Hemoperitoneum from omental variceal bleed resulting in first documented successful liver transplant: A case report

Abstract

BACKGROUND

While varices and variceal bleeds are well-known and feared complications of advanced cirrhosis and portal hypertension, omental variceal bleed are a rare sequala even in patients with known esophageal or gastric varices. While rare, omental varices pose a risk for hemoperitoneum if ruptured, which is a life-threatening complication with high mortality rates despite surgical intervention.

CASE SUMMARY

This report reviews the case of a patient 36-year-old female with alcohol related cirrhosis decompensated by ascites, but no history of varices admitted for hemorrhagic shock from spontaneous rupture of omental varices requiring emergency surgery. She underwent the first documented successful orthotopic liver transplantation the same admission.

CONCLUSION

This case report and literature review stresses the importance of early consideration and identification of intraabdominal variceal sources in cirrhotic patients with refractory shock.

Key Words: Omental varices; Alcoholic liver disease; Alcohol related cirrhosis; Variceal bleed; Orthotropic liver transplant; Hemoperitoneum; Omental variceal bleed; Case report

Core Tip: While varices and variceal bleeds are well-known and feared complications of advanced cirrhosis and portal hypertension, omental varices are a rare sequala even in patients with known esophageal or gastric varices. Omental varices pose a risk for hemoperitoneum if ruptured, which is a life-threatening complication with high mortality rates despite surgical intervention. This case report reviews the first documented case of successful liver transplantation after hemorrhagic shock secondary to omental variceal bleed.

INTRODUCTION

While varices and variceal bleeds are well-known and feared complications of advanced cirrhosis and portal hypertension, intra-abdominal variceal bleeds are a rare sequala even in patients with known esophageal or gastric varices. While previously noted intra-abdominal varices have been reported in the right colic gutter, mesentery, periumbilical, and retroperitoneal regions, few case reports exist of omental varices. While rare, omental varices pose a risk for hemoperitoneum if ruptured, which is a life-threatening complication with high mortality rates despite intervention.

CASE PRESENTATION

Chief complaints

A 36-year-old female with a past medical history of alcohol-related cirrhosis decompensated by ascites was transferred to the emergency department of a large, urban hospital due to a one-week history of progressive weakness and abdominal pain.

History of present illness

The patient had initially presented to an outside hospital due to severe abdominal pain where she was noted to have a hemoglobin of 5.8 g/dL, and computed tomography (CT) angiography of the abdomen was notable for hemoperitoneum but negative for active bleeding. She was transfused with 3 units of packed red blood cells and transferred to the nearest tertiary care center.

History of past illness

Personal history notable for alcohol-related cirrhosis decompensated by ascites. Of note, given six months of sobriety, her cirrhosis had recently been stable, and her diuretics had been weaned. Less than two months prior to presentation, she had a screening esophagogastroduodenoscopy (EGD), which was negative for evidence of gastric or esophageal varices.

Personal and family history

Personal history notable for alcohol and substance use disorder.

Physical examination

On arrival to the Emergency Department, patient was endorsing dizziness, and vitals were notable for tachycardia (heart rate: 110), hypotension (96/60); without any fever. Her physical exam was notable for jaundice and mild abdominal distention.

Laboratory examinations

MELD 3.0 on arrival was 30 (Cr 1.7 mg/dL, Na 132 mmol/L, total bilirubin 3.3 mg/dL, albumin 2.5 g/dL, international normalized ratio 2.3). Hemoglobin on arrival was 7.9 g/dL; however, the patient subsequently became more hypotensive with a mean arterial pressure in the 50s, requiring pressor support. Hemoglobin was repeated at this time and was noted to be 6.6 g/dL.

Imaging examinations

CT angiogram was repeated which was notable for stable large-volume ascites with hemoperitoneum with no evidence of active bleed (Figures 1 and 2).

Figure 1 Left image showing initial computed tomography angiography abdomen/pelvis prior to transfer demonstrating hemoperitoneum. Right image showing repeat computed tomography angiography abdomen pelvis approximately eight hours later showing stable large volume hemoperitoneum.

Figure 2 Computed tomographic angiography abdomen/pelvis with orange arrow showing omental varix in right abdomen that was the likely source of bleed.

MULTIDISCIPLINARY EXPERT CONSULTATION

She was transferred to the medical intensive care unit (ICU), where she was noted to have rapidly escalating pressor requirements despite adequate transfusion and abrupt abdominal distention. Given progressive rapid hemodynamic instability, the patient underwent emergency laparotomy, which revealed brisk omental variceal bleeding in the right upper quadrant and adhesions from omentum to the pelvis with additional bleeding noted. Hemostasis was achieved with cautery and hemoclips and over 2 liters of blood was evacuated; no pathologic samples or intra-operative photographs were taken.

FINAL DIAGNOSIS

Hemorrhagic shock secondary to hemoperitoneum from ruptured omental varices.

TREATMENT

Emergency laparotomy with hemostasis via cautery and hemoclips.

OUTCOME AND FOLLOW-UP

After conclusion of the surgery, the patient was transferred back to the medical ICU, where her condition stabilized, pressors were weaned, MELD down-trended to 22, and she underwent liver transplant evaluation. Her course was complicated by hyperkalemia and acute kidney failure secondary to hypovolemia requiring brief continuous renal replacement therapy; however, renal function and hemodyamic instability improved and she was transferred out of the ICU.

Approximately two weeks after the presentation for hemorrhagic shock and hemoperitoneum secondary to ruptured omental varices, she underwent an uncomplicated orthotopic liver transplant. Over six months after transplant, the patient has remained stable with no further bleed, repeat hospitalization, or evidence of transplant rejection.

