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Alcoholic with DUBFrom: ainsron@msn.comWed Jun 21 12:20:53 2000
I saw an interesting patient in the ER yesterday with a problem I've never seen before. She is a known alcoholic, C/O heavy vaginal bleeding with clots for six weeks. 2wks before she was seen in the ER, examined by a PA and placed on Provera 10mg BID for the working Dx of annovulatory DUB; I'd seen her for a similar problem several years ago. She was scheduled to see me in two weeks but because the bleeding wasn't controlled, she returned to the ER. On exam this time, the ER doc didn't see any bleeding from the cervix, it was coming from the posterior vaginal wall and ultrasound showed no endometrial thickening, polyp, etc. She denies any intercourse since the bleeding started or instrumentation of the vagina, but had been using tampons. When I examined her she had two large desquamated areas on the anterior and posterior walls with active bleeding from the posterior wall. It was not indurated or otherwise abnormal in appearance. I took her to the OR, biopsied the areas (bled like hell when I biopsed them, several small pumpers) and oversewed them and packed the vagina overnite, which controlled the bleeding. Her preop labs showed abnormal LFTs, mild hyperbilirubinemia, neutropenia, thrombocytopenia (49,000), normal PT, PTT and INR. She had several large bruises and bleeding time was over 30 minutes. My working diagnosis is bleeding disorder secondary to hyperspleenism. Anyone ever seen anything similar? Does portal hypertension cause problems with vaginal varices, like it does at the esophagus? No bleeding when I took the pack out, but she also ended up in the ICU in DTs this AM.
-- Ronald E. Ainsworth, MD
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