Iatrogenic DIC Causing Splenic Hemorrhage: An Unexpected Complication of Peritoneovenous Shunt Placement
Disseminated intravascular coagulation (DIC) is a life threatening systemic process. Once diagnosed, the challenge lies in treating the precipitating cause. Peritoneovenous (Denver) shunt placement for the management of recurrent ascites refractory to regular paracentesis is a rare cause of DIC.
A 69 year old male with a history significant for coronary artery disease status post CABG and abdominal aortic aneurysm (AAA) with repair suffered from recurrent chylous ascites requiring weekly paracentesis one year following AAA repair. Multiple lymphangiograms were performed but no leak was found. The patient opted for a Denver shunt. He had dramatic improvement following shunt placement with resolution of ascites. However less than one month later he was admitted for splenic hemorrhage requiring emergent arterial embolization. At that time, hematology confirmed the diagnosed disseminated intravascular coagulation (DIC) which was deemed to be secondary to the shunt itself. The shunt was closed and the patient had moderate recovery. DIC ensued once again on re-opening of the shunt, therefore it was eventually removed.
Disseminated intravascular coagulation is commonly seen in the setting of sepsis, malignancy, and obstetrical complications. However, there are less notable causes of DIC, such as peritoneovenous shunt placement. The coagulopathy is presumed to be due to excess tissue plasminogen factors shunted into the blood from the peritoneal fluid. Post shunt coagulopathy is reported in up to 5% of patients following shunt placement. It is crucial to monitor patients with shunt placement for DIC as the risk of serious complications is high.
Edhi A, Hafeez A, Adhikari A. Iatrogenic DIC causing splenic hemorrhage: An unexpected complication of peritoneovenous shunt placement. American College of Physicians (ACP) Resident’s Day, Sterling Heights, MI, May 5, 2017.