06%.1 Spontaneous hemoperitoneum in cats continues to be a rare diagnosis as evidenced by the documentation of only 65 cases over a 13-year period at 7 large referral clinics in the present study. However, this may be a result of hemoperitoneum in cats being underdiagnosed or misdiagnosed resulting in underestimation.

The diagnosis of spontaneous hemoperitoneum in cats may be delayed as a result of the prevalence of nonspecific historical findings such as lethargy, anorexia, and vomiting. Many of these cats are critically ill with signs of shock including pale mucous membranes, hypothermia, and depressed mentation, likely induced by blood loss.

A previous study1 of cats diagnosed with spontaneous hemoperitoneum reported that only 1 of 16 cats was suspected of having an abdominal effusion on physical examination. Forty-six percent of cats in the present study had abnormal findings on abdominal palpation, suggesting intra-abdominal disease. However, a mass was only palpated in 15% of the affected cats that were eventually diagnosed with an intra-abdominal mass. These findings of intra-abdominal abnormalities will likely be beneficial in the acute phase of this disease process as important diagnostics such as abdominocentesis and abdominal ultrasonography can be pursued earlier.

Clinicopathologic abnormalities such as anemia, hyperlactatemia, and increases in serum liver enzyme activities are consistent with cats that have had acute hemorrhage and subsequently decreased perfusion. Of the 17% (10/60) of cats that were not anemic on the JAVMA, Vol 236, No. 9, May 1, 2010

basis of PCV, all had increased serum total protein concentrations, suggesting that dehydration may have been masking the true PCV. Another consideration is that some of those cats may have had chronic hemorrhage that had ceased and they had begun to compensate for the blood loss, thus increasing their PCV. Unfortunately, reticulocyte counts were not routinely performed in many of these cats, and therefore the identification of a regenerative versus nonregenerative anemia is difficult.

The blood lactate concentration, which is used as an indicator of perfusion,9 was increased in 19 of 24 cats in which it was measured.

In 1 study,1 elevations of the activities of serum liver enzymes ALT and ALP were common, occurring in 83% and 50%, respectively, of cats with spontaneous hemoperitoneum. High serum liver enzyme (specifically ALT and AST) activities were found in most affected cats of the present study as well. Of the 26 cats with liver disease, 15 (58%) had high serum liver enzyme activities.

Other potential causes for increases in these enzymes include hepatic hypoperfusion secondary to blood loss and muscular necrosis with subsequent increases in serum AST activity; however, high liver enzyme activities were found much less commonly in those cats without hepatic disease.

Neoplasia accounts for spontaneous hemoperitoneum in 80% of affected dogs.4 Unlike dogs, the cause of hemoperitoneum in cats was nearly equally distributed between neoplastic and nonneoplastic diseases.

However, the causes of spontaneous hemoperitoneum in cats hold some similarities to that in dogs. In both species, the spleen is the organ most likely to develop neoplasia that results in rupture.4 Additionally, the most common neoplasia resulting in hemoperitoneum is hemangiosarcoma in both species; however, hemangiosarcoma occurs less frequently in cats (18/30; 60%) than dogs, where hemangiosarcoma accounts for 88% of the malignant neoplasia causing hemoperitoneum.4 In cats, lymphoma is often found intraperitoneally,10 but rarely results in rupture and subsequent bleeding of an abdominal organ. Among the cats with hemoperitoneum in the present study, lymphoma only accounted for hemoperitoneum in 1 cat.

Liver disease most commonly resulted in spontaneous hemoperitoneum in cats. This finding is similar to that of another study1; however, hepatic disease was almost twice as likely to occur in the previous study, compared with the present study (75% vs 40%, respectively). Hepatic neoplasia was the cause of bleeding in 10 of 65 (15%) cats in our study as opposed to 31% of cats in the previous study.1 This tendency toward hepatic disease resulting in hemoperitoneum in cats also varies from findings in dogs; the source of bleeding is the spleen or liver in 75% and 13%, respectively, of dogs with hemoperitoneum that undergo surgery.4 On the basis of physical examination and clinical laboratory findings, spontaneous hemoperitoneum in cats often appears to be a dynamic, unstable condition.

With the high prevalence of anemia and subsequent hypovolemia resulting in hypoperfusion as well as the often concomitant coagulopathies, treatment with IV administration fluids and transfusion products will likely be necessary regardless of whether surgery is pursued.

