Clin J Gastroenterol (2013) 6:75–79 DOI 10.1007/s12328-012-0349-7
CASE REPORT
Spontaneous hemoperitoneum due to rupture of the paraumbilical vein successfully treated with balloon-occluded retrograde transvenous obliteration Sho Kitagawa • Takahiro Sato • Katsu Yamazaki • Takumi Ohmura Yoshiyasu Karino • Jouji Toyota • Takashi Hasegawa • Wataru Sakai • Ryo Morita
•
Received: 30 August 2012 / Accepted: 3 December 2012 / Published online: 22 December 2012 Ó Springer Japan 2012
Abstract Spontaneous hemoperitoneum is an uncommon condition, which may be critical even if treated appropriately. The paraumbilical vein is a portosystemic collateral vein that develops in patients with portal hypertension, and is rarely found to be a source of bleeding. Here we present a case report of spontaneous hemoperitoneum due to rupture of the paraumbilical vein successfully treated with balloon-occluded retrograde transvenous obliteration (B-RTO). A 69-year-old man with cirrhosis due to nonalcoholic steatohepatitis was admitted to our hospital with abdominal distention and pain. Computed tomography revealed hemoperitoneum with a dilated paraumbilical vein, and rupture of the paraumbilical vein was diagnosed to be the cause of anemia. B-RTO was performed via the left femoral vein with upstream embolization using microcoils, and thrombosis of the paraumbilical vein was confirmed after B-RTO. The patient was discharged without complications 20 days after B-RTO and he experienced no further episodes of bleeding during the subsequent 6-month period.
Introduction
Keywords Ruptured paraumbilical vein Spontaneous hemoperitoneum Intraperitoneal varices Balloon-occluded retrograde transvenous obliteration Portal hypertension
Case report
S. Kitagawa (&) T. Sato K. Yamazaki T. Ohmura Y. Karino J. Toyota Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan e-mail: [email protected] T. Hasegawa W. Sakai R. Morita Department of Radiology, Sapporo Kosei General Hospital, Sapporo, Japan
Spontaneous hemoperitoneum is defined as blood within the peritoneal cavity from a nontraumatic cause, and usually presents with acute abdominal pain. It is a relatively uncommon condition [1]. The development of intraperitoneal collateral veins is seen in patients with portal hypertension, and their rupture was first reported by Ellis et al. in 1958 [2]. To our knowledge, only seven cases of hemoperitoneum due to a ruptured paraumbilical vein have been reported [3–7]. Surgical intervention was undertaken in six of those cases with the diagnosis of hemoperitoneum [3–6]. The preoperative diagnosis of ruptured paraumbilical vein was made in only one case and was treated by percutaneous transhepatic coil embolization [7]. We herein report the first case of spontaneous hemoperitoneum due to rupture of the paraumbilical vein that was successfully treated with balloon-occluded retrograde transvenous obliteration (B-RTO).
