S2222 Not Your Usual Variceal Bleed: A Rare Case of Ectopic Variceal Bleeding in the Gallbladder With Gallbladder Rupture

Abstract

INTRODUCTION: Portal hypertension in cirrhosis leads to the formation of portosytemic collaterals, the rupture of which can lead to life-threatening bleeding. We present a rare case of a patient with cirrhosis who developed gallbladder rupture and hemoperitoneum from spontaneous rupture of gallbladder varices. CASE DESCRIPTION/METHODS: A 74 year-old male with cirrhosis due to hereditary hemochromatosis complicated by gastroesophageal variceal bleeding 20 years ago and portal vein thrombosis (PVT), presented with epigastric and right upper quadrant pain, malaise, and syncope. Further evaluation revealed anemia with a 3 gm/dL decrease in hemoglobin from baseline, a normal echocardiogram, and normal brain imaging. Contrasted CT of the abdomen and pelvis was notable for known PVT and hemoperitoneum with higher density material throughout the gallbladder, concerning for active gallbladder bleeding. Empiric antibiotics and blood products were administered for the correction of anemia and coagulopathy. A repeat CT further identified gallstones in the peritoneal cavity along with pericholecystic and abdominal varices, suggesting ectopic variceal bleeding and rupture of the gallbladder. For portal decompression and control of bleeding, intravenous octreotide infusion was started and a transjugular intrahepatic portosystemic shunt procedure was attempted but unsuccessful due to PVT. A transsplenic intrahepatic portosystemic shunt procedure was then successfully placed. Open cholecystectomy (CCY) was then performed without complication, showing a ruptured gallbladder on a bed of varices. DISCUSSION: We describe a case of pericholecystic variceal bleeding in a patient with cirrhosis. Ectopic varices are often an incidental radiologic finding, but can be prone to fatal complications, particularly gallbladder varices including bleeding and gallbladder rupture. Due to the higher morbidity and mortality associated with both open and laparoscopic CCY with cirrhosis, current practices favor non-invasive strategies aimed at portal decompression. However, in symptomatic patients, practice diverges, particularly for higher risk patients (Child-Pugh Class C), in which portosystemic shunting is recommended to relieve portal hypertension in conjunction with percutaneous cholecystostomy drain or CCY. This case highlights the need for early recognition of ectopic varices and, given risks associated with CCY in patients with cirrhosis, describes measures to consider before proceeding to surgery in patients with gallbladder varices.Figure 1.: Open cholecystectomy was done showing a ruptured gallbladder on a bed of varices and a cirrhotic liver.Figure 2.: Contrasted computed tomography (CT) scan of the abdomen and pelvis notable for portal vein thrombosis (triangle), gallbladder varices, splenomegaly, gallstones and high-density material throughout the gallbladder concerning for active gallbladder bleeding (arrow and diamond).Figure 3.: A subsequent CT showed hemoperitoneum (star), gallstones in both the gallbladder (arrow) and peritoneal cavity (circled) along with pericholecystic varices, confirming ectopic variceal bleeding and rupture of the gallbladder.