Education and imaging. Hepatobiliary and pancreatic: bleeding vaginal varices

New sights in ectopic varices in portal hypertension

Ectopic varices and associated bleeding, although rare, pose a significant risk to patients with portal hypertension, carrying a relatively high mortality rate. These varices can occur in various anatomical regions, excluding the gastroesophageal region, which is typically associated with portal vein drainage. The limited data available in the literature, derived mostly from case reports and series, make the diagnosis and treatment of ectopic variceal bleeding particularly challenging. Furthermore, it is crucial to recognize that ectopic varices in different sites can exhibit variations in key decision-making factors such as aetiology and vascular anatomy, severity and bleeding risk and hepatic reserve. These factors significantly influence treatment strategies and underscore the importance of adopting individualized management approaches. Therefore, the objective of this review is to provide a comprehensive overview of the fundamental knowledge surrounding ectopic varices and to propose site-oriented, stepwise diagnosis and treatment algorithms for this complex clinical issue. A multidisciplinary treatment approach is strongly recommended in managing ectopic varices. In addition, to enhance clinical reference, we have included typical case reports of ectopic varices in various sites in our review, while being mindful of potential publication bias.

Ectopic Vaginal Varices With Hemorrhage After Hysterectomy

Vaginal and uterine varices are well documented in pregnancy, although development of vaginal varices in patients with portal hypertension occurs in an exceptionally rare subset. Only 12 cases are reported in the literature; all but 3 of these cases involved patients with a history of hysterectomy, with 1 of the remaining 2 exhibiting partial obliteration of the uterine plexus due to radiation therapy for cervical cancer. We present a case of recurrent vaginal variceal bleeding in a patient with a history of hysterectomy, initially managed with vaginal tamponade and ultimately requiring definitive treatment with transjugular intrahepatic portosystemic shunt insertion.

An unusual cause of postmenopausal vaginal haemorrhage: a case report

Background

Post-menopause vaginal haemorrhage is typically related to gynaecological malignancies. Bleeding from vaginal varices rarely occurs, especially in nonpregnant women. Moreover, nonpregnancy-related causes of vaginal varicosities include portal hypertension, especially that caused by liver cirrhosis, pelvic congestion syndrome and Klippel-Trenaunay syndrome or Parkes-Weber syndrome. Here, we report an unusual cause of nonpregnancy-associated vaginal variceal bleeding.

Case presentation

A 55-year-old postmenopausal woman presented in our outpatient department with complaints of recurrent bloody vaginal discharge. A group of varicose veins and several haemorrhagic spots were found on her vaginal wall during a vaginal speculum examination. Genital cancers were excluded by colposcopy and transvaginal ultrasonography; furthermore, a pelvic arteriovenous fistula was not found on a pelvic computed tomography (CT) scan. However, congenital varicosities and deep arteriovenous shunts were observed in her left leg on arterial angiography. Moreover, vaginal bleeding was improved after resolution of the underlying deep arteriovenous shunts in her left leg. Therefore, congenital arteriovenous shunts and elevated inferior vena cava pressure might be responsible for her recurrent vaginal varicose bleeding.

Conclusion

Haemorrhage due to vaginal varices is easily detected with a vaginal speculum examination. However, diagnosis and treatment of the original disease are important after bleeding is controlled.