Hematuria in a Cirrhotic Female: Expect the Unexpected

A 62-year-old female was brought to the emergency department with a history of massive hematuria for 2 days. Examination showed mild pallor. Investigations revealed Hb of 8.1 gm%, platelets 54,000/µL, total bilirubin 2.5 mg/dL, aspartate transaminase/alanine aminotransferase 90/76 U/L, albumin 3.0 gm/dL, international normalized ratio 1.6, HBsAg, and anti-hepatitis C virus negative. Ultrasonography of the abdomen showed nodular liver, mild splenomegaly (13 cm), and a large urinary bladder clot. Triphasic contrast-enhanced computed tomography (CECT) of abdomen and pelvis showed portal vein of 13 mm, no portal cavernoma, and a 3.5 × 3.0 cm mass with arterial hyperenhancement and venous washout in segment VI ([Fig. 1]). Multiple peri-vesical and bilateral parametrial collaterals are seen protruding into the posterior surface of the bladder, draining into the external iliac vein and splenic vein on the right and left side, respectively ([Fig. 2]). No ascites was seen. Alpha-fetoprotein (AFP) was 1,000 ng/mL. The Child–Pugh–Turcotte score was 8 (Child B), and the model for end-stage liver disease Na score was 15. She was managed conservatively with blood transfusion, somatostatin infusion, and antibiotics. Cystoscopy showed a clot with large intravesical varices and active ooze ([Figs. 3] and [4]). Upper gastrointestinal endoscopy did not show esophageal or fundic varices. The patient was advised on glue injections for vesical varices and was offered microwave ablation for the hepatocellular carcinoma (HCC). As the bleeding subsided, she wanted to get the procedures done when the bleeding recurs.

Fig. 1 CECT abdomen showing liver SOL (black arrow). CECT, contrast-enhanced computed tomography.

Fig. 2 CECT abdomen showing intravesical varices (arrow heads). CECT, contrast-enhanced computed tomography.

Fig. 3 Cystoscopy showing large vesical varices.

Fig. 4 Cystoscopy showing vesical varices with active ooze.

Practical Implications for Endoscopists

• This case presents several unusual features, including presentation with hematuria from vesical varices,[1] suggesting decompensation despite the absence of esophageal or fundal varices, no portal cavernoma, and high AFP in the context of HCC.

• A high index of suspicion is needed to identify ectopic vesical varices presenting as hematuria. Coagulopathy, urinary tract infection, cystitis, and iatrogenic trauma (post-catheterization) are more common causes.

• The threshold for investigation should be low. A good triple-phase CECT of the abdomen and pelvis established the diagnosis of vesical varices and was confirmed by cystoscopy.[2]

• Vesical varices result from portosystemic collateral formation due to portal hypertension when the usual sites of collateral, like esophageal or gastric varices, are obliterated by endoscopic variceal ligation or glue injection.

• Beta blockers are not as effective as in esophageal varices. Injecting glue into varices under cystoscopy guidance may be necessary if bleeding persists, and transjugular intrahepatic portosystemic shunt may be required for refractory bleeding.[3] [4]

 

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Conflict of Interest

None declared.

• References

• 1 Sano K, Shuin T, Takebayashi S. et al. A case of vesical varices as a complication of portal hypertension and manifested gross hematuria. J Urol 1989; 141 (02) 369-371
• 2 Helmy A, Al Kahtani K, Al Fadda M. Updates in the pathogenesis, diagnosis and management of ectopic varices. Hepatol Int 2008; 2 (03) 322-334
• 3 Tripathi D, Stanley AJ, Hayes PC. et al; Clinical Services and Standards Committee of the British Society of Gastroenterology. U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut 2015; 64 (11) 1680-1704
• 4 de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C. Baveno VII Faculty. Baveno VII - Renewing consensus in portal hypertension. J Hepatol 2022; 76 (04) 959-974

Publication History

Article published online:
11 September 2025