Case Report 
External Hemorrhage from a Portacaval Anastomosis ina Patient with Liver Cirrhosis
MuratBiyik,
1
RamazanUcar,
2
SamiCifci,
1
OrhanOzbek,
3
GokhanGungor,
4
OzlemOzerCakir,
1
FatmaYavuz,
5
HuseyinAtaseven,
1
andAliDemir
1
󰀱
Department of Gastroenterology, Meram School of Medicine, Necmettin Erbakan University, Meram, 󰀴󰀲󰀰󰀹󰀰 Konya, urkey 
󰀲
Department of Immunology and Allergic Diseases, Meram School of Medicine, Necmettin Erbakan University, 󰀴󰀲󰀰󰀹󰀰 Konya, urkey 
󰀳
Department of Radiology, Meram School of Medicine, Necmettin Erbakan University, 󰀴󰀲󰀰󰀹󰀰 Konya, urkey 
󰀴
Division of Gastroenterology, Konya Education and Research Hospital, 󰀴󰀲󰀰󰀹󰀰 Konya, urkey 
Department of Internal Medicine, Meram School of Medicine, Necmettin Erbakan University, 󰀴󰀲󰀰󰀹󰀰 Konya, urkey 
Correspondence should be addressed to Murat Biyik; drmuratbiyik@gmail.comReceived 󰀲󰀷 May 󰀲󰀰󰀱; Accepted 󰀱 July 󰀲󰀰󰀱; Published 󰀸 July 󰀲󰀰󰀱Academic Editor: Melanie DeutschCopyright © 󰀲󰀰󰀱 Murat Biyik et al. Tis is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the srcinal work is properly cited.Variceal bleeding is the major complication o portal hypertension in patients with liver cirrhosis. Hemorrhage mainly occursin gastrointestinal lumen. Extraluminal hemorrhages are quite rare, such as intraperitoneal hemorrhages. We aimed to present a varicealbleedingcaseromtheanastomosisontheanteriorabdominalwall,asanextraordinarybleedinglocation,inapatientwithportal hypertension in whom there were no esophageal and gastric varices.
1. Introduction
Among the complications o chronic liver disease due toportalhypertensionarevaricealbleeding,ascites,andhepaticencephalopathy. Variceal bleeding occurs mainly rom theesophageal and gastric veins, but in rare cases bleeding intothe intraperitoneal region may occur. We describe here apatient with external bleeding in the anterior abdominalwall arising rom the anastomosis between the splenic andepigastric veins.
2. Case
A 󰀶󰀱-year-old man with an 󰀸-year history o cryptogenicliver cirrhosis was admitted to the emergency departmentwith massive hemorrhage rom the anterior abdominal wall.Physical examination showed blood pressure 󰀸󰀰/󰀵󰀰mmHg,heart rate 󰀹󰀶/min, massive ascites, and bleeding rom a vessel around the umbilicus (Figure 󰀱). Laboratory param-eters included hemoglobin 󰀱󰀰.󰀹g/dL, platelets 󰀱󰀲󰀱󰀰󰀰󰀰
u/L,INR 󰀱.󰀶, albumin 󰀲.󰀳g/dL, total bilirubin 󰀲.󰀹mg/dL, AS
u/L, and AL 󰀱
u/L. Te bleeding vessel was suturedby a cardiovascular surgeon and hemorrhage control wasachieved. Subsequent medical treatment included inusionso somatostatin and human serum albumin and transu-sions with erythrocyte suspensions and resh rozen plasma.Gastroscopy perormed afer the patient stabilized revealedportal hypertensive gastropathy but no esophageal varices.Abdominal computerized tomography showed collateralsin the umbilical region originating rom the anastomo-sis between the splenic and epigastric veins (Figure 󰀲).Te patient was discharged. One month later, however, hewas admitted to the emergency department with hepaticencephalopathy and died.
3. Discussion
Portal hypertension is defined as a pressure above 󰀱󰀲mmHgin the portal vein, leading to portosystemic shunts in severalanatomic regions. Te most common sites are betweenthe gastroesophageal vein and azygos/hemiazygos system,between the hemorrhoidal and internal iliac veins, andbetween the umbilical and periumbilical veins draining intothe epigastric veins o the anterior abdominal wall [󰀱, 󰀲].
Hindawi Publishing CorporationCase Reports in Hepatology Volume 2014, Article ID 523610, 2 pageshttp://dx.doi.org/10.1155/2014/523610
 
󰀲 Case Reports in Hepatolog
F󰁩󰁧󰁵󰁲󰁥 󰀱: External hemorrhage rom periumbilical anastomosis onthe anterior abdominal wall.F󰁩󰁧󰁵󰁲󰁥󰀲:Aberrantvenouscollateralsbetweenumbilicalandsplenic veins are shown with arrows.
Bleedingduetoportosystemicshuntsmainlyresultsromesophageal and gastric varices. In rare cases, intraperitonealand retroperitoneal hemorrhage due to portal hypertensionhave been reported [󰀳]. Te first case o intra-abdominalhemorrhage resulting rom cirrhosis was reported in 󰀱󰀹󰀵󰀸[]. While esophageal variceal bleeding mainly presentswith hematemesis and melena, hemoperitoneum presentswith abdominal pain and distention, hypotension, and hem-orrhagic shock [󰀵]. Te diagnosis o hemoperitoneum isestablished by paracentesis, Doppler ultrasonography, andcomputed tomography [󰀶]. Because o the limited numbero cases to date, optimum therapy has not been determined.Mostpatientswithhemoperitoneumhavebeentreatedsurgi-cally [󰀱]. Hepatic unctional reserve, the occurrence o hem-orrhagic shock, and early surgical interventionare importantprognostic actors in patients with hemoperitoneum [󰀵].Bleeding in our patient occurred rom the collateralsbetween the splenic and epigastric veins on the anteriorwall o the abdomen, an area in which bleeding has not,to our knowledge, been reported in a patient with portalhypertension. Tis patient is thereore the first with livercirrhosis to experience external hemorrhage rom a porta-caval anastomosis. Initial treatment in such patients shouldbebasedonachievinghemostasisbysurgicalinterventiononthebleedingvessel,hemodynamicstabilizationwitherythro-cyte suspensions and fluid replacement, and correction o coagulopathy with resh rozen plasma. Portal hypertensionmaybereducedbyvasoconstrictorssuchassomatostatinandterlipressin [󰀷].
Conflict of Interests
Te authors declare that there is no conflict o interestsregarding the publication o this paper.
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