CASE REPORTS
Spontaneous rupture of the inferior vena cava is a rare clinical entity. Diagnosis of this condition, in the absence of any relevant history , is usually made at laparotomy. Only one such case has previously been reported in the literature. We report a case of spontaneous rupture of the inferior vena cava which was diagnosed following laparotomy for hypovolaemia and acute abdominal pain. This case highlights the fact that spontaneous rupture of the inferior vena cava may be a cause of massive intra-abdominal bleeding not associated with trauma or rupture of the abdominal aorta.
Keywords: inferior vena cava, spontaneous rupture
J.R.Coll.Surg.Edinb., 45, August 2000, 252-253
A 71-year-old male patient was admitted as an emergency with a history of abdominal pain of 10 days duration, which was getting progressively worse. The patient experienced a sudden onset of central abdominal pain, which was stabbing in nature, after moving some furniture at home 10 days prior to his admission. He treated himself with analgesics and antacids, obtaining some relief. He did not contact his doctor or hospital until 10.00 a.m. on the day of admission when the pain started radiating down to his lower back, abdomen and groin. He had no bowel or urinary symptoms. He had undergone a right nephrectomy for tuberculosis approximately 35 years previously.
On clinical examination he looked pale and dehydrated. His pulse rate was 80/minute and weak. The blood pressure was 140/70 mm of Hg. He was fully conscious and had no neurological signs. Abdominal examination revealed tenderness on the right side of his abdomen with generalised rigidity. Rectal examination revealed tenderness but no mass was palpable and there was no blood on the examining finger. A naso-gastric tube was inserted which did not show any signs of bleeding from the upper gastro-intestinal tract. Intravenous fluid therapy was initiated. Laboratory investigations documented a normochromic normocytic anaemia with an Hb of 9.6 gm/dl. The clotting profile was normal. Biochemical analysis of blood and urine were normal. Electrocardiogram was normal as were plain radiographs of the abdomen and chest.
Within 2 hours of admission he suddenly went into oligaemic shock. An abdominal paracentesis revealed fresh blood in the peritoneal cavity and ultrasonography showed a large retro-peritoneal haematoma and a slightly dilated aorta. A provisional diagnosis of a ruptured abdominal aorta was made.
After resuscitation, laparotomy was carried out which showed a large right-sided retro-peritoneal haematoma and free blood in the peritoneal cavity. The retroperitoneal haematoma was causing anterior displacement of the caecum and ascending colon. The posterior peritoneum medial to the ascending colon had given way through which fresh blood was pouring out. The abdominal aorta was of normal calibre throughout its length with no evidence of an aneurysm or rupture. The right side of the colon was mobilised to ascertain the source of bleeding. There was a 0.75 cm tear in the inferior vena cava posterio-laterally on the right side 2 cm below the L2-L3 level. The tear was closed with a 4/0 non-absorbable continuous suture. No other source of bleeding was encountered. The abdomen was closed in layers.
The patient's initial recovery was uneventful, but after the first post-operative day he went into acute renal failure. He was transferred to the intensive care unit and underwent renal dialysis. Despite intensive treatment, however, the patient died on the 11th post-operative day.
Post-mortem examination was carried out the same day which showed no further bleeding and the suture line on the inferior vena cava was intact. The inferior vena cava was histologically normal. Cause of death was recorded as acute tubular necrosis of the left kidney (the patient had had a right nephrectomy in the past).
Injury to the inferior vena cava carries a very high mortality, varying from 57% to 95%.1 The usual cause of death in such cases is oligaemic shock or ensuing renal failure. Injury to the inferior vena cava results from trauma or during operative procedures in the vicinity.2,3 If recognised early and repaired the prognosis is particularly good, in cases of peri-operative damage to the inferior vena cava.4
Nearly 33% of patients with traumatic rupture or tear of the vena cava die before reaching hospital. In the remaining 67%, the mortality is reported to be as high as 50%, despite active resuscitation and an early operation.1
Spontaneous rupture of the inferior vena cava is extremely rare and the diagnosis is only made at operation. In the absence of any history of trauma the clinical diagnosis is that of a ruptured abdominal aneurysm. In such cases computerised tomography scan may prove to be diagnostic. Unfortunately, due to the patient's poor condition this was not possible with our patient. In this particular case, the presence of only one kidney contributed to his acute renal failure. He had lost more than 50% of his circulating volume prior to surgery resulting in oligaemic shock and acute tubular necrosis. In our opinion had the patient been admitted sooner the prognosis may have been better.
We believe that there has been only one previous case report of spontaneous rupture of the inferior vena cava.5 The course of events in the case reported by Nair et al (1986) was identical though in their report the patient was younger and there was no history of previous surgery.5
We postulate that the cause of the tear in the inferior vena cava was due to fixation of the inferior vena cava, due to post operative adhesions following the right nephrectomy, associated with a sudden brisk movement of the spine. Moving heavy furniture 10 days before his admission may have resulted in a small tear in the inferior vena cava, which with time enlarged and caused a massive retroperitoneal haemorrhage.
Spontaneous rupture of the inferior vena cava is an exceptionally rare cause of intra-abdominal haemorrhage. The case we have presented illustrates the difficulty of diagnosis and management of this very rare condition and highlights the poor outcome in these patients.
Copyright date: 7th March 2000
Correspondence: S Chaturvedi, Consultant Surgeon, Edith Cavell Hospital, Bretton Gate, Peterborough PE3 9GZ, U.K.
©2000 The Royal College of Surgeons of Edinburgh, J.R.Coll.Surg.Edinb.