Julian Remouns, DO, MS1, Hadi Minhas, MD2, Seth Richter, MD3 1Resident, Albany, NY; 2Albany Medical Center, Albany, NY; 3Albany Medical College, Albany, NY
Introduction: Spontaneous external umbilical vein hemorrhage is very rare even in the setting of portal hypertension. Few case reports exist in medical literature, and more often, hemorrhage is intraperitoneal. We present a case of external varix hemorrhage that was resolved with non-surgical management.
Case Description/Methods: 82 year old woman with cirrhosis secondary to primary biliary cholangitis (PBC) on ursodiol was brought in by ambulance after being found down in a pool of blood at her assisted living facility. Bleeding was suspected from her umbilical area but was hemostatic upon EMS arrival. Patient had limited memory of the preceding events. Initial blood pressure (BP) in the field was 89/52 which improved with 250mL normal saline bolus. Despite this, patient continued to be confused on transport. Family reported that this was the 4th episode over the last week. The past 3 events were managed with suturing at the umbilical site at an outlying hospital. No recent history of trauma, hematemesis, hematochezia, or melena was reported. In the ED, patient was normotensive, alert and oriented to person, place and time. Hemoglobin (Hgb) was 6 for which she received 2 units of packed red blood cells (PRBCs). Other labs included potassium 5.9, CO2 18, BUN 27, creatinine 1.33, total bilirubin 1.3, alkaline phosphatase 197, AST 78 and ALT 40 and lactic acid 6.22 (range 0.4-2.0 mmol/L). Hepatobiliary surgery re-sutured the wound. CT of abdomen and pelvis showed liver cirrhosis with dilated portal vein, recanalization of the umbilical veins, and esophageal, gastric and umbilical varices. She was started on empiric antibiotics and octreotide drip. Upon admission, patient had another episode of bleeding when using the bedside commode. Hemostasis was achieved with direct pressure and another unit of PRBCs were given. Upon recheck, Hgb 11. She was put on bedrest and subsequently received transjugular intrahepatic portoystemic shunt (TIPS) placement with coil embolization of dilated paraumbilical vein as well as embolization of a coronary vein supplying prominent gastroesophageal varices. Her hemoglobin remained stable and there were no further episodes of hemorrhage.
Discussion: While surgical management is indicated in intraperitoneal umbilical varix hemorrhage, this patient presented with an unusual complication. Embolization and subsequent TIPS placement controlled her active hemorrhage. As more cases are reported, we may be able to identify patients at higher risk and better tailor their management.
Disclosures: Julian Remouns indicated no relevant financial relationships. Hadi Minhas indicated no relevant financial relationships. Seth Richter indicated no relevant financial relationships.
Julian Remouns, DO, MS1, Hadi Minhas, MD2, Seth Richter, MD3. P0812 - A Rare Bleed: Spontaneous External Umbilical Varix Hemorrhage, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.