2354 Massive Hematochezia Due to Bleeding Cecal Varices in a 35-Year-Old

Abstract

INTRODUCTION: Bleeding from cecal varices is a rare complication of portal hypertension. We present a case of bleeding cecal varices manifesting as massive hematochezia in a 35 year-old woman with alcoholic cirrhosis. CASE DESCRIPTION/METHODS: A 35yo woman with chronic alcoholism presented with hematochezia, hypotension, and syncope. She endorsed a 15-year history of heavy alcohol intake, with no known liver disease or prior GI bleeding. Vital signs included HR 112 bpm and BP 83/48 mmHg. Labs indicated hemoglobin 6.6 g/dL, platelet count 58 K/uL, BUN 12 mg/dL, INR 1.5. Upper endoscopy showed no esophageal varices or blood. Colonoscopy showed red blood in the entire colon causing impaired visualization of underlying mucosa. The patient had continued hematochezia and hypotension requiring massive transfusion. CT angiography revealed active bleeding in the cecum and proximal ascending colon with abnormal surrounding vascularity, consistent with bleeding cecal varices (Figure 1). Arteriography demonstrated rectal, splenic, gastric, and small esophageal varices. The patient underwent transhepatic intravenous portosystemic shunt (TIPS) with an associated portosystemic gradient decrease from 24mmHg to 14mmHg. She had no further bleeding and was started on Nadolol for further reduction in portosystemic pressure. The patient was discharged in stable condition. DISCUSSION: Bleeding colonic varices are an uncommon manifestation of portal hypertension, with an incidence of 0.07%. Specifically, bleeding cecal varices are far more rare, and have been reported in less than 20 cases in the literature. This report describes a case of bleeding cecal varices in a 35 year-old with alcoholic cirrhosis; there is only one other report of bleeding cecal varices in a younger patient. Hemorrhage from these lesions is life threatening and requires robust knowledge of diagnostic and therapeutic options. Diagnosis is often attempted with colonoscopy, however can be difficult due to visual obscuration by bleeding. Mesenteric angiography is most effective in diagnosis. Endoscopic and radiologic interventions include cyanoacrylate injection, endoscopic variceal ligation, coil embolization, balloon occluded retrograde transverse obliteration (BRTO), and TIPS. In our case, the decision to pursue TIPS was made due to complicated superior mesenteric artery anatomy precluding coil embolization. Aggressive resuscitation and collaboration between gastroenterology, surgery, and radiology made for a successful outcome for this young patient.