Life-threatening rectal bleeding with Klippel-Trenaunay syndrome controlled by angiographic embolization and rectal clips

Gastrointestinal bleeding with Klippel-Trenaunay syndrome: a case report

Background

Gastrointestinal bleeding caused by gastrointestinal tract involvement in patients with Klippel–Trenaunay syndrome (KTS) is extremely rare and often overlooked.

Case presentation

A 9-year-old girl who presented with chronic gastrointestinal bleeding was admitted to our hospital. Laboratory examinations revealed microcytic hypochromic anemia and a positive fecal occult blood test. Computed tomography (CT) of the lower limbs combined with physical examination confirmed KTS. The pelvic CT showed concentric thickening of the sigmoid colon and rectum, with progressive enhancement after the administration of a contrast agent. Colonoscopy demonstrated vascular malformations of the sigmoid colon and rectum. The patient was finally diagnosed with KTS with gastrointestinal tract involvement. The patient improved after receiving conservative treatment.

Conclusions

A suspicion of gastrointestinal tract involvement as an etiology for gastrointestinal bleeding should not be overlooked in patients with KTS. Endoscopy and imaging modalities can synergistically help diagnose this condition.

Klippel-Trenaunay Syndrome of the Rectosigmoid Colon Presenting as Severe Anemia

A 23-year-old female with Klippel-Trenaunay syndrome presented with abdominal pain and severe anemia. Colonoscopy revealed diffuse venous congestion extending circumferentially from the midsigmoid to the rectum, with multiple large varicosities. This case emphasizes that Klippel-Trenaunay syndrome may have visceral manifestations beyond the classic presentation, which can be a significant source of morbidity and mortality.

Sphincter-saving resection of rectal hemangioma based on Doppler transrectal ultrasonography findings: report of a case

A 52-year-old woman was diagnosed with rectal hemangioma that had resulted in chronic bleeding. Klippel-Trenaunay syndrome was diagnosed by clinical examination. She was referred 30 years later because of progressive anemia. Colonoscopy revealed multiple bluish, polypoid nodules with severe vascular congestion and varicosis that had circumferentially spread along the wall from the dentate line to the rectosigmoid lesion. Selective abdominal angiography indicated that the hemangioma fed from the sigmoid artery and superior rectal artery. Doppler transrectal ultrasonography showed heterogeneous lesions with hypoechoic areas mostly in the submucosal layer, partly forming the mosaic pattern of the color flow signal in the intersphincteric layer on the oral side from the dentate line to 1 cm. Anterior resection and coloanal anastomosis with covering ileostomy was performed. Using a transanal approach, mucosectomy and intersphincteric resection were performed based on the Doppler transrectal ultrasonography results. There were no intraoperative complications, and her anemia resolved postoperatively.

Assessment of the role of LASER-Doppler in the treatment of port-wine stains in infants

BACKGROUND

Port-wine stains (PWS) are malformations of capillaries in 0.3% of newborn children. The treatment of choice is by pulsed dye LASER (PDL), and requires several sessions. The efficacy of this treatment is at present evaluated on the basis of clinical inspection and of digital photographs taken throughout the treatment. LASER-Doppler imaging (LDI) is a noninvasive method of imaging the perfusion of the tissues by the microcirculatory system (capillaries). The aim of this paper is to demonstrate that LDI allows a quantitative, numerical evaluation of the efficacy of the PDL treatment of PWS.

METHOD

The PDL sessions were organized according to the usual scheme, every other month, from September 1, 2012, to September 30, 2013. LDI imaging was performed at the start and at the conclusion of the PDL treatment, and simultaneously on healthy skin in order to obtain reference values. The results evidenced by LDI were analyzed according to the "Wilcoxon signed-rank" test before and after each session, and in the intervals between the three PDL treatment sessions.

RESULTS

Our prospective study is based on 20 new children. On average, the vascularization of the PWS was reduced by 56% after three laser sessions. Compared with healthy skin, initial vascularization of PWS was 62% higher than that of healthy skin at the start of treatment, and 6% higher after three sessions. During the 2 months between two sessions, vascularization of the capillary network increased by 27%.

