Mohammed Siddiqui
Advocate Christ Medical Center
Oak Lawn, Illinois
Disclosure information not submitted.
Juan Pablo Gomez, MD
Resident Physician
Advocate Christ Medical Center, United States
Disclosure information not submitted.
Joseph Quinn, DO
Attending Physician
Advocate Christ Medical Center, United States
Disclosure information not submitted.
Title: A Case of Hemorrhagic Shock in the Setting of Umbilical Varices
Case Report Body:
Introduction: Umbilical varices are a relatively rare complication of portal hypertension. Around 20% of patients with cirrhosis and portal hypertension will develop umbilical varices. They are caused by the portosystemic communication between the umbilical and periumbilical veins.
Description: Patient is a 36 year old female with a past medical history significant for Child-Pugh class B cirrhosis secondary to alcoholic liver disease, portal hypertension, and umbilical varices who presented to the emergency department in cardiac arrest. Prior to her cardiac arrest, the patient had significant bleeding from her umbilicus. Following CPR, ROSC was achieved. Patient’s hemoglobin was 10.8 g/dL on admission which decreased to 7.8 g/dL. Patient had thrombocytopenia with a platelet count of 122 K/mcL. Patient received three units of packed red blood cells, two units of fresh frozen plasma, one unit of platelets, and two liters of crystalloid fluid. The patient was taken to surgery for ligation of her umbilical vessel. She was subsequently started on an octreotide infusion and was transferred to the intensive care unit for close hemodynamic monitoring. Patient was evaluated by interventional radiology for transjugular intrahepatic portosystemic shunt (TIPS) however she developed gram positive bacteremia which delayed her procedure. While awaiting TIPS, the patient developed recurrent bleeding from her umbilicus and was taken for an exploratory laparotomy and ligation of the recanalized umbilical vein. Following surgery, the patient was transferred to a tertiary care center for higher level of care. At the outside facility, the patient had a successful TIPS procedure. She was discharged to begin outpatient liver transplant evaluation.
Discussion: In cirrhotic patients, portal venous hypertension develops due to the obstruction of the portal circulation. The increased portal venous pressures leads to the development of umbilical varices. Development of bleeding outside of the gastroesophageal region is rare and makes up only 5% of all variceal bleeding. They require urgent therapy with a combination of surgical ligation, TIPS, vasoactive medications, and hemodynamic support as necessary. Our case highlights the importance of early recognition of bleeding umbilical varices given the high mortality seen in these patients.