Arnold C, Haag K, Blum H E, Rössle M
School of Medicine, Department of Gastroenterology and Hepatology, University of Freiburg, Germany.
Gastroenterology. 1997 Sep;113(3):978-82. doi: 10.1016/s0016-5085(97)70210-5.
Hemoperitoneum resulting from rupture of mesenteric varices is a rare complication of portal hypertension with a high mortality of up to 70%. This case report describes the symptoms, clinical course, and treatment of 4 patients with acute hemoperitoneum caused by mesenteric variceal bleeding after large-volume paracentesis. Abdominal pain and/or hemorrhagic shock developed in 4 patients (age, 48-68 years), admitted for refractory ascites, 3 hours to 4 days after 1-4 large-volume paracenteses (> 4000 mL). Duplex sonography, performed in 3 of the 4 patients before onset of bleeding, showed retrograde flow in the mesenteric veins, suggesting large-caliber mesenteric collateralization. Treatment consisted of surgical ligation followed by transjugular intrahepatic portosystemic shunt (TIPS) (2 patients) and emergency TIPS with embolization of the bleeding vessel (1 patient). One patient died before any intervention could be initiated. In these 4 patients, the concurrence of large-volume paracentesis and hemoperitoneum suggests their causal relationship. The mechanism may be a sudden reduction in intraperitoneal pressure increasing the pressure gradient across the wall of the mesenteric varices, resulting in rupture and bleeding. The awareness of this complication may accelerate the diagnostic process and treatment.
肠系膜静脉曲张破裂导致的腹腔积血是门静脉高压的一种罕见并发症，死亡率高达70%。本病例报告描述了4例因大量腹腔穿刺放液后肠系膜静脉曲张出血导致急性腹腔积血患者的症状、临床过程及治疗情况。4例患者（年龄48 - 68岁）因难治性腹水入院，在1 - 4次大量腹腔穿刺放液（> 4000 mL）后3小时至4天出现腹痛和/或失血性休克。4例患者中有3例在出血发作前进行了双功超声检查，显示肠系膜静脉有逆流，提示存在大口径肠系膜侧支循环。治疗包括手术结扎，随后行经颈静脉肝内门体分流术（TIPS）（2例患者），以及对出血血管进行栓塞的急诊TIPS（1例患者）。1例患者在能够开始任何干预之前死亡。在这4例患者中，大量腹腔穿刺放液与腹腔积血同时出现提示它们之间存在因果关系。其机制可能是腹腔内压力突然降低，增加了肠系膜静脉曲张壁上的压力梯度，导致破裂出血。认识到这种并发症可能会加快诊断过程和治疗。