A 69-year-old man with cirrhosis was admitted to our hospital with acute abdominal pain and distention. At 63 years of age, he had been diagnosed with liver cirrhosis due to nonalcoholic steatohepatitis, based on laboratory data and imaging studies, and liver biopsy. He underwent endoscopic injection sclerotherapy (EIS) for esophageal varices at 67 years of age. When he was 68 years old, EIS was performed for recurrent esophageal varices and endoscopic band ligation for gastric antral vascular ectasia. Upon hospitalization, the patient was 167 cm tall and weighed 67 kg. Blood pressure was 124/60 mmHg, pulse 84/min and regular, and body temperature 36.8 °C. He was
123
76
Clin J Gastroenterol (2013) 6:75–79 b Fig. 1 a Computed tomography revealed a dilated paraumbilical vein
in the paramedial abdominal wall, accompanied by high attenuation (arrowheads). The high attenuation clot descends along the right paracolic gutter (arrow). b The high attenuation clot in the right paracolic gutter (described in Fig. 1a) reaches the pouch of Douglas (arrow). c In the reconstructed computed tomography image, a dilated paraumbilical vein drains into the left inferior epigastric vein (arrow)
observed to have pale conjunctivae and scleral icterus. Physical examination revealed abdominal distention with generalized tenderness. He had had no episode of melena
123
or hematochezia, and on admission denied any trauma to his abdomen. Laboratory findings were: red blood cells 180 9 104/lL (normal 387–525 9 104/lL), hemoglobin 6.3 g/dL (12.6–16.5 g/dL), white blood cells 7500/lL (3600–9000/lL), platelets 6.1 9 104/lL (13.8–30.9 9 104/lL), serum albumin 2.8 g/mL (4.0–5.2 g/mL), total bilirubin 2.3 mg/mL (0.2–1.2 mg/mL), glutamic oxaloacetic transaminase 30 IU/L (8–38 IU/L), glutamic pyruvic transaminase 26 IU/L (4–44 IU/L), alkaline phosphatase 241 IU/L (104–338 IU/L), blood urea nitrogen 29.2 mg/dL (7.0–24.0 mg/dL), and creatine 1.87 mg/dL (0.6–1.20 mg/dL). Prothrombin time was 57 % and serological assays for markers of hepatitis B and hepatitis C viruses were negative. An abdominal contrast-enhanced computed tomography (CT) scan revealed a high-attenuation clot descending along the right paracolic gutter into the pouch of Douglas without hepatocellular carcinoma (HCC) (Fig. 1a). In addition, a dilated paraumbilical vein with a maximum diameter of 3.7 cm was seen in the paramedial abdominal wall, leading from the left portal vein into the left inferior epigastric vein. Paraumbilical vein rupture was diagnosed based on to high attenuation (measuring 75–110 HU) around the dilated paraumbilical vein (Fig. 1b). The patient became hypotensive, complaining of abdominal distention. A reconstructed computed tomography image was taken to clarify the vascular anatomy before treatment (Fig. 1c). We obtained informed consent and decided to perform B-RTO via the left femoral vein for hemostasis. The left femoral vein was punctured. Under fluoroscopy, a guidewire was advanced into the paraumbilical vein thorough the left inferior epigastric vein in order to place a 7-French long sheath. Through the sheath, a 6.5-French balloon catheter (Artec Balloon Catheter, B-RTV type I, 19 mm in diameter; Create Medic, Yokohama, Japan) was advanced into the paraumbilical vein. Portography showed a large paraumbilical vein, but there was no leakage of contrast medium evident from the paraumbilical vein, even under balloon-occluded retrograde transcatheter venography (Fig. 2a). We made the diagnosis of paraumbilical vein rupture according to CT findings and clinical course, and B-RTO was subsequently performed. With the aim of reducing the blood flow, upstream coil embolization was performed with five fibered platinum coils (four 0.035inch, 9 mm, 6 cm; one 0.035-inch, 7 mm, 4 cm) and two microcoils (0.018-inch, 10 mm). B-RTO using 5 % ethanolamine oleate iopamidol (EOI) was performed with
Clin J Gastroenterol (2013) 6:75–79
77
Fig. 2 a Balloon-occluded retrograde transcatheter venography showed a large paraumbilical vein. b Following upstream coil embolization (arrow), balloon-occluded retrograde transvenous obliteration was performed using 5 % ethanolamine oleate iopamidol (arrowheads)
Fig. 3 a The paraumbilical vein before balloon-occluded retrograde transvenous obliteration. b Computed tomography shows thrombosis of the paraumbilical vein after balloon-occluded retrograde transvenous obliteration
14 mL of total sclerosant while maintaining EOI over a period of 30 min (Fig. 2b). No worsening of anemia was observed, but abdominal pain persisted into the following day, and the patient was febrile from the second to the fifth day after B-RTO. The transient worsening in renal function was managed conservatively, and at the same time the increase in ascites was controlled adequately with diuretics. Thrombosis of the paraumbilical vein (Fig. 3a, b) and intrahepatic portal vein patency were confirmed by CT and transabdominal color Doppler ultrasonography seven days after B-RTO. No noticeable worsening of esophagogastric and rectal varices
were found on upper gastrointestinal endoscopy and colonoscopy 14 and 16 days after B-RTO, respectively. The patient was discharged without worsening of liver function and complications 20 days after B-RTO.
