A Rare Cause of Hemoperitoneum in a Patient with Cirrhosis and Portal Hypertension

A 48-year-old man, diagnosed case of portal hypertension secondary to alcohol related cirrhosis of the liver, presented to the gastrointestinal (GI) Bleed Unit, with jaundice and worsening abdominal distension for a period of five days. Clinical examination revealed an emaciated patient in grade 2 hepatic encephalopathy with pulse rate 98 per minute and mean arterial pressure 66 mmHg in the right supine brachial region, with Child Pugh score 10 and Model for End Stage Liver Disease score 18. Upper GI endoscopic evaluation revealed small low risk esophageal varices without active bleeding or stigmata of recent hemorrhage and normal colonoscopy. Bedside diagnostic paracentesis revealed bloody aspirate with fluid hematocrit 17% and fluid red blood cell count of 35,000 per mm3 suggestive of hemoperitoneum. An urgent computed tomography (CT) angiography of the abdomen revealed shrunken dysmorphic liver with hyper dense free fluid and dependent clots in pelvis without active bleeding. Interestingly, multiple thread-like structures with contrast opacification in venous phase were noted in the distal duodenum and jejunal region [black arrows (Figure 1A, maximal intensity projection, CT coronal) and corresponding white arrows (Figure 1B, CT curved planar reformation, 3-dimensional)] along with multiple contrast opacified mesenteric and retroperitoneal vessels (Figure 1C, asterisk). Commencement of broad spectrum antimicrobials, blood transfusions, and terlipressin with serial hemoglobin monitoring, and abdominal girth charting was undertaken. The patient had an uneventful recovery from the bleeding episode and is currently listed in the deceased donor liver transplantation program.