An Unusual Cause of Massive Per Vaginal Bleeding

Abstract

Massive per vaginal bleeding from ectopic pelvic varices is an exceedingly rare presentation in patients with cirrhosis. A 60-year-old postmenopausal woman presented with massive per vaginal (PV) bleeding. Computerized tomography scan showed extensive portosystemic collaterals with a large collateral vessel from the splenic vein to the region of her previous caesarean scar, on a background of liver cirrhosis. The cause of the massive PV bleeding was identified as arising from the uterine varix. She was transferred to a tertiary liver unit where she underwent angiographic embolization of the uterine varix and splenic vein shunt with successful obliteration of the culprit collateral vessel. A high index of suspicion is required in a cirrhotic patient with massive PV bleeding for ectopic variceal bleeding. Once stabilized, prompt consultation should be made to a tertiary center for further assessment and consideration of definitive treatment with obliteration of varices and shunt, as well as transjugular intrahepatic portosystemic shunt, to reduce risk of recurrent bleeding.

Keywords: Cirrhosis; Portal Hypertension; Uterine Varices.

Figure 1.

Ultrasound of the pelvis showed a thickened endometrium with increased vascularity near the site of the caesarean scar.

Figure 2.

Computed tomography scan: scan did not show any abnormal mass lesion in the pelvis but incidentally revealed liver cirrhosis with extensive portosystemic collaterals indicating the presence of clinically significant portal hypertension.

Figure 3.

Computed tomography scan (axial): large collateral vessel arising from the splenic vein extending to the lower anterior uterine wall.

Figure 4.

Computed tomography scan (coronal): large collateral vessel arising from the splenic vein extending to the lower anterior uterine wall.

Figure 5.

Acrylic glue and lipoidal were injected directly into the varix, splenic shunt, and surrounding collaterals with consequent obliteration.