Discussion Spontaneous hemoperitoneum is defined as blood within the peritoneal cavity from a nontraumatic cause. It is an uncommon condition, which may be rapidly fatal even if treated appropriately [1]. The most common cause of
123
78
hemoperitoneum is rupture of an ectopic pregnancy [8]. In cirrhosis, spontaneous hemoperitoneum develops from a structural lesion, such as HCC, rupture of ectopic varices, or metastatic liver tumor. Acute hemoperitoneum develops in 5–15 % of patients with HCC [9]. Spontaneous hemoperitoneum due to rupture of intraperitoneal varices was first reported by Ellis et al. in 1958 [2]. It is a rare condition, the incidence of which is unknown, whereas it has a mortality of 75 % [10]. In these cases, a ruptured umbilical or paraumbilical vein accounts for 20–25 % of these deaths [3, 11]. The paraumbilical vein is a portosystemic collateral vein that develops in up to 43 % of patients with portal hypertension [12–17], leading from the left branch of the portal vein to connect with the superficial and deep epigastric veins in the anterior abdominal wall. Both the superficial and deep epigastric veins have superior and inferior branches, and the deep inferior epigastric veins drain into the external iliac vein [18]. There has been a controversy over whether the umbilical vein recanalizes or not. Aagaard et al. [19] reported a 26 % incidence of umbilical vein patency among 107 patients with portal hypertension as determined by percutaneous transhepatic portography. In contrast, Lafortune et al. [20] reported that a reopened umbilical vein was never found, although it was sought in 200 umbilicoportographies and in seven autopsy-dissected falciform ligaments, and that the vessel involved was actually an enlarged paraumbilical vein. In our case, contrast-enhanced CT scan findings strongly suggested hemoperitoneum due to rupture of the paraumbilical vein, based on the following points. First, there was no HCC, which is the most frequently reported etiology of spontaneous hemoperitoneum [1]. Second, the paraumbilical vein was markedly enlarged with a maximum diameter of 3.7 cm. In patients without portal hypertension, the paraumbilical vein is very small or collapsed, and is not typically identified on CT [18]. Third, high attenuation (measuring 75–110 HU) was seen around the paraumbilical vein, accompanied by a high attenuation clot which was found closest to the site of bleeding on CT [21], along the right paracolic gutter into the pouch of Douglas. Shanmuganathan et al. [22] reported that attenuation values of active hemorrhage and clotted blood ranged from 85 to 370 HU (mean 132 HU) and 40 to 70 HU (mean 51 HU), respectively. To our knowledge, seven cases of hemoperitoneum due to rupture of the paraumbilical vein have been reported [3–7]. Surgical intervention was undertaken in six cases with the preoperative diagnosis of hemoperitoneum and, as a result, rupture of the paraumbilical vein was diagnosed and its ligation was performed in these cases. In the other case, in which diagnosis was made by technetium-99mlabeled red blood cell scintigraphy, percutaneous
123
Clin J Gastroenterol (2013) 6:75–79
transhepatic coil embolization under ultrasonic guidance was performed successfully, after failure of direct percutaneous puncture of the vein [7]. So far, there has been no reported case successfully treated by B-RTO. Sincos et al. recommended early surgical intervention with laparotomy in the case of peritoneal hemorrhage from varices [11]; however, Assis et al. [23] noted that surgery should be used as a last resort in patients with poor liver function like Child–Pugh class B or C cirrhosis. The percutaneous transhepatic approach is often difficult due to atrophic liver and massive ascites, and coagulation abnormalities present the risk of hemorrhage in cases of cirrhosis with portal hypertension. A 16.5 % rate of procedurerelated complications has been reported [24]. In this case, B-RTO is a more feasible and safe procedure because of its approach via the femoral vein. Embolization of the paraumbilical vein, although it was inevitable in this case, has the possibility of worsening portal hypertension. Abraham et al. [25] reported the disappearance of ascites with a spontaneously recanalized umbilical vein. On the other hand, some studies showed no relationship between the paraumbilical vein and the presence of varices [19, 26–28]. However, these reports are not focused on changes in portal venous pressure and varices after occluding the paraumbilical vein. Following treatment, a transient worsening in renal function and ascites was observed, thus the worsening of portal hypertension led to the potential for the increase in ascites. In the present case, noticeable worsening of the varix was not observed; however, we should pay attention to development of other collateral veins or ascites. We present the first case of spontaneous hemoperitoneum due to rupture of a paraumbilical vein successfully treated by B-RTO. Conflict of interest of interest.
