Hematuria in a Cirrhotic Female: Expect the Unexpected

A 62-year-old female was brought to the emergency department with a history of massive hematuria for 2 days. Examination showed mild pallor. Investigations revealed Hb of 8.1 gm%, platelets 54,000/µL, total bilirubin 2.5 mg/dL, aspartate transaminase/alanine aminotransferase 90/76 U/L, albumin 3.0 gm/dL, international normalized ratio 1.6, HBsAg, and anti-hepatitis C virus negative. Ultrasonography of the abdomen showed nodular liver, mild splenomegaly (13 cm), and a large urinary bladder clot. Triphasic contrast-enhanced computed tomography (CECT) of abdomen and pelvis showed portal vein of 13 mm, no portal cavernoma, and a 3.5 × 3.0 cm mass with arterial hyperenhancement and venous washout in segment VI ([Fig. 1]). Multiple peri-vesical and bilateral parametrial collaterals are seen protruding into the posterior surface of the bladder, draining into the external iliac vein and splenic vein on the right and left side, respectively ([Fig. 2]). No ascites was seen. Alpha-fetoprotein (AFP) was 1,000 ng/mL. The Child–Pugh–Turcotte score was 8 (Child B), and the model for end-stage liver disease Na score was 15. She was managed conservatively with blood transfusion, somatostatin infusion, and antibiotics. Cystoscopy showed a clot with large intravesical varices and active ooze ([Figs. 3] and [4]). Upper gastrointestinal endoscopy did not show esophageal or fundic varices. The patient was advised on glue injections for vesical varices and was offered microwave ablation for the hepatocellular carcinoma (HCC). As the bleeding subsided, she wanted to get the procedures done when the bleeding recurs.