Saturday, June 26, 2010

Post-enterocystoplasty massive bleeding because of Arteriovenous malformation from bowel arteries : A very Rare Case

A 65 year old man presented to us with frank hematuria of 1 day duration. he was known case of small capacity bladder with hemorrhagic cystitis with no apparent reason.He was operated in 2002 for clam cystoplasty. He was apparently alright for 8 years just to land up in emergency department with gross total hematuria.He is known case coronary artery disease and hypertension on medication.He was on ecosprin when he came for hematuria.Immediately ecosprin was stopped.He was supported with irrigation,tranexa and cystoscopy and evacuation followed by alum irrigation.After this surgery he was fine for 2 days then suddenly he had bout of frank hemturia causing fall of Hb from 13 TO 10 GM% and BP to fall from 130/80 mm Hg to 70/30 mmHg.He was immediate taken up for cystoscopy and clot evacuation again with institution of proper blood support and plasma expander support.The bladder base region had angry looking globular mass? Rest of the bladder mucosa and the intestinal mucosa was normal.The clots were removed with resectoscope and cautery and ellicke evacuator.A three way Foleys catheter was introduced wnd alum irrigation was started..The urine effluent was clear.AFTER THE CLOT EVACUATION WAS DONE BILATERAL ANGIOEMBOLISATION WAS CARRIED OUT SELECTIVELY ON ANTERIOR DIVISION OF INTERNAL ILIAC ARTER USING SELDINGERS TECHNIQUE.

The both iliac arteries anterior divison was blocked with gel foam mixture viscous with the contrast,

The process of Angioembolisation of the internal iliac artery --the end result of the embolisation is seen as the disapperance of the terminal branches of the vesical arteries.The next plan was if the patient bleeds again then abdominal exploration.The patient again bleede after 5 days; again the bleed was torrential causing drop in hematocrit.

The patient was taken up for CT Angiography which showed a big arteriovenous malformation on the dome of the bladder feeded by superior mesenteric arteries.

the mesenteric artery being very crucial one the angioembolisation of it was not taken into consideration thinking of the sequele of catastrophe of mistaken blockage of main trunks.

The exploratotry laparotomy was performed.The adhesiolysis was performed.The dome of the bladder was thickened with multiple serpigenious vessels .This part of the bladder was excised and bladder was closed with Suprapubic tube in situ.

The abdomen was closed in layers with drain in pelvis.The post-operative period was uneventful with no episode of hematuria till 3 weeks post-operatively.

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