The authors declare that they have no conflict
References 1. Lucey BC, Varghese JC, Anderson SW, Soto JA. Spontaneous hemoperitoneum: a bloody mess. Emerg Radiol. 2007;14:65–75. 2. Ellis H, Griffiths PW, MacIntyre A. Haemoperitoneum; a record of 129 consecutive patients with notes on some unusual cases. Br J Surg. 1958;45:606–10. 3. Goldstein AM, Gorlick N, Gibbs D, Fernandez-del Castillo C. Hemoperitoneum; a record of 129 consecutive patients with notes on some unusual cases. Am J Gastroenterol. 1995;90:315–7. 4. Ross AP. Portal hypertension presenting with haemoperitoneum. Br Med J. 1970;28:544. 5. Paizis B, Krespis E, Filiotou A, Kalochairetis P, Golematis B. Rupture of a periumbilical vein causing hemoperitoneum in a cirrhotic patient. Mt Sinai J Med. 1986;53:123–5. 6. Sato H, Kamibayashi S, Tatsumura T, Yamamoto K. Intraabdominal bleeding attributed to ruptured periumbilical varices.
Clin J Gastroenterol (2013) 6:75–79
7.
8. 9. 10.
11.
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13.
14.
15.
16.
17.
A case report and a review of the literature. Jpn J Surg. 1987;17:33–6. Lee JM, Kim HL, Lee YH, Lee SH, Kim JK. Hemoperitoneum due to ruptured paraumbilical vein in a cirrhotic patient with portal hypertension: treatment by means of coil embolization. J Korean Radiol Soc. 2000;42:751–5. Fox L, Crane SA, Bidari C, Jones A. Intra-abdominal hemorrhage from ruptured varices. Arch Surg. 1982;117:953–6. Akriviadis EA. Hemoperitoneum in patients with ascites. Am J Gastroenterol. 1997;92:567–75. Vallalta Morales M, Cano B, Morata Aldea C, Calabuig Alborch JR. Hemoperitoneum secondary to spontaneous rupture of the umbilical vein (in Spanish with English abstract). Gastroenterol Hepatol. 2004; 27: 414–6. Sincos IR, Mulatti G, Mulatti S, Sincos IC, Belczak SQ, Zamboni V. Hemoperitoneum in a cirrhotic patient due to rupture of retroperitoneal varix. HPB Surg. 2009;2009:240780. Hoevels J, Lunderquist A, Tyle´n U, Simert G. Porto-systemic collaterals in cirrhosis of the liver. Selective percutaneous transhepatic catheterization of the portal venous system in portal hypertension. Acta Radiol Diagn (Stockh). 1979; 20: 65–77. Schabel SI, Rittenberg GM, Javid LH, Cunningham J, Ross P. The ‘‘bull’s-eye’’ falciform ligament: a sonographic finding of portal hypertension. Radiology. 1980;136:157–9. McCain AH, Bernardino ME, Sones PJ Jr, Berkman WA, Casarella WJ. Varices from portal hypertension: correlation of CT and angiography. Radiology. 1985;154:63–9. Cho KC, Patel YD, Wachsberg RH, Seeff J. Varices in portal hypertension: evaluation with CT. Radiographics. 1995;15: 609–22. Ohhira M, Ohta H, Ohhira M, Matsumoto A, Ohtake T, Fujimoto Y, et al. Altered intrahepatic pathway of para-umbilical vein in portal hypertension. J Gastroenterol Hepatol. 1998;13:691–5. Zardi EM, Uwechie V, Caccavo D, Pellegrino NM, Cacciapaglia F, Di Matteo F, et al. Portosystemic shunts in a large cohort of patients with liver cirrhosis: detection rate and clinical relevance. J Gastroenterol. 2009;44:76–83.
