A Case of Portal Hypertension with Rupture of Small-intestinal Varices Caused by Bowel Adhesion to the Port Site After Laparoscopic Cholecystectomy

Abstract

The patient was a 42 year-old man who was transported by ambulance to our hospital with melena. He had undergone treatment for esophageal varices secondary to liver cirrhosis, and prior to that, laparoscopic cholecystectomy for gallbladder stones. Laboratory examination revealed mild anemia and CT showed no evidence of extravasation from the varices in the small intestine. Upper gastrointestinal endoscopy revealed no source of bleeding and the patient was admitted to our hospital. However, the melena as well as the anemia worsened on the night of admission; emergency colonoscopy revealed no source of bleeding, which was suspected as being caused by bleeding from small-intestinal varices. Interventional radiology (IVR) was planned, but since the approach to the varices via the right inferior epigastric vein, which drains blood into the right femoral vein, would have been difficult, emergency surgery was performed. Because varices had formed at the site of adhesion of the small intestine to the previous laparoscopic port site, a small laparotomy was performed to avoid injury to the varices, and the affected segment of the small intestine with the varices was resected. In this case, the patient, who had portal hypertension, had developed collateral circulation at the site of adhesion of the small intestine to a previous laparoscopic surgical wound, and rupture of the varices at this site caused melena. Aggressive measures to prevent adhesions, even during laparoscopic surgery, is necessary for patients with portal hypertension undergoing surgery.