A Case of Idiopathic Colonic Varices Presenting as a Lower Gastrointestinal Bleed

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Introduction: Colonic varices remains a rare cause of lower gastrointestinal bleeding in the literature, with an incidence rate of 0.07%. Most commonly, they are secondary to portal hypertension with other less common causes, including congestive heart failure, mesenteric vein thrombosis or compression, splendid vein thrombosis, and adhesions. In a very few reported cases, it has been attributed to being idiopathic. Case Report: A 76-year-old with history of prostate cancer status post robotic surgery but otherwise healthy was admitted with sudden onset left lower quadrant pain, hematochezia, and anemia with hemoglobin 7 requiring blood transfusions. Upon admission, a colonoscopy was performed, which showed large ectopic, colonic varices at the splenic flexure and descending colon region. Similarly, dilated and prominent veins were noted in the rectum as well. No active bleeding was noted at the time of endoscopy, and therefore, no intervention was done. There were very few small diverticula in the left colon as well, but no bleeding stigmata were appreciated. He remained stable post endoscopy, and was eventually discharged home with an outpatient work-up that included complete hepatitis panel, right upper quadrant ultrasound, computed tomography, abdominal and pelvis scan, and also an upper endoscopy, all of which were negative. Subsequently, an interventional radiology-guided mesenteric angiogram was done, which showed no evidence of arterial venous malformation or arteriovenous fistulas. The draining veins were noted to be quite prominent. No intervention was performed. Given that he remained asymptomatic with no evidence of further bleeding or anemia, conservative follow-up was recommended with plan on referral for a surgical evaluation in the future if he re-bleeds. Conclusion: Diagnosing idiopathic colonic varices continues to be a challenge, given its rare presentation. When encountering a patient with lower gastrointestinal bleeding suspected to be from colonic varices on a colonoscopy, a subsequent systemic work-up should be initiated, including a thorough evaluation for causes of portal hypertensive, as well as other vascular abnormalities, before concluding that they are idiopathic in nature. One may have to consider clinical, radiological, and at times, even surgical information collectively for a proper diagnosis. In general, patients with idiopathic colonic varices usually have a better prognosis than patients with colonic varices secondary to portal hypertension.