79 18. Horton KM, Fishman EK. Paraumbilical vein in the cirrhotic patient: imaging with 3D CT angiography. Abdom Imaging. 1998;23:404–8. 19. Aagaard J, Jensen LI, Sorensen TI, Christensen U, Burcharth F. Recanalized umbilical vein in portal hypertension. AJR. 1982;139:1107–10. 20. Lafortune M, Constantin A, Breton G, Legare AG, Lavoie P. The recanalized umbilical vein in portal hypertension: a myth. AJR. 1985;144:549–53. 21. Lubner M, Menias C, Rucker C, Bhalla S, Peterson CM, Wang L, et al. Blood in the belly: CT findings of hemoperitoneum. Radiographics. 2007;27:109–25. 22. Shanmuganathan K, Mirvis SE, Sover ER. Value of contrastenhanced CT in detecting active hemorrhage in patients with blunt abdominal or pelvic trauma. AJR. 1993;161:65–9. 23. Assis DN, Pollak J, Schilsky ML, Emre S. Successful treatment of a bleeding umbilical varix by percutaneous umbilical vein embolization with sclerotherapy. J Clin Gastroenterol. 2012;46: 115–8. 24. Ohta M, Hashizume M, Kawanaka H, Akazawa K, Ueno K, Tomikawa M, et al. Complications of percutaneous transhepatic catheterization of the portal venous system in patients with portal hypertension. J Gastroenterol Hepatol. 1996;11:630–4. 25. Abraham AS, Atkinson M. The disappearance of ascites in alcoholic cirrhosis with the development of the CruveilhierBaumgarten syndrome. Ann Intern Med. 1965;62:1045–9. 26. Burchell AR, Panke WF, Moreno AH, Rousselot LM. The patent umbilical vein in portal hypertension. Surg Gynecol Obstet. 1970;130:77–86. 27. Gibson RN, Gibson PR, Donlan JD, Clunie DA. Identification of a patent paraumbilical vein by using Doppler sonography: importance in the diagnosis of portal hypertension. AJR. 1989;153:513–6. 28. Morin C, Lafortune M, Pomier G, Robin M, Breton G. Patent paraumbilical vein: anatomic and hemodynamic variants and their clinical importance. Radiology. 1992;185:253–6.
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CASE REPORT
Spontaneous hemoperitoneum due to rupture of the paraumbilical vein successfully treated with balloon-occluded retrograde transvenous obliteration Sho Kitagawa • Takahiro Sato • Katsu Yamazaki • Takumi Ohmura Yoshiyasu Karino • Jouji Toyota • Takashi Hasegawa • Wataru Sakai • Ryo Morita
•
Received: 30 August 2012 / Accepted: 3 December 2012 / Published online: 22 December 2012 Ó Springer Japan 2012
Abstract Spontaneous hemoperitoneum is an uncommon condition, which may be critical even if treated appropriately. The paraumbilical vein is a portosystemic collateral vein that develops in patients with portal hypertension, and is rarely found to be a source of bleeding. Here we present a case report of spontaneous hemoperitoneum due to rupture of the paraumbilical vein successfully treated with balloon-occluded retrograde transvenous obliteration (B-RTO). A 69-year-old man with cirrhosis due to nonalcoholic steatohepatitis was admitted to our hospital with abdominal distention and pain. Computed tomography revealed hemoperitoneum with a dilated paraumbilical vein, and rupture of the paraumbilical vein was diagnosed to be the cause of anemia. B-RTO was performed via the left femoral vein with upstream embolization using microcoils, and thrombosis of the paraumbilical vein was confirmed after B-RTO. The patient was discharged without complications 20 days after B-RTO and he experienced no further episodes of bleeding during the subsequent 6-month period.
