Cristina Calogero, MD1, Dina Halegoua-DeMarzio, MD2, Jonathan Fenkel, MD1
1Thomas Jefferson University Hospital, Philadelphia, PA; 2Thomas Jefferson University, Philadelphia, PA
Introduction: A known consequence of portal hypertension is the development of varices, which are described as “ectopic” when located at unusual sites in the abdomen. Ectopic varices carry a mortality rate as high as 40% after initial hemorrhagic episode. We report a rare case of bladder varices as the presenting symptom for a new diagnosis of cirrhosis.
Case Description/Methods: A 62yo female with a history of treated chronic hepatitis C (HCV) presented to an outside hospital with two days of gross hematuria. She was transferred to our center for further management. She had completed eight weeks of glecaprevir-pibrentasvir a few months prior to admission. On physical exam, she was an obese female without scleral icterus or jaundice, nor cutaneous stigmata of liver disease. Past imaging from six months prior to admission was notable for hepatomegaly only and not cirrhosis. Labs were significant for a hemoglobin of 7.6 and MELD-Na=7. HCV RNA was undetectable. CT imaging of her abdomen/pelvis revealed cirrhosis with varices present along the right bladder wall in connection with the right internal iliac vein and the portal venous system. We performed a transvenous hepatic venogram and pressure study with biopsy. Liver pathology confirmed the presence of chronic hepatitis and cirrhosis and the hepatic venous pressure gradient was 13mm Hg. Urology placed the patient on continuous bladder irrigation and then performed a cystoscopy that revealed large, tortuous veins along the right lateral and posterior bladder, consistent with varices. She received an IV octreotide infusion with some improvement in hematuria, but not cessation. Multidisciplinary discussion resulted in our interventional radiology (IR) team performing a modified balloon-occluded retrograde transvenous obliteration, accessing the varix successfully via percutaneous transhepatic approach through the superior mesenteric vein and into the bladder varix. The hematuria resolved and the patient was safely discharged two days later.
Discussion: The bladder is an uncommon site for ectopic varices to form and hematuria is not often a symptom associated with cirrhosis or portal hypertension. This presentation was even more uncommon as the patient was not previously known to have cirrhosis. Cross-sectional imaging was key to the diagnosis in this case. Recognition of this rare event, combined with multidisciplinary management, helped this patient have a successful outcome.
Citation: Cristina Calogero, MD; Dina Halegoua-DeMarzio, MD; Jonathan Fenkel, MD. P1600 - BLADDER VARICES CAUSING HEMATURIA AND A NEW DIAGNOSIS OF CIRRHOSIS. Program No. P1600. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.