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versión impresa ISSN 1130-0108
Rev. esp. enferm. dig. vol.104 no.3 mar. 2012
LETTERS TO THE EDITOR
Gallbladder variceal bleeding in a patient with alcoholic cirrhosis: a rare entity
Hemorragia por varices en la vesícula biliar en paciente con cirrosis alcohólica. Una entidad excepcional
Key words: Gallbladder. Varices. Haemorraghe. Cirrhosis.
Palabras clave: Vesícula biliar. Varices. Hemorragia. Cirrosis.
Alcoholic cirrhosis is a common condition that can lead to serious complications. The locations of varicose veins such as the anorectal area, the colon, the bladder or the ileal area have been reported more frequently in patients with portal hypertension associated with portal vein thrombosis and with cirrhosis. Several authors have described these varices in relation to the bile duct, but the bleeding from gallbladder varices in a patient with alcoholic cirrhosis, as a cause of death, is very rare. We report a clinical case.
A 49-year-old man with a history of uncontrolled alcoholism was admitted with severe tachycardia and hypotension. The patient required intubation during his arrival at the emergency department. A fluid intake was required to maintain the normal vital signs. A relative referred that the patient complained of pain in the upper right quadrant, nausea, and vomiting in the last two days. Physical examination revealed conjunctiva pallor, progressive abdominal distension. Laboratory tests were normal except for severe acute anemia (hemoglobin, 4.1 mg/dl). A computerized tomography scan (CT scan) showed an intravesicular active bleeding with a gallbladder perforation. CT scan also showed the presence of massive of intraperitoneal fluid (ascites and hemoperitoneum) (Fig. 1A). No thrombosis of the portal vein was found. The patient underwent an emergency laparotomy. During surgery, we found a massive hemoperitoneum with ascites. The gallbladder had a tear in the gallbladder fundus with no signs of acute or chronic cholecystitis (Fig. 1B). Through the perforation, there was massive bleeding into the abdominal cavity. Ten hours after surgery, the patient died developing multiple organ failure with anuria and polytransfusional syndrome.
Gallbladder varices are rare. These are ectopic varices that can develop in patients with portal hypertension, particularly in patients with occlusion of the portal vein. Its incidence is uncertain, but it has been estimated at 12-30% in the field of portal hypertension (1,2). They are usually located in the gallbladder and bile ducts where they can coexist and are usually asymptomatic (1). They are difficult to diagnose by conventional methods because they are rare. However, Doppler ultrasound is generally recognized as the imaging technique with greater sensitivity and specificity. Magnetic resonance imaging and CT scan have proved to be useful for diagnosis (1). Gallbladder's function and mobility are usually not affected by the presence of varicose veins (3). Very few cases have been reported of bleeding varices of the gallbladder as a cause of death (1). The bleeding may occur directly into the abdominal cavity or, as in the present patient, into the gallbladder. In our case, likely due to the rupture of a varix in the gallbladder, the patient developed pain in the right upper abdomen for two days until he came up with a massive hemorrhagic shock due to perforation of the gallbladder likely caused by an intravesicular overpressure.
Gallbladder variceal bleeding is a rare complication in patients with portal hypertension and should be considered in the differential diagnosis of patients with acute bleeding of unknown etiology.
The authors gratefully acknowledge the financial support of Dr. Ramon Vilallonga Foundation to carry out the work (www.fundacioramonvilallonga.org).
Ramón Vilallonga1, Óscar González1, Silvina Bergamini2,
José Manuel Fort1 and Manuel Armengol2
1Department of General Surgery and Digestive Diseases.
Unit of Endocrine, Bariatric and Metabolic Surgery.
2Department of General Surgery and Digestive Diseases.
Hospital Vall d'Hebron, Barcelona. Autonomous University of Barcelona. Spain
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