Massive lower gastrointestinal bleeding from idiopathic ileocolonic varix: report of a case

Rare case of successfully operated idiopathic colonic varicosity

INTRODUCTION

Ectopic gastrointestinal varicosities are defined as dilated portosystemic collateral veins that may localize anywhere in the gastrointestinal tract outside the gastroesophageal region. Ectopic colonic varices can be considered idiopathic when other etiology that related to portal hypertension or portal vein thrombosis have been excluded.

CASE PRESENTATION

A forty-five-year-old female patient has been under treatment for histopathologically confirmed ulcerative colitis since the age of 17. In her forties, the patient developed worsening hematochezia leading to severe anemia. Routine colonoscopy was performed which confirmed extensive rectosigmoid varices. A thorough investigation did not confirm any underlying causes, such as portal hypertension or cirrhosis.

DISCUSSION

The selective percutaneous transhepatic mesenteric angiography, which is recommended as a diagnostic and therapeutic option, was not performed because the interventional radiologists did not consider embolization feasible. Laparoscopic rectosigmoid resection with high ligation of the inferior mesenteric vein led to complete remission of hematochezia. The final histological examination confirmed ectopic rectum and sigmoid varices, and ulcerative colitis was ruled out.

CONCLUSIONS

Lower gastrointestinal bleeding from the colonic varices is very rare, with only a few cases reported in the literature. In the idiopathic form, the prognosis is very good, given the absence of other underlying diseases causing portal hypertension. Ectopic varices present a clinical challenge as they are difficult to diagnose and localize. There are currently no clear guidelines for diagnosis and therapy, and recommendations are based on different case reports. Idiopathic cases can be treated effectively by resection of the affected bowel segment.

New sights in ectopic varices in portal hypertension

Ectopic varices and associated bleeding, although rare, pose a significant risk to patients with portal hypertension, carrying a relatively high mortality rate. These varices can occur in various anatomical regions, excluding the gastroesophageal region, which is typically associated with portal vein drainage. The limited data available in the literature, derived mostly from case reports and series, make the diagnosis and treatment of ectopic variceal bleeding particularly challenging. Furthermore, it is crucial to recognize that ectopic varices in different sites can exhibit variations in key decision-making factors such as aetiology and vascular anatomy, severity and bleeding risk and hepatic reserve. These factors significantly influence treatment strategies and underscore the importance of adopting individualized management approaches. Therefore, the objective of this review is to provide a comprehensive overview of the fundamental knowledge surrounding ectopic varices and to propose site-oriented, stepwise diagnosis and treatment algorithms for this complex clinical issue. A multidisciplinary treatment approach is strongly recommended in managing ectopic varices. In addition, to enhance clinical reference, we have included typical case reports of ectopic varices in various sites in our review, while being mindful of potential publication bias.

Usefulness of coil-assisted retrograde transvenous obliteration II (CARTO-II) for the treatment of ascending colonic varix: a case report

Background

Colonic varices are rare among ectopic varices. A previous report demonstrated that once bleeding from colonic varices occurs, it can be fatal. Several treatments for colonic varices exist, including surgical, endoscopic, and endovascular treatments; however, management of colonic varices has not been standardized. For colonic varices, minimally invasive therapies would be desirable. Balloon-occluded retrograde transvenous obliteration (B-RTO) is one of the treatment options for colonic varices to prevent their rupture. Two cases of successful conventional B-RTO for these varices have already been reported. However, B-RTO using coil-assisted retrograde transvenous obliteration II (CARTO-II) procedure for these varices has not been reported.

Case presentation

A 71-year-old male patient had liver cirrhosis caused by hepatitis C virus infection. A varix was located at the ascending colon, which was coincidentally found on colonic endoscopy. Contrast-enhanced computed tomography (CT) showed that the feeder vein was the ileocolic vein and that the main draining vein was the right renal vein. Physicians concluded that treatment was required to avoid the risk of death from massive bleeding due to varix rupture. However, endoscopic and surgical treatments were difficult due to the anatomical location of the varix and the high risk of operative compilations, respectively. This ascending colonic varix was treated by balloon-occluded retrograde transvenous obliteration (B-RTO) using coil-assisted retrograde transvenous obliteration II (CARTO-II) procedure via the right renal vein. There were no complications during the procedure and no recurrences for 36 months during long-term follow-up.

