Enrique Ortiz-Diaz, n/a
Physician, Pulmonary and Critical Care
Houston Methodist Hospital, United States
Disclosure information not submitted.
Harvindepal Singh, n/a
Physician, General Surgery
Houston Methodist Hospital, United States
Disclosure information not submitted.
Julie McClung, n/a
Nurse Practioner
Houston Methodist Hospital, United States
Disclosure information not submitted.
Valarie Barard, n/a
Critical Care Nurse
Houston Methodist Hospital, United States
Disclosure information not submitted.
David Victor, n/a
Physician, Hepatologist
Houston Methodist Hospital, United States
Disclosure information not submitted.
Robert McMillan, n/a
Physician Transplant Surgeon
Houston Methodist Hospital, United States
Disclosure information not submitted.
Title: Successful Hemorrhage Control and Liver Transplantation due to Ectopic Venous Varix Rupture
Case Report Body:
Introduction: Non-Traumatic Hemoperitoneum (NTH) is a rare complication in end stage liver disease (ESLD)1. It's caused primarily by vascular pathologies such as variceal, and neoplastic related erosions. The case exemplifies this rare presentation with an unexpected outcome.
Description: 34 y/o lady with alcohol related ESLD (MELD: 14), presented to the emergency department after having syncope. No history of previous trauma, malignancy or surgery was reported. The Intensive Care Unit (ICU) was consulted due to hypotension. Physical exam found a lethargic patient with mottled extremities and noticeable tender abdominal distention. Ultrasound found preserved systolic function, virtual inferior vena cava and large echogenic ascites. Massive transfusion protocol was started and patient was intubated. Bladder pressure was 24 cm H2O. Diagnostic paracentesis found grossly bloody ascites. Surgery was consulted and exploratory laparotomy was performed. The culprit was a splenic ectopic varix (EV) which was ligated. Patient returned and was started on dialysis and antibiotics. One day later, she was transferred to our tertiary center. Three weeks later, she received an orthotropic liver transplant (OLT). Six weeks later, she was discharged to a long term acute care facility where she was discharged home.
Discussion: Intra-peritoneal EV's are an unusual cause of non-traumatic hemoperitoneum.1 A case series including 1296 ESLD patients, only 6 had NTH with 100% mortality. All patients received ICU support , some artificial liver support but no surgical or transjugular intrahepatic venous shunting (TIPS).2 Sincos et al. summarized 35 cases in the literature where 77.1%, 8.6% and 2.8% received ligation, shunting and embolization, respectively. Survival was 34.3% but OLT was not reported.3 Another series followed 53 patients with EVs who underwent TIPS from 1992-2016 in tertiary centers. 4 Twelve and sixteen patients had re-bleeding and stenosis. Five patients had OLT. Our patient, was considerably younger without other comorbidities, had prompt surgical control and was supported until OLT.
To our knowledge, this is the first EV rupture controlled by surgical ligation, had OLT and returned to non-frail functional state.This case report brings provocative optimism in the management of this potentially lethal complication.