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\begin{document}

\title{Spontaneous intercostal artery bleeding in a patient with
alcohol-induced liver cirrhosis}



\author[1]{Mandeep Singh Rahi}%
\author[1]{Prachi Pednekar}%
\author[1]{Gaurav Parmar}%
\author[1]{Lauren Keibel}%
\author[1]{Kulothungan Gunasekaran}%
\author[1]{Kwesi Amoah}%
\author[1]{Christopher Winterbottom}%
\affil[1]{Bridgeport Hospital}%


\vspace{-1em}



  
  \date{April 30, 2024}


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\selectlanguage{english}
\begin{abstract}
An adult male with alcoholic cirrhosis presented with acute blood loss
anemia, hypotension and a painful bruise over his body's left side. He
denied any trauma or falls. Computed tomography of the chest showed left
chest wall hematoma. Emergent angiography with successful embolization
of the left intercostal artery was performed.%
\end{abstract}%



\sloppy


\textbf{Spontaneous intercostal artery bleeding in a patient with
alcohol-induced liver cirrhosis}

Mandeep Singh Rahi, MD\textsuperscript{1}; Prachi Pednekar,
MD\textsuperscript{2}; Gaurav Parmar, MD\textsuperscript{3}; Lauren
Keibel, DO\textsuperscript{1}; Kulothungan Gunasekaran,
MD\textsuperscript{1}; Kwesi Amoah, MD\textsuperscript{1}; Christopher
Winterbottom, MD\textsuperscript{1}

\textsuperscript{1}Division of Pulmonary Diseases and Critical Care
Medicine, Yale-New Haven Health Bridgeport Hospital,

Bridgeport, CT, USA

\textsuperscript{2}Department of Internal Medicine, Yale-New Haven
Health Bridgeport Hospital, Bridgeport, CT, USA

\textsuperscript{3}Department of Radiology, Yale-New Haven Health
Bridgeport Hospital, Bridgeport, CT, USA

Correspondence to:

Mandeep Singh Rahi, MD

Division of Pulmonary Diseases and Critical Care Medicine

Yale-New Haven Health Bridgeport Hospital

267 Grant Street

Bridgeport, CT 06610, USA

Phone: 571-314-1212

Fax: 203-330-7498

Email: rahi.mandeepsingh@yahoo.com

A 44-year-old male with alcoholic cirrhosis presented with one day of
fatigue. He noticed a painful bruise over his body's left side but
denied any trauma or falls. On arrival, he was hypotensive with a
hemoglobin of 2.7 g/dL, platelet count of 46,000/mm\textsuperscript{3},
and INR of 2.04. Computed tomography of the chest and abdomen revealed a
large intramuscular hematoma within the left lateral chest wall
extending to the upper abdomen measuring 12 cm x 5 cm and several foci
of high attenuation suggestive of acute hemorrhage (Figures 1 and 2). In
addition to resuscitation, emergent angiography was performed. Active
extravasation from the left ninth intercostal artery was noted.
Successful embolization with 500 to 700-micron embospheres followed by
gel foam slurry was performed (Figures 3 and 4). Spontaneous intercostal
artery bleeding is rare in cirrhosis, with few cases reported so
far.\textsuperscript{1} Risk factors, in addition to thrombocytopenia
and clotting factor deficiency in cirrhotic patients, are alcohol use,
trauma, hypertension, and anticoagulation.\textsuperscript{2} Management
of closed space spontaneous bleeding in cirrhotic patients is
challenging. In mild cases, medical management with judicious use of
blood products should suffice. Severe cases are managed with
transcatheter arterial embolization and, ultimately, liver
transplantation.

\textbf{REFERENCES}

1. Seon CS, Jo Y, Lee J, et al. Spontaneous Arterial Bleeding in
Patients with Alcoholic Liver Cirrhosis: a Series of Three
Cases.\emph{Korean J Med} . 10 2014;87(4):449-454.
doi:10.3904/kjm.2014.87.4.449

2. Gunasekaran K, Rajasurya V, Devasahayam J, et al. A Review of the
Incidence Diagnosis and Treatment of Spontaneous Hemorrhage in Patients
Treated with Direct Oral Anticoagulants. \emph{J Clin Med} . Sep 15
2020;9(9)doi:10.3390/jcm9092984

\textbf{FIGURE LEGENDS}

\textbf{Figure 1:} A computed tomography of the chest and abdomen in the
coronal view showing a large intramuscular hematoma within the left
lateral chest wall and extending to the upper abdomen, denoted by a
star.

\textbf{Figure 2:} A computed tomography of the chest and abdomen in the
axial view showing foci of high attenuation in the intramuscular
hematoma involving the left lateral chest wall suggestive of acute
bleeding, denoted by arrows.

\textbf{Figure 3:} Angiographic image of the left intercostal arteries
showing active extravasation from the ninth intercostal artery, denoted
by arrows.

\textbf{Figure 4:} Angiographic image of the left intercostal arteries
showing no extravasation after successful embolization of the night
intercostal artery.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1-CT-coronal-view/Figure-1-CT-coronal-view}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2-CT-axial-view/Figure-2-CT-axial-view}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-3-Pre-embolization/Figure-3-Pre-embolization}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-4-Post-embolization/Figure-4-Post-embolization}

\end{center}
\end{figure}

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