CONCLUSION

This study shows that LDI can demonstrate and measure the efficacy of PDL treatment of PWS in children. The figures obtained when measuring the results by LDI corroborate the clinical assessments and may allow us to refine, and perhaps even modify, our present use of PDL and thus improve the efficacy of the treatment.

Massive per rectal bleeding in a child due to caecal arteriovenous malformation treated successfully by embolisation

A 12-year-old girl presented with a sudden onset of per rectal bleeding. After admission, she had further episodes of large volume per rectal bleeding and developed hypotensive shock. Hence a massive haemorrhage protocol was activated. Surgical, paediatric and anaesthetic support was sought immediately. Further resuscitation with packed red cells, platelets and fresh frozen plasma was successful. An urgent CT angiogram of the abdomen confirmed active arterial bleeding from an arteriovenous malformation in the caecum. After a detailed discussion between the surgeons and the interventional radiologists, it was decided to attempt therapeutic embolisation first, failing which surgery was the option. The patient and family were fully informed. Through a right femoral approach under local anaesthesia, the superior mesenteric artery was catheterised and the bleeding vessel was successfully controlled with two microembolisation coils. Except for some initial abdominal discomfort, she made an uneventful recovery and was discharged home.

Rectal bleeding, deep venous thrombosis, and coagulopathy in a patient with Klippel-Trénaunay syndrome

Klippel-Trénaunay syndrome (KTS) is a rare noninheritable congenital disorder comprising vascular malformations that predispose patients to a paradoxical condition where bleeding occurs in a hypercoagulable state. A 16-year-old boy with a complicated lifetime course of KTS presented with massive rectal bleeding. He underwent a partial colectomy, endorectal resection, and splenectomy. Postoperatively, he developed a saddle pulmonary embolus, ultimately requiring placement of an inferior vena cava filter. He eventually did well and has since had his diverting ostomy reversed and resumed his usual activities. This report validates the use of endorectal resection for venous malformation of the rectum in patients with KTS and highlights the difficult balance of controlling bleeding by correction of a consumptive coagulopathy and the increased risk of thromboembolic complications.

Diagnosis and management of extensive vascular malformations of the lower limb: part II. Systemic repercussions [corrected], diagnosis, and treatment

At least nine types of vascular malformations with specific clinical and radiologic characteristics must be distinguished in the lower limbs: Klippel-Trénaunay syndrome, port-wine stain with or without hypertrophy, cutis marmorata telangiectatica congenita, macrocephaly-capillary malformation, Parkes Weber syndrome, Stewart-Bluefarb syndrome, venous malformation, glomuvenous malformation, and lymphatic malformation. Extensive vascular malformations are often more complex than they appear and require a multidisciplinary therapeutic approach. Vascular malformations may be associated with underlying disease or systemic anomalies. Part II of this two-part series on the diagnosis and management of extensive vascular malformations of the lower limb highlights the systemic repercussions [corrected] (bone, articular, visceral, and hematologic involvement), diagnosis, and treatment of these lesions.

[Involvement of splenic hemangioma and rectal varices in a patient with klippel: trenaunay syndrome]

Klippel - Trenaunay syndrome (KTS) is characterized by a cutaneous vascular nevus of the involved extremity, bone and soft tissue hypertrophy of the extremity and venous malformations. We present a case of KTS with splenic hemangiomas and rectal varices. A 29-year-old woman was referred for intermittent hematochezia for several years. She had history with a number of operations for cutaneous and soft tissue hamangiomas since the age of one year old and for increased circumference of her left thigh during the last few months. Abdominal CT revealed multiple hemangiomas in the spleen, fusiform aneurysmal dilatation of the deep veins and soft tissue hemangiomas. There was no evidence of hepatosplenomegaly or liver cirrhosis. Colonoscopy revealed hemangiomatous involvement in the rectum. There were rectal varices without evidence of active bleeding. Upon venography of the left leg, we also found infiltrative dilated superficial veins in the subcutaneous tissue and aneurysmal dilatation of the deep veins. The patient was finally diagnosed with KTS, and treated with oral iron supplementation only, which has been tolerable to date. Intervention or surgery is not required. When gastrointestinal varices or hemangiomatous mucosal changes are detected in a young patient without definite underlying cause, KTS should be considered.

