Traumatic omental variceal rupture-treatment with transjugular portosystemic shunt (TIPS) and embolization

Abstract

Bleeding ectopic varices is an uncommon but life-threatening complication of portal hypertension that requires a high clinical index of suspicion for early diagnosis and management. Transjugular intrahepatic portosystemic shunt is a safe and effective treatment option for bleeding ectopic varices. However, due to a high re-bleeding rate despite a patent shunt and reduced portosystemic gradient, adjunctive measures directed at embolization of the varices should be attempted. Herein, we report a case of bleeding omental varices after traumatic injury in a cirrhotic patient presenting with hemoperitoneum and hemorrhagic shock.

Keywords: Ectopic varices; Embolization; Omental varices; TIPS.

Fig. 1

Axial contrast-enhanced image of the abdomen and pelvis shows hemoperitoneum with layering blood products (arrowheads) and abnormal tangle of vessels in the periumbilical region and in the region of the greater omentum (arrows). No active extravasation was noted.

Fig. 2

Digital subtraction venogram performed by injection of contrast through the pigtail catheter at the confluence of the splenic vein and superior mesenteric vein (arrowhead) shows flow of contrast through the newly created TIPS (arrow) with no abnormal filling of the varices.

Fig. 3

Axial contrast-enhanced images of the abdomen and pelvis (A–D) show contrast blush in the umbilical region on the arterial phase (white circle) with continued contrast pooling in the venous (C) and 90-second delayed phase images (D), consistent with active bleeding (white arrows). The culprit vessels were traced to the omental veins from the superior mesenteric vein (not shown).

Fig. 4

Intraprocedure angiographic images (A–C) show abnormally dilated and tortuous omental vessels with active bleeding (arrows) after selective catheterization of the origin of the omental vein (arrowhead in “A”) off the superior mesenteric vein. These were successfully embolized using a combination of Gelfoam and metallic coils (C).