Introduction
Keywords Ruptured paraumbilical vein Spontaneous hemoperitoneum Intraperitoneal varices Balloon-occluded retrograde transvenous obliteration Portal hypertension
Case report
S. Kitagawa (&) T. Sato K. Yamazaki T. Ohmura Y. Karino J. Toyota Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan e-mail: [email protected] T. Hasegawa W. Sakai R. Morita Department of Radiology, Sapporo Kosei General Hospital, Sapporo, Japan
Spontaneous hemoperitoneum is defined as blood within the peritoneal cavity from a nontraumatic cause, and usually presents with acute abdominal pain. It is a relatively uncommon condition [1]. The development of intraperitoneal collateral veins is seen in patients with portal hypertension, and their rupture was first reported by Ellis et al. in 1958 [2]. To our knowledge, only seven cases of hemoperitoneum due to a ruptured paraumbilical vein have been reported [3–7]. Surgical intervention was undertaken in six of those cases with the diagnosis of hemoperitoneum [3–6]. The preoperative diagnosis of ruptured paraumbilical vein was made in only one case and was treated by percutaneous transhepatic coil embolization [7]. We herein report the first case of spontaneous hemoperitoneum due to rupture of the paraumbilical vein that was successfully treated with balloon-occluded retrograde transvenous obliteration (B-RTO).
A 69-year-old man with cirrhosis was admitted to our hospital with acute abdominal pain and distention. At 63 years of age, he had been diagnosed with liver cirrhosis due to nonalcoholic steatohepatitis, based on laboratory data and imaging studies, and liver biopsy. He underwent endoscopic injection sclerotherapy (EIS) for esophageal varices at 67 years of age. When he was 68 years old, EIS was performed for recurrent esophageal varices and endoscopic band ligation for gastric antral vascular ectasia. Upon hospitalization, the patient was 167 cm tall and weighed 67 kg. Blood pressure was 124/60 mmHg, pulse 84/min and regular, and body temperature 36.8 °C. He was
123
76
Clin J Gastroenterol (2013) 6:75–79 b Fig. 1 a Computed tomography revealed a dilated paraumbilical vein
in the paramedial abdominal wall, accompanied by high attenuation (arrowheads). The high attenuation clot descends along the right paracolic gutter (arrow). b The high attenuation clot in the right paracolic gutter (described in Fig. 1a) reaches the pouch of Douglas (arrow). c In the reconstructed computed tomography image, a dilated paraumbilical vein drains into the left inferior epigastric vein (arrow)
observed to have pale conjunctivae and scleral icterus. Physical examination revealed abdominal distention with generalized tenderness. He had had no episode of melena
123
or hematochezia, and on admission denied any trauma to his abdomen. Laboratory findings were: red blood cells 180 9 104/lL (normal 387–525 9 104/lL), hemoglobin 6.3 g/dL (12.6–16.5 g/dL), white blood cells 7500/lL (3600–9000/lL), platelets 6.1 9 104/lL (13.8–30.9 9 104/lL), serum albumin 2.8 g/mL (4.0–5.2 g/mL), total bilirubin 2.3 mg/mL (0.2–1.2 mg/mL), glutamic oxaloacetic transaminase 30 IU/L (8–38 IU/L), glutamic pyruvic transaminase 26 IU/L (4–44 IU/L), alkaline phosphatase 241 IU/L (104–338 IU/L), blood urea nitrogen 29.2 mg/dL (7.0–24.0 mg/dL), and creatine 1.87 mg/dL (0.6–1.20 mg/dL). Prothrombin time was 57 % and serological assays for markers of hepatitis B and hepatitis C viruses were negative. An abdominal contrast-enhanced computed tomography (CT) scan revealed a high-attenuation clot descending along the right paracolic gutter into the pouch of Douglas without hepatocellular carcinoma (HCC) (Fig. 1a). In addition, a dilated paraumbilical vein with a maximum diameter of 3.7 cm was seen in the paramedial abdominal wall, leading from the left portal vein into the left inferior epigastric vein. Paraumbilical vein rupture was diagnosed based on to high attenuation (measuring 75–110 HU) around the dilated paraumbilical vein (Fig. 1b). The patient became hypotensive, complaining of abdominal distention. A reconstructed computed tomography image was taken to clarify the vascular anatomy before treatment (Fig. 1c). We obtained informed consent and decided to perform B-RTO via the