Spontaneous intercostal artery bleeding in a patient with alcohol-induced liver cirrhosis
Mandeep Singh Rahi, MD1; Prachi Pednekar, MD2; Gaurav Parmar, MD3; Lauren Keibel, DO1; Kulothungan Gunasekaran, MD1; Kwesi Amoah, MD1; Christopher Winterbottom, MD1
1Division of Pulmonary Diseases and Critical Care Medicine, Yale-New Haven Health Bridgeport Hospital,
Bridgeport, CT, USA
2Department of Internal Medicine, Yale-New Haven Health Bridgeport Hospital, Bridgeport, CT, USA
3Department of Radiology, Yale-New Haven Health Bridgeport Hospital, Bridgeport, CT, USA
Correspondence to:
Mandeep Singh Rahi, MD
Division of Pulmonary Diseases and Critical Care Medicine
Yale-New Haven Health Bridgeport Hospital
267 Grant Street
Bridgeport, CT 06610, USA
Phone: 571-314-1212
Fax: 203-330-7498
Email: rahi.mandeepsingh@yahoo.com
A 44-year-old male with alcoholic cirrhosis presented with one day of fatigue. He noticed a painful bruise over his body’s left side but denied any trauma or falls. On arrival, he was hypotensive with a hemoglobin of 2.7 g/dL, platelet count of 46,000/mm3, and INR of 2.04. Computed tomography of the chest and abdomen revealed a large intramuscular hematoma within the left lateral chest wall extending to the upper abdomen measuring 12 cm x 5 cm and several foci of high attenuation suggestive of acute hemorrhage (Figures 1 and 2). In addition to resuscitation, emergent angiography was performed. Active extravasation from the left ninth intercostal artery was noted. Successful embolization with 500 to 700-micron embospheres followed by gel foam slurry was performed (Figures 3 and 4). Spontaneous intercostal artery bleeding is rare in cirrhosis, with few cases reported so far.1 Risk factors, in addition to thrombocytopenia and clotting factor deficiency in cirrhotic patients, are alcohol use, trauma, hypertension, and anticoagulation.2 Management of closed space spontaneous bleeding in cirrhotic patients is challenging. In mild cases, medical management with judicious use of blood products should suffice. Severe cases are managed with transcatheter arterial embolization and, ultimately, liver transplantation.