Conclusions

CARTO-II can be one of the effective treatment techniques for ascending colonic varices.

Colonic varices: a rare complication of pancreatic cancer

A 55-year-old man was diagnosed with pancreatic cancer of the uncus and received chemotherapy (modified FOLFIRINOX). Ten months later, he was admitted to our hospital with massive lower gastrointestinal bleeding. Contrast-enhanced CT showed ascending colon varices caused by the occlusion of the superior mesenteric vein (SMV) due to pancreatic cancer invasion. Colonoscopy revealed tortuous varices with red spots in the ascending colon. The patient received blood transfusions and was discharged; however, he was hospitalized for recurrent massive lower gastrointestinal bleeding 3 months later. During this readmission, we performed the transileocolic vein obliteration method due to SMV stenosis and the absence of an obvious shunt. He experienced an uneventful post-operative recovery, and contrast-enhanced CT after 2 months revealed no recurrence of colonic varices. Ectopic varices are portosystemic venous collaterals resulting from portal hypertension occurring in any locations other than the esophagogastric region. Colonic varices have rarely been reported before. Patients with pancreatic cancer may present with gastrointestinal bleeding caused by tumor bleeding or esophagogastric varices; however, ectopic varices such as colon varices, a rare complication of pancreatic cancer, should be considered in patients with obscure gastrointestinal bleeding.

Laparoscopic colectomy in idiopathic colonic varices: a safe endeavour

A 32-year-old man presented to the emergency department with recurrent episodes of haematochezia and haemodynamic instability. He had no complaints of alteration in bowel habits or mucus discharge in the stool. He was a non-smoker and does not consume alcohol. After stabilising the patient, clinical evaluation and investigations with gastrointestinal endoscopy revealed dilated and tortuous submucosal veins involving the entire colon excepting the distal sigmoid. CT angiography and Doppler ultrasonography revealed normal patency and flow in the mesenteric vessels as well as hepatic, portal vein and inferior vena cava. With the exclusion of the secondary causes, we made the diagnosis of the rare entity of idiopathic colonic varices. He underwent a laparoscopic colectomy with ileorectal anastomosis, without any additional technical challenges intra-op and had an uneventful postoperative recovery. Idiopathic colonic varices can be a differential diagnosis of gastrointestinal bleeding and one can safely proceed with laparoscopic colectomy.

Familial Idiopathic Pan-Colonic Varices Found Incidentally in a Young Patient with a Hepatic Flexure Tumor

Patient: Male, 24-year-old

Final Diagnosis: Colon cancer

Symptoms: —

Medication: —

Clinical Procedure: Laparoscopic right hemi-colectomy

Specialty: Surgery

Idiopathic Ileocolonic Varices Coexisting with a Colon Polyp Treated Successfully by Endoscopy: A Case Report and Literature Review

Colonic varices are usually associated with portal hypertension. Idiopathic colonic varices are extremely rare. A 68-year-old man with a positive fecal occult blood test result underwent colonoscopy. We detected idiopathic ileocolonic varices and a coexisting ascending colon polyp. While reviewing the literature, we found cases of biopsies and polypectomies resulting in significant bleeding. We herein report a case of idiopathic ileocolonic varices coexisting with a colon polyp treated successfully by endoscopy. The coexistence of colonic varices and a colorectal lesion that requires endoscopic treatment may lead to significant bleeding. During management, the development of a treatment strategy and obtaining informed consent are necessary.

A Case of Idiopathic Colonic Varices

Colonic varices, usually detected by means of colonoscopy, are extremely rare and typically indicative of portal hypertension or chronic hepatopathology. Even more rare are those cases with no underlying disease, or idiopathic colonic varices. The authors report a case of these unexplained varices found during colonoscopy of a 30-year-old man with a 10-year history of diarrhea and occasional bloody stool. A thorough workup was performed, revealing no underlying abnormalities for his varices. Additionally, the authors review the literature of this rare diagnosis. Physicians must rule out hepatic, vascular, and cardiac causes before classifying a case of varices as idiopathic.