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(Table 1). No significant difference between cats with hemoperitoneum induced by neoplastic disease versus cats with hemoperitoneum induced by nonneoplastic disease were found when sex (P = 0.175), breed (P = 0.183), and clinical signs such as vomiting (P = 0.333), lethargy (P = 0.461), anorexia (P = 0.108), abdominal distension (P = 1.000), and abdominal discomfort (P = 0.383) were compared between groups. There was no significant (P = 0.359) difference in PCV or total protein (P = 0.289) of the effusion between neoplastic and nonneoplastic groups. Cats with neoplasia were significantly (P < 0.001) older and had significantly (P = 0.025) lower PCVs than cats with nonneoplastic causes of hemoperitoneum. Receiver operating curve analysis revealed that a cutoff of an initial PCV â&#x2030;¤ 22% had a sensitivity of 85% for detecting neoplasia but only 56% specificity with an overall correct classification of 68% (area under the curve, 0.67). Similarly, an age â&#x2030;Ľ 12 years old had a sensitivity of 63% and 86% specificity (overall 75.4% accuracy; area under the curve, 0.81) in detecting neoplasia as the cause of the hemoperitoneum. Overall, outcome (survival time) was not significantly different between these 2 groups in comparison of both cats that were discharged (P = 0.399) and those cats that were not discharged (P = 0.723).

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Many of the nonneoplastic causes of spontaneous hemoperitoneum in cats are either medically or surgically treatable. While the causes of the coagulopathies are often associated with severe conditions such as sepsis and pancreatitis, the administration of blood products and supportive treatments may have proven successful in the treatment of these cases. The prognosis in cats with coagulopathies would depend on the etiology, stage of disease, and response to treatment, as surgery would likely not be indicated.

Spontaneous hemoperitoneum in cats from conditions such as ruptured bladder, gastric and duodenal ulceration, and perinephric pseudocyst was only recorded for a few cats, and the bleeding in those cats was likely caused by damage or erosion of blood vessels secondary to the underlying pathological condition. Surgical exploration and treatment may have resulted in cessation of bleeding in those cats. Surgical treatment of liver disease would depend on the amount of hepatic involvement and an assessment of the extensiveness of hepatectomy. Although the regenerative capacity of the liver in cats following massive hepatectomy has not been evaluated, experimentally dogs cannot survive with 84% partial hepatectomy; however, 70% removal is tolerated.11 Nonneoplastic conditions such as hepatic amyloidosis and hepatic necrosis may affect most or all of the liver preventing surgical excision.

Unfortunately, surgery was attempted in only 14 of 65 (22%) cats in the present study.

Most of the cats of the present study were euthanized. Only 8 cats survived to be discharged. Retrospectively, it is difficult to determine why euthanasia was performed or if it was recommended. In cats with spontaneous hemoperitoneum without evidence of rodenticide toxicosis, it seems reasonable to recommend surgical exploration following stabilization and correction of coagulation abnormalities, as the cause of spontaneous hemoperitoneum was a nonneoplastic condition in 54% (35/65) of the cats in the present study. In cats where neoplasia is found during surgical exploration, adjuvant treatment options may be pursued. However, the treatment of intraperitoneal neoplasia with adjuvant chemotherapy is rarely described in affected cats.12,13 Determining whether hemoperitoneum is induced by a neoplastic or nonneoplastic cause preoperatively is an important advance in our ability to treat a patient as well as prepare an owner for what to expect during treatment. A few recent studies14,15 in dogs have attempted to use diagnostic tests preoperatively to determine whether a neoplastic or nonneoplastic disease process resulted in hemoperitoneum. In 1 study,15 contrast harmonic ultrasonography was not useful in distinguishing splenic hemangiosarcoma from splenic hematoma. In a separate study,14 dogs with hemoperitoneum caused by splenic hemangiosarcoma had significantly lower total solid concentrations and platelet counts at admission.14 In the present study, cats with hemoperitoneum caused by neoplasia had significantly lower PCVs and were older than cats with hemoperitoneum caused by nonneoplastic diseases.

Several limitations of the present study should be noted. The retrospective nature and the reliance on

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medical record review pose inherent problems with data collection. Various clinicians performed physical examinations, recorded historical findings, and performed surgery, and bias can result. Additionally, information on several cats with hemoperitoneum was not included, as a specific cause of hemoperitoneum was not determined because of a lack of histopathologic, surgical, or necropsy diagnosis. Surgery was not pursued in most cats, and recommendations about surgical techniques are limited. However, surgeons electing abdominal exploration should be prepared to confront hepatic disease, and extensive supportive care may be necessary both pre- and postoperatively because of the common occurrence of coagulopathies. Lastly, conclusions regarding survival to discharge and long-term outcome are limited as a result of the high proportion of cats that were euthanized. a. b.

Microsoft Office Excel, Microsoft Corp, Redmond, Wash.

Stata 8.0 for Windows, College Station, Tex.

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