A Sudden Increase in Abdominal Girth in a 48-Year-Old Cirrhotic Patient
A 48-year-old man is called into his primary care provider’s office to discuss abnormal laboratory values from a specimen drawn during a prior visit. The patient is an alcoholic with a recent diagnosis of cirrhosis. On presentation, it is noted that the patient has developed increased abdominal distension and looks generally unwell. He is advised to report immediately to the nearest emergency department (ED). At the ED, the patient complains of vague abdominal pain that is dull in nature and poorly localized. Paracentesis is performed to exclude spontaneous bacterial peritonitis. The ascitic fluid obtained is grossly hemorrhagic, with a spun hematocrit (HCT) of 20%. His serum HCT has dropped dramatically, from 41.5% 2 days earlier to 25.9% in the ED. His international normalized ratio (INR) is 1.7. He is started on intravenous fluids, vitamin K is administered, and he is transferred to another ED for
a higher level of care.
On arrival, his vital signs include an oral temperature of 98°F (36.7°C), a heart rate of 98 bpm, a blood pressure of 143/60 mm Hg, a respiratory rate of 12 breaths/min, and an oxygen saturation of 98% on 2 L/min oxygen by nasal cannula. His physical examination is significant for a grossly distended abdomen, with notable periumbilical ecchymosis (positive Cullen’s sign; Figure 1), minimal abdominal tenderness (especially to deep palpation), and shifting dullness to percussion, along with marked scleral icterus and mild tremulousness. He intermittently loses orientation to time and place, with a waxing and waning pattern of attention, and appears to have difficulty responding to simple questions.
Laboratory tests performed in the ED are notable for an HCT of 24%, a platelet count of 94 × 103/μL (94 × 109/L), INR of 1.95, total serum bilirubin level of 6.9 mg/dL (117.99 µmol/L), fibrinogen level of 136 mg/dL (3.99 µmol/L), and serum potassium level of 2.9 mEq/L (2.9 mmol/L). His lactate level is 26.13 mg/dL (2.9 mmol/L). An electrocardiogram shows sinus tachycardia with U waves.
An abdominal computed tomography (CT) scan with intravenous contrast reveals a small, nodular liver; an enlarged spleen; perisplenic collateralized vessels; and significant dense ascites (Figure 2). The fluid density is consistent with hemorrhagic ascites. The scan reveals no evidence of trauma or malignancy.
The patient is transfused with 6 units of packed red blood cells, 6 units of fresh frozen plasma (FFP), and 1 unit of cryoprecipitate. In addition, intravenous potassium, additional vitamin K, and lorazepam (for treatment of presumed alcohol withdrawal) are administered. Although his condition stabilizes during the course of his stay in the ED, his prognosis is deemed grave.
Questions answered incorrectly will be highlighted.
Which of the following choices is the most likely underlying etiology of this patient’s hemoperitoneum?
Hint: Keep in mind this patient’s hemorrhagic ascites in the setting of long-standing cirrhosis.
The patient in this case was thought to be suffering from rupture of an intraperitoneal varix. After discussion with the attending surgeon and interventional radiologist on call, a transjugular intrahepatic portosystemic shunt (TIPS) was inserted to decompress his portal system, with embolization of any actively bleeding varices. The likelihood of his surviving major surgery was considered to be extremely low.