A case of ascending colon variceal bleeding treated with venous coil embolization

A 38-year-old female with a history of alcoholic liver cirrhosis visited our hospital with a massive hematochezia. An esophagogastroduodenoscopy did not demonstrate any bleeding source, and a colonoscopy showed a massive hemorrhage in the ascending colon but without an obvious focus. The source of the bleeding could not be found with a mesenteric artery angiography. We performed an enhanced abdominal computed tomography, which revealed a distal ascending colonic varix, and assumed that the varix was the source of the bleeding. We performed a venous coil embolization and histoacryl injection to obliterate the colon varix. The intervention appeared to be successful because the vital signs and hemoglobin laboratory data remained stable and because the hematochezia was no longer observed. We report here on a rare case of colonic variceal bleeding that was treated with venous coil embolization.

Minimally invasive surgery for obscure idiopathic ileal varices diagnosed by capsule endoscopy and double balloon endoscopy: report of a case

Small intestinal bleeding is difficult to detect and can be life-threatening. Capsule endoscopy (CE) is a new, minimally invasive diagnostic procedure designed to detect gastrointestinal (GI) bleeding. We report the successful management of idiopathic ileal varices by capsule endoscopy and laparoscopic surgery. Massive bleeding occurred suddenly with intermittent melena, and the patient was finally admitted to a local hospital in hypovolemic shock. Her condition was stabilized with conservative therapy but the site of bleeding was not defined by endoscopy, computed tomography, scintigraphy, or angiography. Thus, she was transferred to our hospital. On admission, CE revealed idiopathic ileal varices, so we performed laparoscopic partial ileal resection immediately. Follow-up CE has shown no evidence of recurrence in the 2 years since surgery. Idiopathic ileal varices are rare, difficult to diagnose, and often fatal. Capsule endoscopy is a minimally invasive diagnostic procedure that detects this disorder in time for laparoscopic surgery to be performed effectively and safely.

Recurrent lower gastrointestinal bleeding from idiopathic ileocolonic varices: a case report

Introduction

Varices of the colon are a rare cause of lower gastrointestinal bleeding, usually associated with portal hypertension due to liver cirrhosis or other causes of portal venous obstruction. Idiopathic colonic varices are extremely rare. Recognition of this condition is important as idiopathic colonic varices may be a cause of recurrent lower gastrointestinal bleeding.

Case presentation

We report the case of a 21-year-old Asian man from north India who presented with recurrent episodes of lower gastrointestinal bleeding. Colonoscopy revealed varices involving the terminal ileum and colon to the sigmoid. Thorough evaluation was undertaken to rule out any underlying portal hypertension. Our patient underwent subtotal colectomy including resection of involved terminal ileum and an ileorectal anastomosis.

Conclusion

Colonic varices are an uncommon cause of lower gastrointestinal bleeding. Idiopathic colonic varices are diagnosed after excluding underlying liver disease and portal hypertension. Recognition of this condition is important as prognosis is good in the absence of liver disease and is curable by resection of the involved bowel.

Successful endoscopic sclerotherapy for cholecystojejunostomy variceal bleeding in a patient with pancreatic head cancer

Variceal bleeding outside the esophagus and stomach is rare but important because of its difficult diagnosis and treatment. Bleeding from cholecystojejunostomy varices has been reported to be a late complication of palliative biliary surgery for chronic pancreatitis. Such ectopic variceal bleeding has never been reported after palliative surgery for pancreatic cancer, probably because of the limited lifespan of these patients. Herein, we report our successful experience using endoscopic cyanoacrylate sclerotherapy to treat bleeding from cholecystojejunostomy varices in a 57-year-old man with pancreatic head cancer. To our knowledge, this is the first case report in the literature of this rare complication.

Arteriovenous malformation causing ileocecal variceal bleeding in liver cirrhosis: case report and review of the literature

Varices that occur at sites other than the esophagogastric area are termed ectopic varices. An ileal varix is a very rare cause of lower gastrointestinal bleeding. Although ileal varices are generally associated with prior intra-abdominal surgery and adhesions, an arteriovenous malformation (AVM) in the ileocecal area can cause ileal varices and bleeding in patients with portal hypertension who have not received previous intra-abdominal surgery, which is due to an intestinal or colonic AVM dilating the collateral veins and further aggravating portal hypertension. Surgical treatment should be considered in patients with massive ectopic variceal bleeding. We report a case of massive ileocecal variceal bleeding associated with an AVM that occurred in a patient with alcoholic liver cirrhosis.