Vaginal varices with massive hemorrhage in a patient with nonalcoholic steatohepatitis and portal hypertension: Successful treatment with liver transplantation

McHugh, Patrick P.; Jeon, Hoonbae; Gedaly, Roberto; Johnston, Thomas D.; DePriest, Paul D.; Ranjan, Dinesh

doi:10.1002/lt.21506

Cited by 14 publications

(18 citation statements)

References 8 publications

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“…The occurrence of the varices at the vaginal wall is rare, although it is more common on the vulvar area. Only a few cases have been reported in the literature, and these cases exhibited vaginal bleeding from the varices, as a complication of portal hypertension [3,4]. In contrast, our patient displayed neither portal hypertension nor any other varices.…”

Section: Discussioncontrasting

confidence: 49%

A case of vaginal varix during pregnancy

Kim

Lee

2012

Korean J Obstet Gynecol

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Vaginal varix during pregnancy is a rare condition. Only a few cases have been reported in the literature. Most vaginal varices are asymptomatic, but some are associated with a sense of local mass, or severe discomfort and spontaneous vaginal bleeding. A 32-year-old woman was admitted for acute spontaneous vaginal bleeding at 37+6 weeks' gestation. Upon pelvic inspection, we observed dilated vascular structure on the suburethral vaginal wall, and the trans-labial ultrasound imaging revealed a blood fl ow along the vaginal area, confi rming the presence of a vaginal varix. Instead of a normal delivery, we performed a Cesarean section to prevent the potential risk of the profuse vaginal bleeding. The postoperative course was uneventful, and the mass spontaneously resolved 6 weeks after the delivery. The authors believe that this case of vaginal varix found during pregnancy is the fi rst documented case in Korea. Keywords:Vaginal varicose veins; Pregnancy; Hemorrhage CASE REPORT Received: 2011. 7.20. Revised: 2011. 9. 7. Accepted: 2011 Vulvar varices are reported in 4% of women [1], and most of them may be secondary to pregnancy from other anatomical and pathological diseases such as Klippel-Trenaunay-Weber syndrome or pelvic congestion syndrome. However, the vaginal varices, located in the vaginal and periurethral wall, are reported less frequently. Vaginal varix in non-pregnant women does not exhibit a serious threat; however, during pregnancy, the spontaneous laceration of the vaginal varix can cause significant blood loss. Therefore, an obstetrician should be aware of its clinical importance. We report a case of vaginal varix during pregnancy and its clinical features for the fi rst time in Korea. Case ReportA 32-year-old multiparous woman who was a nonsmoker with no signifi cant medical history visited the department of obstetrics and gynecology because of acute spontaneous vaginal bleeding. The woman was at 37+6 week of gestation with the fetus having a cephalic presentation. The pregnancy had been normal during the prenatal check 2 weeks ago, when the patient experienced cough and rhinorrhea. The patient recognized the lesion had been enlarged as the pregnancy continued few months into the conception. We found the vaginal bleeding and performed a pelvic inspection by spreading the labia minor with two fingers, and were surprised to find a strawberry sized vascular lesion on the suburethral vaginal wall, obstructing the vaginal lumen (Fig. 1). We detected a bleeding point on the varix. On the visit, the patient's vital signs were stable and the fetal heart rate pattern on non-stress test was reactive. The sonographic examination revealed a mixed echogenic mass that was 2.3 × 2.7 cm in size at the anterior vaginal wall area. Maximal systolic and diastolic velocity at 21.7 cm/sec and 12.8 cm/sec, respectively, was found using Power Doppler sonography, and the resistance index was 0.41 (Fig. 2). The fetus grew normally according to the gestational age. Also, the placenta showed left lateral attachment and the am...

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Section: Discussioncontrasting

confidence: 49%

A case of vaginal varix during pregnancy

Kim

Lee

2012

Korean J Obstet Gynecol

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“…The only communication between this plexus and the portal system is through the superior portion of the haemorrhoidal plexus. While anorectal varices are quite commonly found in cirrhotics, the extensive uterovaginal venous plexus ensures that the effects of portal hypertension are effectively decompressed without the formation of varices [ 38 ]. Thus, uterovaginal varices (Fig.…”

Section: Varicesmentioning

confidence: 99%

“…Massive haemorrhage has been reported to occur from vaginal varices that had to be controlled using suture ligation, banding, or sclerotherapy, together with local tamponade. TIPS has also been reported to be beneficial as a temporizing measure in reducing variceal pressure [ 38 ]. However, liver transplantation remains the definitive treatment [ 38 ].…”

