A case report of massive vaginal variceal hemorrhage in a patient with cirrhosis secondary to nonalcoholic steatohepatitis unresolved even after successful liver transplantation.

Massive hemorrhage from vaginal varices in patients with cirrhosis and a previous hysterectomy can be life-threatening. In the few previous reports, the treatments have all included an initial local tamponade followed by interventional radiology procedures, transvenous intrahepatic portosystemic shunts, surgical shunt, or liver transplantation. A patient with cirrhosis secondary to nonalcoholic steatohepatitis developed massive vaginal variceal hemorrhage. Control of the bleeding was achieved initially with local tamponade. Upon admission to the intensive care unit, the patient was upgraded to urgent status on the liver transplant waiting list, which was performed on day 7. Due to a portal vein thrombosis, an interpositional vein graft to the superior mesenteric vein was required. Postoperatively despite a functional graft and normalization of coagulation system, the vaginal bleeding continued as the left-sided portal hypertension had not been decompressed by the liver transplantation. During a subsequent laparotomy, splenectomy and ligation of the inferior mesenteric vein were required to definitively control the vaginal variceal hemorrhage. The degree and anatomy of the portal hypertension play a crucial role in determining the proper course of management and treatment of vaginal varices in a cirrhotic patient.