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A woman, aged 36, was admitted to hospital with major vaginal bleeding. She had cirrhosis caused by hepatitis C and had been previously treated with band ligation for recurrent bleeds from esophageal varices. She also had an episode of bleeding from varices in the small bowel that settled with conservative management including splanchnic vasoconstrictor therapy. Additional past history included a hysterectomy. The vaginal bleeding was controlled with vaginal packing, infusion of blood products and ligation of a bleeding lesion in the vaginal wall. However, episodes of vaginal bleeding continued over the subsequent 3 weeks. A contrast-enhanced computed tomography scan showed large pelvic varices and these were confirmed by the presence of prominent veins at vaginoscopy (Figure 1). Because of continued major bleeding, transjugular portal venography was performed. There was a portosystemic gradient of 11 mmHg with extensive pelvic varices associated with the inferior mesenteric vein (Figure 2 left). A 10 x 80 mm portosystemic shunt (TIPS) was then deployed that extended from the right portal vein through the right hepatic vein and into the inferior vena cava (Figure 2 right). This was followed by embolization of the pelvic varices with foamed fibrovein sclerosant. Since the procedure, the patient has remained well with no further bleeding from portal hypertension.

The gastro-esophageal region is the most common area for portal hypertensive hemorrhage. Varices that occur outside of this area are often called “ectopic” varices, but these only account for a minority (5%) of all episodes of variceal bleeding. The more common sites for bleeding ectopic varices include gastrointestinal stomas (30%), duodenum (20%), jejunum and ileum (20%), colon and rectum (8%) and peritoneum (10%). Vaginal variceal bleeding appears to be rare as there are only 7 case reports in the medical literature. Most of these patients have had a hysterectomy, presumably with the development of post-surgical collaterals. The initial management of vaginal varices consists of resuscitation and local control with tamponade. This is the third patient in the medical literature who has been treated with TIPS but other options include balloon-occluded retrograde transvenous obliteration and liver transplantation. For patients with active bleeding who are not appropriate for TIPS, the transhepatic approach to the portal vein is usually preferred because of more rapid access into the mesenteric venous system.

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