P2952 - Spontaneous Retroperitoneal Bleeding in a Patient With Newly Diagnosed Cirrhosis of the Liver

Samuel C. Purkey, DO, Samuel Treat, MD, Daphne Norwood, MD
University of Tennessee Medical Center, Knoxville, TN

Introduction: Bleeding is a well-known complication of cirrhosis. Many patients present to the hospital due to gastrointestinal bleeding. A present a unique case of spontaneous retroperitoneal bleeding from the vertebral arteries in a patient with newly diagnosed cirrhosis.

Case Description/Methods: We present a 57-year-old male with alcoholic steatohepatitis presenting for increased confusion. Physical exam revealed scleral icterus, jaundice, and a nontender abdomen. Lab work-up included a creatinine of 1.58mg/dL, bilirubin 5.0mg/dL, AST 177U/L, ALT 82U/L, ammonia of 147uMol/L, hemoglobin (Hgb) 11.3g/dL, platelet count of 137,000k/uL, PT 16.5sec, and INR of 1.61. Hepatitis panel, drug screen, and acetaminophen levels were unremarkable. Ultrasound of the liver revealed hepatic steatosis. He received lactulose for presumed hepatic encephalopathy. On day 5, he developed worsening hypotension with worsening confusion and back pain. His morning Hgb returned 7.4g/dL prompting discontinuation of prophylactic heparin. A non-contrasted CT image of the abdomen was obtained showing a large retroperitoneal hemorrhage from the diaphragm into the left inguinal canal. Notably, the CT revealed cirrhosis, as compared to the ultrasound. Repeat Hgb was 4.3g/dL leading to 2 units of RBCs and transfer to the ICU. A CT angiography was obtained revealing a focal area of active extravasation. Interventional radiology performed a left-sided lumbar arteriograms demonstrating scattered small pseudoaneurysms from the left L2 and L4 lumbar arteries requiring treatment with gelatin sponge and coil embolization. Unfortunately, he never recovered from the detrimental bleed and was transitioned to comfort care.

Discussion: Cirrhosis presents an array of complications including gastrointestinal bleeding, as well as paradoxical hypercoagulability. A less commonly reported complication is retroperitoneal bleeding. This poses clinical conundrums for clinicians regarding anticoagulation, as anticoagulation remains a risk factor for spontaneous retroperitoneal bleeding. With the most common location being the iliopsoas muscle or rectus sheath, we present a unique case involving the lumbar vertebral arteries. Patients with cirrhosis, especially on anticoagulation, who develop hemodynamic instability with or without abdominal pain, flank pain, or the classic findings including Grey-Turner or Kehr signs deserve consideration and work-up for spontaneous retroperitoneal bleeding as the mortality rate remains high.



Disclosures:


Samuel C. Purkey, DO, Samuel Treat, MD, Daphne Norwood, MD. P2952 - Spontaneous Retroperitoneal Bleeding in a Patient With Newly Diagnosed Cirrhosis of the Liver, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.