Vaginal variceal hemorrhage in a patient with primary biliary cirrhosis: a case successfully treated by balloon-occluded retrograde transvenous obliteration

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.

A case report of massive vaginal variceal hemorrhage in a patient with cirrhosis secondary to nonalcoholic steatohepatitis unresolved even after successful liver transplantation

Massive hemorrhage from vaginal varices in patients with cirrhosis and a previous hysterectomy can be life-threatening. In the few previous reports, the treatments have all included an initial local tamponade followed by interventional radiology procedures, transvenous intrahepatic portosystemic shunts, surgical shunt, or liver transplantation. A patient with cirrhosis secondary to nonalcoholic steatohepatitis developed massive vaginal variceal hemorrhage. Control of the bleeding was achieved initially with local tamponade. Upon admission to the intensive care unit, the patient was upgraded to urgent status on the liver transplant waiting list, which was performed on day 7. Due to a portal vein thrombosis, an interpositional vein graft to the superior mesenteric vein was required. Postoperatively despite a functional graft and normalization of coagulation system, the vaginal bleeding continued as the left-sided portal hypertension had not been decompressed by the liver transplantation. During a subsequent laparotomy, splenectomy and ligation of the inferior mesenteric vein were required to definitively control the vaginal variceal hemorrhage. The degree and anatomy of the portal hypertension play a crucial role in determining the proper course of management and treatment of vaginal varices in a cirrhotic patient.

Vaginal bleeding in a patient with type C liver cirrhosis without a past history of laparotomy: successful treatment with partial splenic artery embolization

A 47-year-old female patient with type C liver cirrhosis underwent endoscopic injection sclerotherapy for esophageal varices 13 years ago. The patient had no past history of hysterectomy or any other gynecological disorders. She was admitted to our hospital because of persistent vaginal bleeding and exacerbation of anemia. A contrast-enhanced computed tomography scan revealed marked dilation of not only the inferior mesenteric vein, but also the left ovarian vein, the uterine vein and the internal iliac vein. A celiac arteriography showed that the blood in the splenic vein was flowing almost totally hepatofugally into the dilated inferior mesenteric vein. An ovarian venography demonstrated knob-shaped dilation of the left ovarian vein draining into the left internal iliac vein. A proximally wedged left ovarian venography visualized the right ovarian vein and the right internal iliac vein with contrast medium via a palisade venous plexus from the dilated uterine and ovarian veins. Partial splenic embolization (PSE) was performed to increase platelet count and to reduce splenic venous blood flow into the ovarian vein. Following the PSE, the platelet count increased, and the blood flow in the dilated ovarian vein and uterine vein diminished. In addition, the portal blood flow became hepatopetal, and remarkably increased. There has as yet been no case report in which vaginal bleeding developed in women with liver cirrhosis without any past history of hysterectomy or other gynecological disorders. The present case report may be warranted in view of the rarity of the condition.

Vaginal bleeding complicating portal hypertension: a particular entity - report of two cases and review of the literature

Vaginal haemorrhage arising from varices is an exceptional complication of portal hypertension. Two cases successfully treated by transjugular intrahepatic portosystemic stent shunt are presented here. Both these patients previously had a total hysterectomy as did three out of four cases reported in the literature. Clinicians should be aware of 'vaginal bleeding' in the context of both hysterectomy and chronic liver disease in order to adopt the correct diagnostic and therapeutic approach. Definitive treatment can be obtained only if the underlying portal hypertension is adequately taken into consideration.