Case Presentation: 69-year-old male with history of cirrhosis from nonalcoholic steatohepatitis, coronary artery disease, hypertension, and diabetes presents to hospital for abdominal pain and weakness. Before the onset of symptoms earlier in the day, he states he was lifting heavy objects and exerting himself. On physical exam, patient was pale, with abdominal distention and diffuse tenderness, guarding and rebound. Exam also positive for Cullen’s sign around umbilicus. Vital signs included respiratory rate of 23, blood pressure 110/61. Labs remarkable for for hemoglobin 7.0/14.1, platelets 51, international normalized ratio 1.3, BUN/creatinine 18.9/1.48. Bedside ultrasound was done on arrival and hyperechoic density was seen indicating hemoperitoneum. Patient was given 4 units packed red blood cells and 40 miligrams protonix intravenously. Interventional radiology and general surgery were consulted stat. He was taken for triphasic CT scan of abdomen which revealed a large tortuous vessel connecting distal splenic venous circulation to the left renal/gonadal veins, moderate hemoperitoneum, hepatomegaly, and cholelithiasis. Patient was given 1 unit platelets as well as started on octreotide drip. Decision was discussed with patient regarding Transjugular intrahepatic portosystemic shunt (TIPS) or Balloon assisted retro/antegrade transvenous obliteration of the ectopic bleeding varix (BRTO). Patient and family decided for BRTO. After procedure, patient was monitored and remained stable.
Discussion: Hemoperitoneum secondary to retroperitoneal varices rupture is rare. To date, in medical literature, only about 35 cases have been reported, with an incidence of 0.1% of cirrhotic patients. Here we present a case of a patient who has never been diagnosed with portal hypertension who presented in hemorrhagic shock from retroperitoneal, ectopic splenic varix rupture. The most common cause is trauma, which in our patient had occured earlier when he was lifting objects. With a reported fatality of 65%, diagnosing and taking a patient to surgery as soon as possible is key.
Conclusions: Hemoperitoneum from retroperitoneal varix is a rare entity in cirrhotic patients. When a patient with a history of cirrhosis presents with signs and symptoms of hemoperitoneum, time to surgery should be limited. Treatment of retroperitoneal bleeding is still not established as no protocol or guidelines exist. All patients should be treated in ICU with monitoring, blood transfusions and eventually source control.
