Recurrent bleeding from cutaneous venous collaterals in portal hypertension.

Abstract

SUMMARY In portal hypertension, three types of cutaneous portosystemic collaterals may develop: the 'classical' caput Medusae, enterostomal varices and scar or adhesion-related abdominal collaterals. Two patients were treated with severe and recurrent bleeding from adhesion-related collaterals, a complication not reported previously. In the first patient bleeding was only controlled by mesocaval shunt operation; the second patient suffered no further recurrence after local sclerotherapy.Portal hypertension is characterised by the development of splanchnic systemic venous connections that decompress the portal venous system. Although this is a protective adaptation, several pathological conditions, such as hepatic encephalopathy and pulmonary hypertension,' can be associated with the collateral blood flow. The most important is gastrointestinal haemorrhage, usually from oesophagogastric varices but occasionally from varices elsewhere in the intestinal or biliary tract.2 Moreover, intra-abdominal bleeding from peritoneal varices,3 external bleeding from stomal varices,4 and genitourinary variceal bleeding2 may occur. We report on two patients with severe and recurrent bleeding from cutaneous, scar related collaterals that developed after abdominal surgery. This is a complication which, to our knowledge, has not been previously described in the literature.PATIENT 1 A 48 year old man with biopsy diagnosed alcoholic cirrhosis was admitted with bleeding from the abdominal wall which started as a result of scratching. Four years previously a sigmoid resection with construction of a stoma of the transverse colon was carried out because of perforation of the sigmoid

A case of fatal cutaneous caput medusae hemorrhage

“…Treatment of this condition includes standard resuscitation protocols as an initial approach in order to obtain hemodynamic stabilization with local measures to control the bleeding during the resuscitation, such as direct pressure, suture ligation, or cautery. [20][21][22] Other measures in the management of caput medusae hemorrhage are the correction of coagulopathy and the reduction of portal hypertension. Coagulopathy in liver disease results from thrombocytopenia and impaired humoral coagulation.…”

Massive umbilical variceal bleeding in alcoholic cirrhosis and its long‐term successful treatment by rubber band ligation

“…Among these treatments, the simple suture ligation of varices for the control of external hemorrhage from umbilical varix is unlikely to achieve long‐term effectiveness due to the high risk of rebleeding . Nevertheless, as in our case, a patient with hemodynamic instability should initially be managed with standard resuscitation therapy and local measures, such as local ligation, cautery and direct pressure which can all be performed during resuscitation . This usually achieves temporary relief from hemorrhage but is associated with high rebleeding rates .…”

Recurrent major umbilical bleeding caused by omental varices in two patients with umbilical hernia and portal hypertension

“…The significant abnormality in both cases was the presence of an umbilical hernia containing incarcerated omentum and the presence of omental varices within the umbilical hernia. Previous reports have described spontaneous bleeding from abdominal wall scars in patients with portal hypertension where the bleeding has arisen from venous communications between the scar and underlying adherent omental varices 9. This led us to believe that in both cases the umbilical bleeding originated from omental varices incarcerated within the umbilical hernia.…”

“…Spontaneous umbilical bleeding has been reported from umbilical varices1–4 and has been treated with transjugular intrahepatic portosystemic shunt,5 sclerotherapy,6 laparotomy and ligation of the recanalised umbilical vein,7 and laparoscopically assisted ligation of the umbilical vein and epigastric veins8 to decompress the periumbilical varices. Spontaneous cutaneous bleeding from abdominal scars has also been reported in patients with cirrhosis and portal hypertension 9. This occurs when venous communications develop between veins in the cutaneous scar and underlying adherent omental varices 9.…”

“…Spontaneous cutaneous bleeding from abdominal scars has also been reported in patients with cirrhosis and portal hypertension 9. This occurs when venous communications develop between veins in the cutaneous scar and underlying adherent omental varices 9. These cases have been treated with mesocaval interposition shunt and sclerotherapy 9…”