Kathy Williams, MD, MS
New York, New York
Kathy N. Williams, MD, MS1, David Kadosh, MD1, Richa Bhardwaj, MBBS2, Elena Ivanina, DO, MPH2
1Lenox Hill Hospital / Northwell Health, New York, NY; 2Lenox Hill Hospital, New York, NY
Introduction: Ascites is commonly seen in patients with decompensated cirrhosis. Hemorrhagic ascites is a rare, but a dangerous complication of cirrhosis. This case uniquely highlights an uncommon but important association between cirrhosis and spontaneous hemoperitoneum.
Case Description/Methods: A 57-year-old female with a history of decompensated alcoholic cirrhosis with ascites presented with acute diffuse abdominal pain with hypotension. She denied hematemesis, hematochezia or melena. On exam she had scleral icterus with asterixis. Her abdomen was distended and diffusely tender with hypoactive bowel sounds. Her MELD-Na was 20. An abdominal CTA showed moderate to high density ascites suggestive of hemorrhagic ascites, without active bleeding (Image 1). Paracentesis showed evidence of sanguineous fluid with 1.9 million RBC/u L. Following which she had a drop in her hemoglobin from 9 to 6.5 g/d L, with worsening of abdominal pain and distension. She underwent an exploratory laparotomy with evacuation of 7 liters of blood and diffuse oozing from visceral and peritoneal surfaces. The paracentesis tract was noted to be without hemorrhage. Labs showed platelets 43, fibrinogen < 80, PTT 131, suggestive of disseminated intravascular coagulation (DIC). She subsequently became hemodynamically unstable despite resuscitation and passed away from cardiopulmonary arrest.
Discussion: Spontaneous hemoperitoneum is rare and occurs in patients with decompensated cirrhosis with high MELD scores. In these patients, hemoperitoneum can be either related to trauma or spontaneous secondary to leakage of RBCs from the interstitial spaces of the liver or splanchnic bed or intra-abdominal bleeding from a small vessel portosystemic collateral or bleeding form HCC. The known coagulation disturbances associated with liver cirrhosis place these patients at increased risk for hemorrhage. The patient described in this case report is an example of spontaneous hemoperitoneum in the setting of a coagulation disturbance, which lead to hemorrhagic shock and highlights the importance of considering this diagnosis in patients who present with similar symptoms due to high rates of morbidity and mortality.
Citation: Kathy N. Williams, MD, MS; David Kadosh, MD; Richa Bhardwaj, MBBS; Elena Ivanina, DO, MPH. P1348 - A CASE OF SPONTANEOUS HEMOPERITONEUM IN A PATIENT WITH DECOMPENSATED ALCOHOLIC CIRRHOSIS. Program No. P1348. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.