left femoral vein for hemostasis. The left femoral vein was punctured. Under fluoroscopy, a guidewire was advanced into the paraumbilical vein thorough the left inferior epigastric vein in order to place a 7-French long sheath. Through the sheath, a 6.5-French balloon catheter (Artec Balloon Catheter, B-RTV type I, 19 mm in diameter; Create Medic, Yokohama, Japan) was advanced into the paraumbilical vein. Portography showed a large paraumbilical vein, but there was no leakage of contrast medium evident from the paraumbilical vein, even under balloon-occluded retrograde transcatheter venography (Fig. 2a). We made the diagnosis of paraumbilical vein rupture according to CT findings and clinical course, and B-RTO was subsequently performed. With the aim of reducing the blood flow, upstream coil embolization was performed with five fibered platinum coils (four 0.035inch, 9 mm, 6 cm; one 0.035-inch, 7 mm, 4 cm) and two microcoils (0.018-inch, 10 mm). B-RTO using 5 % ethanolamine oleate iopamidol (EOI) was performed with
Clin J Gastroenterol (2013) 6:75–79
77
Fig. 2 a Balloon-occluded retrograde transcatheter venography showed a large paraumbilical vein. b Following upstream coil embolization (arrow), balloon-occluded retrograde transvenous obliteration was performed using 5 % ethanolamine oleate iopamidol (arrowheads)
Fig. 3 a The paraumbilical vein before balloon-occluded retrograde transvenous obliteration. b Computed tomography shows thrombosis of the paraumbilical vein after balloon-occluded retrograde transvenous obliteration
14 mL of total sclerosant while maintaining EOI over a period of 30 min (Fig. 2b). No worsening of anemia was observed, but abdominal pain persisted into the following day, and the patient was febrile from the second to the fifth day after B-RTO. The transient worsening in renal function was managed conservatively, and at the same time the increase in ascites was controlled adequately with diuretics. Thrombosis of the paraumbilical vein (Fig. 3a, b) and intrahepatic portal vein patency were confirmed by CT and transabdominal color Doppler ultrasonography seven days after B-RTO. No noticeable worsening of esophagogastric and rectal varices
were found on upper gastrointestinal endoscopy and colonoscopy 14 and 16 days after B-RTO, respectively. The patient was discharged without worsening of liver function and complications 20 days after B-RTO.
Discussion Spontaneous hemoperitoneum is defined as blood within the peritoneal cavity from a nontraumatic cause. It is an uncommon condition, which may be rapidly fatal even if treated appropriately [1]. The most common cause of
123
78
hemoperitoneum is rupture of an ectopic pregnancy [8]. In cirrhosis, spontaneous hemoperitoneum develops from a structural lesion, such as HCC, rupture of ectopic varices, or metastatic liver tumor. Acute hemoperitoneum develops in 5–15 % of patients with HCC [9]. Spontaneous hemoperitoneum due to rupture of intraperitoneal varices was first reported by Ellis et al. in 1958 [2]. It is a rare condition, the incidence of which is unknown, whereas it has a mortality of 75 % [10]. In these cases, a ruptured umbilical or paraumbilical vein accounts for 20–25 % of these deaths [3, 11]. The paraumbilical vein is a portosystemic collateral vein that develops in up to 43 % of patients with portal hypertension [12–17], leading from the left branch of the portal vein to connect with the superficial and deep epigastric veins in the anterior abdominal wall. Both the superficial and deep epigastric veins have superior and inferior branches, and the deep inferior epigastric veins drain into the external iliac vein [18]. There has been a controversy over whether the umbilical vein recanalizes or not. Aagaard et al. [19] reported a 26 % incidence of umbilical vein patency among 107 patients with portal hypertension as determined by percutaneous transhepatic portography. In contrast, Lafortune et al. [20] reported that a reopened umbilical vein was never found, although it was sought in 200 umbilicoportographies and in seven autopsy-dissected falciform ligaments, and that the vessel involved was actually an enlarged paraumbilical vein. In our case, contrast-enhanced CT scan findings strongly