University of Rochester Medical Center Rochester, NY, United States
Alexandra France, MD1, Elliot Graziano, MD1, Edwin Lee, MD2, Danielle Marino, MD2 1University of Rochester Medical Center, Rochester, NY; 2University of Rochester Medical Center, Strong Memorial Hospital, Rochester, NY
Introduction: Ectopic varices are portosystemic collateral vessels outside the esophageal and gastric regions and account for 5% of variceal bleeding. Among ectopic varices, those in the colon are the rarest and are scarcely suspected as the cause of massive gastrointestinal bleeding. Due to their rarity, there is no standard of care established for the management of colonic variceal bleeding. We report a case of acute lower gastrointestinal bleeding due to colonic varices that was treated with TIPS and coil embolization.
Case Description/Methods: A 57-year-old male with NASH cirrhosis presented with large volume hematochezia. Despite volume resuscitation, he remained hemodynamically unstable and was admitted to the ICU, where vasopressors were initiated. He underwent esophagogastroduodenoscopy followed by visceral angiography, neither of which revealed a source of bleeding. Colonoscopy was urgently performed without bowel preparation, and a continuous stream of bright red blood was noted until the colonoscope reached its maximum length; no lesion could be identified. CT angiogram of the abdomen and pelvis showed multiple prominent pericolonic collaterals in the right lower quadrant and identified a focally dilated vein communicating with the cecal lumen.
Repeat colonoscopy with bowel preparation showed an intraluminal varix in the right colon with red wale sign (Figure 1). Adjacent hemoclips were placed for radiographic marking, and the patient was taken for urgent TIPS to reduce the portosystemic gradient. Two colonic varices with active filling via the superior mesenteric vein were identified and embolized with coils. After the intervention, the patient had no further hematochezia and his shock resolved.
Discussion: In patients with cirrhosis, colonic varices have an estimated incidence of 0.07% and colonic variceal bleeding accounts for 1-8% of lower gastrointestinal bleeds in this population. A diagnosis of colonic variceal bleed should be considered in cirrhotic patients who present with hemodynamically significant hematochezia in whom an upper source of gastrointestinal bleeding is not found.
Despite several reported therapeutic options for the treatment of colonic varices in the literature, there are currently no evidence-based guidelines available. As our case demonstrates, colonic varices can be responsible for massive, life-threatening gastrointestinal bleeds. Further research comparing therapeutic options for colonic varices is needed to provide clear best practice guidelines for their management.
Figure: Figure 1. Large varix seen in right colon endoscopically (A) displaying red wale sign (B), and in interventional radiology with endoscopically placed hemoclips (C, white arrow) and coil embolization (D).
Alexandra France indicated no relevant financial relationships.
Elliot Graziano indicated no relevant financial relationships.
Edwin Lee indicated no relevant financial relationships.
Danielle Marino indicated no relevant financial relationships.
Alexandra France, MD1, Elliot Graziano, MD1, Edwin Lee, MD2, Danielle Marino, MD2. P1551 - Successful Treatment of Bleeding Right-Sided Colonic Varices With Transjugular Intrahepatic Portosystemic Shunt and Coil Embolization, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.