DISCUSSION

Review of the literature

The PubMed (2000-2025) database was queried for case reports regarding intra-abdominal and omental variceal bleed, and abstracts published in English were screened. Case reports regarding spontaneous intra-abdominal varices in patients without cirrhosis or bleeding in pregnancy were not included. Demographic data and outcomes from fourteen patients can be found in Tables 1 and 2, respectively[1-10].

Table 1 Patient demographics.

Average age	48.7 years (range: 36-63)
Sex
Male	10 (71.4)
Female	4 (28.6)
Cirrhosis previously diagnosed	100 (14/14)
Alcohol related cirrhosis?	92.9.7 (13/14)
Prior history of varices
Yes	28.6 (4/14)
Unknown	57.1 (8/14)
No	14.3 (2/14)

Table 2 Patient outcomes.

Diagnostic method
CTA	64.3 (9/14)
Surgery	14.3 (2/14)
Paracentesis	14.3 (2/14)
Autopsy	7.1 (1/14)
Intervention
Surgery	71.4 (10/14)
TIPS	14.3 (2/14)
IR- glue embolization	7.1 (1/14)
N/A	7.1 (1/14)
Death
Yes	57.1 (8/14)
No	42.9 (6/14)
Source of bleed
Omental	50.0 (7/14)
Peritoneal	7.1 (1/14)
Mesenteric	7.1 (1/14)
Retroperitoneal	7.1 (1/14)
Multiple sources	7.1 (1/14)
Gallbladder	14.3 (2/14)
Unknown	7.1 (1/14)

CTA: Computed tomography angiography; TIPS: Transjugular intrahepatic portosystemic shunt; IR: Interventional radiology; N/A: Not applicable.

The American Association for the Study of Liver Disease and American Gastrological Association have noted that gastroesophageal varices (GEV) are present in 30%-40% of those with compensated cirrhosis and up to 85% of patients with decompensated cirrhosis, with the most common variceal site being esophageal (up to 85%) followed by gastric (15%-25%)[11,12]. GEV bleed occurs at rate of 10%-15% per year and the 5-year mortality after hemorrhage ranges from 20%-80%[11].

While omental variceal bleeds have been documented since 1978, they remain extremely rare sequelae of portal hypertension and have been noted in prior case reports to be more common in middle-aged men with advanced cirrhosis[13]. Intra-abdominal variceal bleeds are associated with hepato-renal syndrome, encephalopathy, and increased mortality rate[11]. Due to its rarity, there is very limited data on the prevalence of omental varices; however, one study in 1995 reported that less than 20% of individuals with portal hypertension had radiologic evidence of omental varices[14]. No further studies have commented on the incidence of omental varices and it is unknown if they are associated with complications of cirrhosis, such as portal vein or SMV thrombosis, or differences in anatomy.

Furthermore, there is limited information regarding the mortality rate of omental variceal bleed. Upon review of the case reports available on PubMed, there was a 57% mortality rate within 2-week of presentation despite procedural/surgical intervention. This is a stark contrast to the mortality rate of those with GEV bleed. A review of these case reports notes a consistent presentation of progressive abdominal pain followed by hypotension and rapidly increasing abdominal girth. Additionally, review of these cases notes that surgical intervention was often preferred over pursuit of transjugular intrahepatic portosystemic shunt (TIPS) or interventional radiology embolization of bleed, which was mirrored in this patient’s presentation. While the decision to pursue surgery over TIPS in many of the cases in unknown, it is likely due to the elevated risk of TIPS in high MELD patients. In this patient’s presentation, due to her rapid clinical deterioration and abdominal distention is conjunction with her high MELD, surgical intervention was preferred over high risk TIPS.

Despite a rapid diagnosis of hemorrhagic shock and hemoperitoneum with paracentesis or CT, adequate volume resuscitation, and intervention, either with surgical hemostasis or TIPS, many patients continued to have a rapid decline and died within days of presentation. While their deaths appear to have ultimately been multifactorial in the setting of possible concomitant septic shock, multi-organ failure, etc., this highlights the dangers of omental and intra-abdominal variceal bleeding and the guarded prognosis this rare manifestation of portal hypertension holds, particularly in comparison to GEV bleed.

Of note, this case report highlights a patient who is unique in multiple facets. This patient was a young female, which is contrary to most case reports in which the average age is 49 years old and patients are typically male (11 out of 14 patients). Next, while having decompensated cirrhosis, she had a recent screening EGD with no evidence of GEV, making the patient’s odds of having any other varices, let alone a variceal hemorrhage, significantly low. On review of prior case reports, it was reported that 28.6% had a history of esophageal varices, however many case reports did not comment on prior variceal history, so this number may be falsely low. Furthermore, given this patient’s hemodynamic stabilization after surgical intervention, she was able to undergo transplant evaluation and ultimately underwent uncomplicated orthotopic liver transplant during the same admission.

CONCLUSION

To the best of our knowledge, this is the first case report of a successful transplant after intra-abdominal variceal bleed. Interestingly, outside of expediting her transplant evaluation and surgery, there were no known perioperative complications of the recent omental bleed on her transplant. It is likely that her recent six-month history of sobriety prior to presentation and young age, in conjunction with rapid diagnosis and intervention at a liver transplant center, led to her exceedingly successful, albeit rare, outcome.

This case stresses the importance of early consideration of hemoperitoneum and intraabdominal varices in cirrhotic patients with refractory shock, even in those with no prior history of varices. Additionally, this shows the need for rapid multidisciplinary treatment with interventional radiology, surgery, and transplant hepatology to maximize patient outcomes. While the prognosis in intra-abdominal variceal hemorrhage in patients with cirrhosis remains a guarded prognosis, this case of successful liver transplant after omental variceal bleed highlights the possibility of success with rapid diagnosis and treatment of the condition.