suggested hemoperitoneum due to rupture of the paraumbilical vein, based on the following points. First, there was no HCC, which is the most frequently reported etiology of spontaneous hemoperitoneum [1]. Second, the paraumbilical vein was markedly enlarged with a maximum diameter of 3.7 cm. In patients without portal hypertension, the paraumbilical vein is very small or collapsed, and is not typically identified on CT [18]. Third, high attenuation (measuring 75–110 HU) was seen around the paraumbilical vein, accompanied by a high attenuation clot which was found closest to the site of bleeding on CT [21], along the right paracolic gutter into the pouch of Douglas. Shanmuganathan et al. [22] reported that attenuation values of active hemorrhage and clotted blood ranged from 85 to 370 HU (mean 132 HU) and 40 to 70 HU (mean 51 HU), respectively. To our knowledge, seven cases of hemoperitoneum due to rupture of the paraumbilical vein have been reported [3–7]. Surgical intervention was undertaken in six cases with the preoperative diagnosis of hemoperitoneum and, as a result, rupture of the paraumbilical vein was diagnosed and its ligation was performed in these cases. In the other case, in which diagnosis was made by technetium-99mlabeled red blood cell scintigraphy, percutaneous
123
Clin J Gastroenterol (2013) 6:75–79
transhepatic coil embolization under ultrasonic guidance was performed successfully, after failure of direct percutaneous puncture of the vein [7]. So far, there has been no reported case successfully treated by B-RTO. Sincos et al. recommended early surgical intervention with laparotomy in the case of peritoneal hemorrhage from varices [11]; however, Assis et al. [23] noted that surgery should be used as a last resort in patients with poor liver function like Child–Pugh class B or C cirrhosis. The percutaneous transhepatic approach is often difficult due to atrophic liver and massive ascites, and coagulation abnormalities present the risk of hemorrhage in cases of cirrhosis with portal hypertension. A 16.5 % rate of procedurerelated complications has been reported [24]. In this case, B-RTO is a more feasible and safe procedure because of its approach via the femoral vein. Embolization of the paraumbilical vein, although it was inevitable in this case, has the possibility of worsening portal hypertension. Abraham et al. [25] reported the disappearance of ascites with a spontaneously recanalized umbilical vein. On the other hand, some studies showed no relationship between the paraumbilical vein and the presence of varices [19, 26–28]. However, these reports are not focused on changes in portal venous pressure and varices after occluding the paraumbilical vein. Following treatment, a transient worsening in renal function and ascites was observed, thus the worsening of portal hypertension led to the potential for the increase in ascites. In the present case, noticeable worsening of the varix was not observed; however, we should pay attention to development of other collateral veins or ascites. We present the first case of spontaneous hemoperitoneum due to rupture of a paraumbilical vein successfully treated by B-RTO. Conflict of interest of interest.
The authors declare that they have no conflict
References 1. Lucey BC, Varghese JC, Anderson SW, Soto JA. Spontaneous hemoperitoneum: a bloody mess. Emerg Radiol. 2007;14:65–75. 2. Ellis H, Griffiths PW, MacIntyre A. Haemoperitoneum; a record of 129 consecutive patients with notes on some unusual cases. Br J Surg. 1958;45:606–10. 3. Goldstein AM, Gorlick N, Gibbs D, Fernandez-del Castillo C. Hemoperitoneum; a record of 129 consecutive patients with notes on some unusual cases. Am J Gastroenterol. 1995;90:315–7. 4. Ross AP. Portal hypertension presenting with haemoperitoneum. Br Med J. 1970;28:544. 5. Paizis B, Krespis E, Filiotou A, Kalochairetis P, Golematis B. Rupture of a periumbilical vein causing hemoperitoneum in a cirrhotic patient. Mt Sinai J Med. 1986;53:123–5. 6. Sato H, Kamibayashi S, Tatsumura T, Yamamoto K. Intraabdominal bleeding attributed to ruptured periumbilical varices.
Clin J Gastroenterol (2013) 6:75–79
7.
8. 9. 10.
11.
12.
13.
14.
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