Rupture of an Ectopic Superior Mesenteric Vein Varix: A Case Report

Ectopic varices represent dilated portosystemic collaterals located outside the gastroesophageal region. Although typically asymptomatic and not requiring treatment, these varices can infrequently precipitate life-threatening intraperitoneal hemorrhage. We describe a case of intra-abdominal hemorrhage caused by rupture of a superior mesenteric vein (SMV) varix due to portal hypertension. An 84-year-old Japanese woman with end-stage hepatocellular carcinoma presented to our emergency department (ED) following a transient loss of consciousness. On arrival, her vital signs were stable despite a slightly distended abdomen. While awaiting diagnostic imaging, she suddenly went into shock. Repeat bedside ultrasonography revealed increased ascites compared with the initial evaluation, accompanied by progressive anemia and worsening metabolic acidosis. Resuscitation was initiated with type O packed red blood cell transfusion and resuscitative endovascular balloon occlusion of the aorta. She was then transferred to the computed tomography (CT) room in the ED, where resuscitative procedures were continued. Contrast-enhanced CT demonstrated massive hemorrhagic ascites and extravasation around the SMV. Although both interventional radiology and surgical intervention were considered, further invasive procedures were withheld given the patient's condition and her family's wishes. Cardiopulmonary arrest occurred two hours after the collapse. Management of intraperitoneal hemorrhage from ectopic varices in the ED remains a significant clinical challenge. Emergency physicians should consider this rare etiology in patients with prolonged portal hypertension. Interventional radiology, such as transjugular intrahepatic portosystemic shunt combined with embolization, may represent a viable treatment option.