Re: Alcoholic with DUB
From: Steve & Eryl Raymond (eryl@intekom.co.za)
Sat Jun 24 03:16:18 2000
This question intrigued me a bit as I thought the answer was
obvious. Alcoholic liver disease, thrombocytopenia, disturbance of
clotting factors and local vaginal skin trauma all add up to the
scenario described. Why are you surprised?
Portal hypertension causes varices in the veins that lead to the
porta hepatis - were there any varices in the vagina?? I think not.
Hypersplenism?? What is the connection??
Von Willebrand's?? Sparrows are more common than canaries.
Steve Raymond
> Portal hypertension causes severe bleeding if you operate on
> hemorrhoids--the vagina and hemorrhoids are close enough that it may
> be something similar. You can also get duodenal, gastric and
> ileostomy varices from portal hypertension. Gail Waldby, MD Huron
> Clinic SD
>
> ainsron@msn.com wrote:
> >
> > 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
>
> Perhaps she needs a more thorough coagulation work up. Supposed she's
> a "hidden" vonWildebrand's who is only now showing up because of
> abnormal liver functions and relatively decreased clotting factors
> (maybe not enough to throw a regular PT/PTT way off)? Also, what
> effect would Provera have on someone whose liver is already out of
> whack?
>
> Joe P.
>
> ------------------------------
Dr. Steve Raymond
> ------------------------------
Head of Department of O & G
> ------------------------------
Empangeni Hospital
Empangeni
SOUTH AFRICA 3880
Ph:(+27)(035)77721111
