An Unusual Cause of Massive Per Vaginal Bleeding

Massive per vaginal bleeding from ectopic pelvic varices is an exceedingly rare presentation in patients with cirrhosis. A 60-year-old postmenopausal woman presented with massive per vaginal (PV) bleeding. Computerized tomography scan showed extensive portosystemic collaterals with a large collateral vessel from the splenic vein to the region of her previous caesarean scar, on a background of liver cirrhosis. The cause of the massive PV bleeding was identified as arising from the uterine varix. She was transferred to a tertiary liver unit where she underwent angiographic embolization of the uterine varix and splenic vein shunt with successful obliteration of the culprit collateral vessel. A high index of suspicion is required in a cirrhotic patient with massive PV bleeding for ectopic variceal bleeding. Once stabilized, prompt consultation should be made to a tertiary center for further assessment and consideration of definitive treatment with obliteration of varices and shunt, as well as transjugular intrahepatic portosystemic shunt, to reduce risk of recurrent bleeding.