Section: Varicesmentioning

confidence: 99%

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Spectrum of hepatofugal collateral pathways in portal hypertension: an illustrated radiological review

et al. 2015

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The purpose of this article is to describe the various portosystemic collateral pathways pertinent to portal hypertension on multi-detector row computed tomography (MDCT) and their clinical relevance, with special emphasis on the uncommon ones. The knowledge and understanding of the various patterns of portosystemic collateral channels has important implications both for the clinician and the interventionist. MDCT with its advanced post processing capabilities can exquisitely demonstrate these vascular pathways to help in therapeutic decision making.Teaching points• Portosystemic collaterals are an important cause of bleeding and hepatic encephalopathy.• Radiologists should be familiar with the imaging findings to effectively identify them.• Pre-operative knowledge of portosystemic collaterals is essential to avoid inadvertent vascular injury.

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“…72,73 Efferent from Vaginal and Uterine Varices Venous plexuses of uterus and vagina, internal iliac vein and uterine veins.…”

Section: Afferent To Vaginal and Uterine Varicesmentioning

confidence: 99%

Collateral Pathways in Portal Hypertension

Sharma

Rameshbabu²

2012

Journal of Clinical and Experimental Hepatology

128

104

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Presence of portosystemic collateral veins (PSCV) is common in portal hypertension due to cirrhosis. Physiologically, normal portosystemic anastomoses exist which exhibit hepatofugal flow. With the development of portal hypertension, transmission of backpressure leads to increased flow in these patent normal portosystemic anastomoses. In extrahepatic portal vein obstruction collateral circulation develops in a hepatopetal direction and portoportal pathways are frequently found. The objective of this review is to illustrate the various PSCV and portoportal collateral vein pathways pertinent to portal hypertension in liver cirrhosis and EHPVO. ( J CLIN EXP HEPATOL 2012;2:338-352) A lmost any vein in the abdomen may serve as a potential collateral channel to the systemic circulation. Presence of abnormal collateral vessels appears to be one of the most sensitive (70-83%) and specific sonographic signs for the diagnosis of portal hypertension. 1 When blood flow through a vessel or a vascular bed is obstructed due to occlusion, as in EHPVO, or distortion, as in liver cirrhosis, collateral pathways open up as blood bypasses the occlusion or obstruction, always flowing down a pressure gradient from a high pressure to a low-pressure vessel or bed. The formation of portosystemic pathways occurs due to reopening of collapsed embryonic channels or reversal of the flow within existing adult veins. 2,3 The number of collateral channels depends on the severity of portal hypertension i.e. the differential gradient driving the flow between the portal and the systemic circulations and the duration of portal hypertension. The more severe and more prolonged the portal hypertension, the higher are the number of portosystemic pathways. However, this traditional hypothesis has been challenged and it has been suggested that the formation of portosystemic collateral circulation may be due in part to angiogenesis driven by vascular endothelial growth factor. 4,5 Almost 50 years have passed since the first detailed description of portosystemic collateral veins (PSCV) in portal hypertension appeared. 6 Precise mapping of PSCV is essential to therapeutic decisions and multidetector computerized tomography (MDCT) is sometimes used for cartography of PSCV. 7 EUS is increasingly being used for evaluation of PSCV and additionally provides an option for performing therapeutic interventions. 8 In addition to PSCV, PPCV pathways are frequently found in extrahepatic portal vein obstruction (EHPVO). The objective of this review is to illustrate the various PSCV and PPCV pathways pertinent to portal hypertension in liver cirrhosis and EHPVO. NORMAL PORTOSYSTEMIC ANASTOMOSESThe left gastric vein (LGV) anastomoses with the esophageal veins, which in turn drain into the azygos vein (AV). The superior rectal vein (SRV) anastomoses with the middle and inferior rectal veins (IRV), which are, respectively, tributaries of the internal iliac and the pudendal veins. The paraumbilical vein (PUV) anastomoses with subcutaneous veins in the anterior abdominal...

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Vaginal varices with massive hemorrhage in a patient with nonalcoholic steatohepatitis and portal hypertension: Successful treatment with liver transplantation

Cited by 14 publications

References 8 publications

A case of vaginal varix during pregnancy

A case of vaginal varix during pregnancy

Spectrum of hepatofugal collateral pathways in portal hypertension: an illustrated radiological review

Collateral Pathways in Portal Hypertension

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