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.