A 48-Year-Old With Cirrhosis and Sudden Abdominal Distension

Jennifer L. Martindale, MD; Jonathan Elmer, MD; Joshua M. Kosowsky, MD


April 05, 2023


The patient in this case was thought to be suffering from rupture of an intraperitoneal varix. After discussion with the attending surgeon and interventional radiologist on call, a transjugular intrahepatic portosystemic shunt (TIPS) was inserted to decompress his portal system, with embolization of any actively bleeding varices. The likelihood of his surviving major surgery was considered to be extremely low. He was intubated and taken to the angiography suite, where successful TIPS placement was performed, with coiling of 2 large varices off of the splenic vein. These varices were thought to be the most likely source of the intraperitoneal bleeding, although no active extravasation of blood was appreciated at the time of angiography.

Cirrhosis of the liver, secondary to years of inflammation, causes portal hypertension. Patients with portal hypertension are at risk for bleeding from collateral vessels that develop between the portal and systemic circulation. These vessels become engorged with blood and become increasingly vulnerable to bleeding. Clinicians are most familiar with the presentation of hematemesis and melena that occurs secondary to the esophagogastric varices; however, collateral circulation can develop in a number of other locations where portal and systemic vessels are juxtaposed. Collateral vessels in locations other than the gastroesophageal region are referred to as ectopic varices. Most commonly, these are intraluminal and present at a different part of the gastrointestinal (GI) tract (eg, duodenum or cecum). Bleeding from ectopic varices is thought to comprise 1%-5% of all variceal bleeds.[1,2]

Although variceal rupture most commonly presents as GI bleeding, ectopic variceal rupture can also present as intraperitoneal or retroperitoneal hemorrhage.[3] The incidence of bleeding from ectopic varices is unknown; most publications on this topic are in the form of case series or reports. In a review of 169 cases of ectopic variceal bleeding, 9% occurred in the peritoneal cavity.[4] Intraperitoneal hemorrhage has been reported to occur most commonly from umbilical and paraumbilical varices.[5] However, bleeding from the left gastric vein, mesenteric varices, and omental varices has also been reported.[6,7,8] The mortality incidence is high regardless of the site, with reports ranging from 40% to more than 50%.[2,9]


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