Rectal bleeding in Klippel-Trénaunay syndrome: treatment with laparoscopic ultralow anterior resection with intersphincteric dissection

Klippel-Trénaunay syndrome is a rare congenital vascular disorder characterized by varicose veins, hypertrophy of the soft tissues and bones, and hemangiomas. Although colorectal angiomatosis is uncommon, this association can lead to life-threatening complications because of acute or chronic bleeding. We report a patient with Klippel-Trénaunay syndrome who presented with transfusion-dependent anemia secondary to chronic rectal bleeding. Endoscopy and image studies revealed venous angiomata involving the rectum and distal sigmoid colon. We performed a laparoscopic ultralow anterior resection with intersphincteric dissection, obtaining good results. After a follow-up of 20 months the patient did not present hematochezia and maintained fecal continence.

Intracranial aneurysms in klippel-trenaunay/weber syndromes: case report

OBJECTIVE

We present a comprehensive review of intracranial aneurysms in Klippel-Trenaunay and Klippel-Trenaunay-Weber syndromes (KTS/KTWS), and examine factors influencing the risks of surgery vs conservative management.

CLINICAL PRESENTATION

A 58-year-old physician with KTS affecting the right extremities presented with left hemispheric cerebellar stroke and was discovered to harbor four intracranial aneurysms of the posterior circulation: fusiform mid and distal BA (2.6 x 2 x 2 cm), fusiform right proximal P1 (2 x 1.3 x 1.3 cm), fusiform right distal P1 (2.8 x 2.7 x 2 cm), and saccular left distal posterior inferior cerebellar artery (2.5 x 2.5 x 2.5 cm). Ten years later he had an infarct in the paramedian distribution of the basilar artery and a right internal capsule stroke. Two months later, he developed hydrocephalus, ultimately presenting in status epilepticus 4 months later secondary to ongoing aneurysm expansion and mass effect.

INTERVENTION

Systemic anticoagulation for acute thrombosis with possible distal arterioarterial embolization from giant P1 aneurysms. Ventriculoperitoneal shunting for hydrocephalus. The patient died within 9 days after admission and 10 years after the initial discovery of aneurysms.

CONCLUSION

Strict control of modifiable risk factors compromising vascular integrity and periodic neuroimaging are warranted in KTS/KTWS patients. KTS/KTWS patients are hypercoagulable, and may be predisposed to aneurysm thrombosis with increased risk for distal arterial microembolization. Stroke-related morbidity secondary to distal arterioarterial aneurysm thrombus embolization and acute aneurysm thrombosis may be decreased with systemic anticoagulation in this patient population. KTS/KTWS patients have significantly higher rates of DVT and PE than the general population, and should be classified in the high-risk category for venous thromboembolism prophylaxis. Both endovascular and open cerebrovascular techniques have been used successfully in KTS/KTWS patients with intracranial aneurysms.

Delayed, life-threatening lower gastrointestinal hemorrhage in an infant after serial transverse enteroplasty: treatment with transcatheter n-butyl-2-cyanoacrylate embolization

We report a case of n-butyl-2-cyanoacrylate glue embolization of life-threatening lower gastrointestinal (LGI) hemorrhage in a 10-month-old boy. The child had a history of gastroschisis and short-bowel syndrome. Six months prior to the LGI bleed, he had undergone a serial transverse enteroplasty (STEP) to lengthen his intestine. To the best of our knowledge this is both the first report of successful glue embolization for LGI bleeding in a child and also the first report of severe hemorrhage after the STEP procedure.

Therapeutic endoscopy for nonvariceal gastrointestinal bleeding

The evaluation and management of acute gastrointestinal bleeding in infants, children, and adolescents is a reason for emergency consultation frequently cited by pediatric gastroenterologists. After stabilization of the patient's condition, endoscopic evaluation remains the most rapid and accurate method to identify the origin of acute bleeding in the majority of lesions in the pediatric age group. Several endoscopic techniques may be applied to bleeding lesions to achieve hemostasis. Familiarity with the various techniques and with the specifics of their use is essential for the pediatric endoscopist. This review focuses on the endoscopic management of acute nonvariceal bleeding in infants and children.