P0822 - A Large Paraumbilical Aneurysm in a Patient With Severe Portal Hypertension and Variceal Hemorrhage

Aaron Weiss, MD¹, Aaron Schluger, MD², Roxana Bodin, MD^2
1Westchester Medical Center, Valhalla, NY; ²New York Medical College Westchester Medical Center, Valhalla, NY

Introduction: When compared to arterial aneurysms, venous aneurysms are exceedingly rare. When they occur in the abdomen, the most common sites are the portal and superior mesenteric veins, and are typically seen in the setting of cirrhosis. While recanalization of the umbilical vein is a common imaging finding in patients with cirrhosis and portal hypertension, frank aneurysmal dilation has not previously been well described. Here we present a case of a patient whose CT showed a recanalized umbilical vein with a massive aneurysmal dilation in the setting of recurrent variceal hemorrhage, requiring Transjugular Intrahepatic Portosystemic Shunt (TIPS) placement.

Case Description/Methods: A 37-year-old man with decompensated alcoholic cirrhosis presented to his local hospital with hematemesis. He underwent EGD with banding of esophageal varices and transferred to our tertiary care center. Repeat EGD at one week showed large esophageal varices which were ligated, and a non-bleeding type 1 isolated gastric varix (IGV1) in the fundus. Triple phase CT notable for a recanalized paraumbilical vein with a 5.7cm aneurysmal dilatation. A few days later, the patient developed hematemesis, hematochezia, hemodynamic instability. Massive transfusion protocol was initiated. He was intubated and underwent emergent EGD significant for a large adherent clot in the distal esophagus. Fresh red blood in the esophagus and stomach obscured further endoscopic views. A Blakemore tube was inserted to good effect. He was transferred emergently to interventional radiology and a successful TIPS was created. Post TIPS portosystemic gradient was 3mmHg (due to the emergent nature, a pre-TIPS gradient was not obtained). Following the procedure, the patient remained clinically stable with no further bleeding.

Discussion: Aneurysmal dilatation of portosystemic collateral vessels arising from recanalized umbilical veins as a result of portal hypertension is a rare occurrence. The ligamentum teres provides resistance to dilatation of these paraumbilical veins. While minimal increases in the vessel diameter can be observed, the formation of a paraumbilical aneurysm, in some reports defined as a diameter >2cm, is a unique anatomical feature. Given the size of this patient’s aneurysm, it offers a rare and impressive presentation of portal hypertension.


Figure: CT scan showing recanalized paraumbilical vein with a 5.7cm aneurysmal dilatation


Disclosures:
Aaron Weiss indicated no relevant financial relationships.
Aaron Schluger indicated no relevant financial relationships.
Roxana Bodin indicated no relevant financial relationships.


Aaron Weiss, MD¹, Aaron Schluger, MD², Roxana Bodin, MD². P0822 - A Large Paraumbilical Aneurysm in a Patient With Severe Portal Hypertension and Variceal Hemorrhage, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.