{'fraction_non_alphanumeric': 0.03720106288751107, 'fraction_numerical': 0.026572187776793623, 'mean_word_length': 5.193784277879342, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Rectovesical ectopic varix intraperitoneal hemorrhage with fatal outcome

TO THE EDITOR: We report the first case of an intraperitoneal bleeding ectopic varix located in the rectovesical pouch with fatal outcome. A 52-yr-old white male with Child-Pugh C classification alcoholic cirrhosis presented with symptoms of sudden onset of weakness, fatigue, diffuse abdominal pain, and progressive abdominal swelling. Initial assessment revealed a blood pressure of 80/50, pulse 100. Physical examination was significant for stigmata of chronic liver disease including palmar erythema, telangiectasia, marked abdominal distension, and grade I encephalopathy. There was mild abdominal tenderness but no guarding or rebound tenderness with bowel sounds. Abnormal laboratory values included a white blood cell count of 30,000 with 83% neutrophils (8% bands); Hb, 10.1 g/dl; platelet count, 160,000; PT, 22.8 with an international normalized ratio of 2.2; albumin, 2.9 g/dl; AST, 1,556 IU; ALT, 986 IU; total bilirubin, 2.3 mg/dl; BUN, 50 mg/dl; and creatinine, 2.6 mg/dl. A diagnostic peritoneal paracentesis revealed bloody ascites with an ascites fluid red cell count of 525,000 and white blood cell count of 272. A CT scan of the abdomen was unremarkable. A visceral angiogram with selective examination of the celiac, superior mesenteric, common hepatic splenic, and inferior mesenteric arteries did not reveal any source of intra-abdominal bleeding. Upper endoscopy noted severe portal hypertensive gastropathy and three columns of grade 3 esophageal varices with no stigmata of recent bleeding. Five days after admission the patient had therapeutic abdominal paracentesis with removal of 8.5 L of bloody ascites fluid and was given 75 g of albumin during the procedure. Two days after the paracentesis, the patient had a syncopal episode and was unresponsive and hypotensive with a systolic blood pressure of 50 mm Hg. He then developed ventricular fibrillation, which was treated with epinephrine, lidocaine, and cardioversion, but eventually died. Postmortem examination, surprisingly, was noteworthy for a large rectovesical pouch varix with a rupture site as the cause of death. Ectopic varices account for 1–5% of all variceal bleeding episodes (1, 2). Duodenal varices have been reported in up to 40% of patients by angiography (2), whereas anorectal varices are seen in 10–20% of cirrhotic patients undergoing colonscopy (3, 4). In a review of 169 cases of bleeding ectopic varices, 17% occurred in the duodenum, 17% in the jejunum or ileum, 14% in the colon, 8% in the rectum, and 9% in the peritoneum (2). Intraperitoneal rupture of an ectopic varix is characterized by a rapid increase in ascites, abdominal pain, and decrease in Hct (5). Diagnostic paracentesis reveals blood-stained ascites. Placement of a transjugular intrahepatic portosystemic shunt has been reported to be an effective treatment of ectopic variceal bleeding, especially of the anorectum or peristomal region (6). Emergency laparotomy with the aim of ligating the bleeding varix can be performed, but this is usually associated with high mortality (7). In summary, intraperitoneal bleeding ectopic varices, as illustrated by this case, are an infrequent complication of portal hypertension. The diagnosis of intraperitoneal hemorrhage is easily made; however, the culprit varix is often difficult to localize.