1921 A Case of Ovarian Varices Bleeding Presenting as an Obscure GI Bleed and Abdominal Pain

Abstract

INTRODUCTION: Upper GI bleed is one of the most common complications in cirrhotic patients with portal hypertension. However, when GI bleed cannot be found after performing endoscopy, one should consider an ectopic gastrointestinal variceal bleeding. Ectopic varices are portosystemic collaterals in locations other than the gastroesophageal region. We present you a case of 44 year old cirrhotic patient, who was seen for nausea, vomiting and abdominal pain with acute blood loss anemia. She was found to have an ectopic gastrointestinal variceal bleeding after a negative endoscopy. CASE DESCRIPTION/METHODS: 44 years old female with past medical history of cirrhosis secondary to NASH presented to the ER with complaint of abdominal pain associated with nausea and vomiting while she was having sexual intercourse. Patient had CT Abdomen and Pelvis with IV contrast which was consistent with evidence of portal hypertension including large venous collaterals and splenomegaly. There was hyperdense ascitic fluid identified on the CT scan. On the left side of the hemiabdomen the fluid was hyperdense, suggestive of blood. But no site of bleeding could be identified on the study. Patient’s hemoglobin dropped by 2 grams in the ER. GI recommended to place NG tube and evaluate for blood contents. Gastric content via NG tube was non-bloody.IR was consulted who, after reviewing her CT scan images, noticed an unusual large IMV supplying large pelvic varices presumably as portal venous compression sites into systemic venous system. IR performed transhepatic portal access with pelvic variceal embolization. Interestingly, they did not find active bleed at the time of procedure. But, given recent history and CT findings, empiric embolization was performed of these varices. At completion, no residual pelvic varices was seen. Patient has successful sclerotherapy and coil embolization of the 2 pelvic-to-ovarian venous plexus varicosities for treatment of presumed source of variceal intraperitoneal bleeding. Patient was discharged home with stable hemoglobin. DISCUSSION: When GI bleed cannot be found after performing endoscopy, one should consider an ectopic gastrointestinal variceal bleeding. Out of all the variceal bleeding, 5% of them are ectopic variceal bleeds. As GI bleed with acute blood loss anemia can be fatal and outcome being time-sensitive, it is necessary to establish diagnosis early. Multi-slice computed tomography with contrast plays an important role in the early diagnosis of ectopic variceal bleed.