S2178 A Shock to All: A Rare Case of a Systemic Varix Causing Hemorrhagic Shock

Abstract

INTRODUCTION: Variceal bleeding is a common complication of cirrhosis and usually occurs within the esophagus or stomach. Sometimes, large portosystemic collaterals known as ectopic varices form outside of the portal system. Though they only account for a small portion of variceal bleeding, mortality is high and prompt identification is critical. We describe a rare case of a gentleman with a history of cirrhosis that developed a massive bleed due an abdominal wall varix. CASE DESCRIPTION/METHODS: A 64-year-old incarcerated male with a history of cirrhosis was transferred from an outside hospital with the chief complaint of unwitnessed hematemesis. Vitals at outside hospital were stable and initial hemoglobin was 13.3 g/dL. A repeat hemoglobin prior to transfer was 6.0 g/dL even though the patient had no further episodes of hematemesis, melena or hematochezia. He was transfused 4 units of packed red blood cells and transferred to our institution. On arrival, the patient was stable however complained of abdominal pain and shortness of breath with new abdominal distention. Shortly after, the patient became diaphoretic, hypotensive and ultimately suffered a cardiopulmonary arrest. Post-arrest labs revealed a hemoglobin of 4.5 g/dL, platelets of 50 thou/cmm and lactate of 8 mmol/L. The Gastroenterology team performed an EGD at bedside which showed no evidence of active variceal bleeding. The patient was emergently taken to the OR for an exploratory laparotomy and seven liters of blood were encountered within the intraabdominal cavity from a bleeding lateral abdominal wall varix. Post-surgery, the patient unfortunately suffered another cardiac arrest due to hemorrhagic shock and expired. DISCUSSION: Ectopic varices are collaterals that can form along the gastrointestinal tract where the portal venous system comes into contact with the systemic system. Ectopic varices are rare and account for 1-4% of variceal bleeding. Unfortunately, bleeding is life-threatening and mortality occurs in about 40% of patients. In our patient, the acute drop in hemoglobin without typical symptoms of gastroesophageal bleeding should have prompted further imaging to evaluate for hemoperitoneum. In absence of imaging, clinical indicators for intraabdominal bleeding include rapid abdominal distention, acute blood loss anemia and hemodynamic instability. Thus, ectopic varices should remain on the differential in cirrhotic patients who present with acute blood loss anemia.