This years multiparous la...

A 63-year-old multiparous woman visited the gynaecology OPD with ongoing postmenopausal bleeding (PMB) for a few months. A pelvic ultrasound showed an enlarged uterus for her age and a thickened endometrium measuring 10 mm. In addition to having chronic liver disease (CLD), she had hypertension and diabetes. Her medication regimen included oral hypoglycaemics, a beta blocker, a diuretic (combination of frusemide and spironolactone), and ursodeoxycholic acid. A Pap smear was taken, and an endometrial biopsy was performed, but only a small amount of endometrial tissue was obtained despite the abnormal thickness. The Pap smear and histopathology examination of the endometrium revealed no abnormalities. She was prescribed Medroxyprogesterone acetate and tranexamic acid tablets, but the vaginal bleeding persisted. A follow-up transvaginal ultrasound showed a persistently abnormal 10 mm thick endometrium. Due to the ongoing bleeding, the patient was scheduled for a total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH BSO), accompanied by a high-risk consent following the recommendation of the supervising Consultant Gastroenterologist, considering her underlying liver disease. Her hemodynamic condition was stable, with a hemoglobin level of 12.3 g/dL, normal renal function tests, elevated alkaline phosphatase and SGOT levels, and SGPT below 100 IU. The APTT and PT showed prolonged values, with an INR of 1.5. An upper abdomen ultrasound revealed cirrhosis, a distended gall bladder with gallstones, prompting a Consultant Surgeon to plan a laparoscopic cholecystectomy before the TAH BSO. The patient received 4 units of Fresh Frozen Plasma (FFP) perioperatively. However, during laparoscopy, extensive macronodular cirrhosis was observed, and the cholecystectomy was abandoned due to the associated high risk. The TAH BSO proceeded smoothly, but after the procedure, there was profuse bleeding from a large variceal omental vessel. The bleeding was eventually controlled by ligating the vessel, and two large-bore intraperitoneal drains were placed in the right hypochondrium and pelvis. The patient was transferred to the Intensive Care Cardiac Unit (ICCU) and received noradrenaline infusion, along with an additional 4 units of FFP and 1 unit of packed red blood cells. She stabilized in the ICCU, and after receiving another unit of packed red blood cells, her hemoglobin level reached 10.3 g/dL. She showed significant recovery in the ICCU, passed stool on the third postoperative day, tolerated a soft diet, and was then transferred to the general ward. On the ninth postoperative day, she started experiencing the leakage of pale yellow serous fluid from the vagina. Initially, it was mistaken for urine, despite the presence of a Foley catheter. Filling the bladder with saline through the catheter did not increase the leakage, leading to the realization that the profuse leakage was likely ascitic fluid draining through the suture line of the vaginal vault. The leakage persisted, and after a few days, the patient's condition deteriorated significantly. She could not tolerate any food, even though her abdomen remained soft with normal bowel sounds. On the twelfth postoperative day, she suddenly developed hepatic encephalopathy (HE) and was transferred back to the ICCU. She remained unresponsive and received aggressive treatment for Grade IV HE, including antibiotics, lactulose, plasmapheresis, and dialysis.