(475) The Unseen Threat: Spontaneous Hemoperitoneum due to Splenic Vein Bleed in Decompensated Cirrhosis

Introduction: Spontaneous hemoperitoneum in cirrhotic patients is an uncommon but dangerous complication that can have catastrophic outcomes. We present a unique case of a critically ill patient who developed a non-traumatic splenic vein bleed leading to compartment syndrome, emphasizing the complexity involved in managing such patients.

Description: A 38-year-old male with a history of decompensated alcoholic cirrhosis and esophageal varices presented with acute diffuse abdominal pain. On examination, he was hypotensive with a distended and diffusely tender abdomen. His MELD-Na score was 23. A CT scan of the abdomen revealed a large quantity of ascites with superimposed high densities. Paracentesis was performed, yielding 5 liters of sanguineous fluid. Despite this intervention, the patient continued to experience severe abdominal pain. A subsequent CTA showed a slow venous bleed along the lateral aspect of the spleen around the collaterals. The patient was transferred to a tertiary center where interventional radiology and surgery were consulted. He underwent splenic varix embolization and a partial transjugular intrahepatic portosystemic shunt (TIPS) procedure. During the procedure, massive transfusion protocol and pressors were initiated. Examination and point-of-care ultrasound indicated compartment syndrome, with a bladder pressure of 48 mmHg. Unfortunately, the patient was not a candidate for surgical intervention due to high risk of additional bleeding, which would likely be uncontrollable. Despite aggressive resuscitation efforts, the patient's pressor requirements continued to escalate requiring the maximum dosage of four pressors. He ultimately succumbed to refractory shock.

Discussion: Spontaneous hemoperitoneum resulting from splenic vein bleeding is a rare and life-threatening condition. This condition can be catastrophic, leading to rapid deterioration and death, thus necessitating prompt diagnosis and intervention. The coagulation disturbances and variceal alterations associated with cirrhosis substantially elevate the risk of hemorrhage in these patients, further complicating their clinical management. Rupture of the splenic vein is a rare condition that should be considered in the differential diagnosis of intra-abdominal hemorrhage in cirrhotic patients.