A SERENDIPITOUS DETOUR: DIRECT PERCUTANEOUS EMBOLIZATION OF ECTOPIC VARIX

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Variceal bleeding can be a devastating complication of cirrhosis; a minority of varices develop at sites apart from the esophagus or the stomach. We present the case of an ectopic variceal bleeding complicated by hemorrhagic shock, managed by direct percutaneous embolization of an ectopic small bowel varix in a ventral hernia. CASE PRESENTATION: A 47-year-old woman with a history of decompensated alcoholic cirrhosis presented with sudden onset profuse bright red bloody output per rectum. She was hypotensive, tachycardic, and had a ventral hernia. Labwork was notable for anemia (hemoglobin 2.9 mg/dL). Computed tomography (CT) angiography of the abdomen and pelvis did not reveal a source of hemorrhage, but did show a large ventral hernia containing small bowel without signs of strangulation. She was treated with pantoprazole, octreotide, transfusions of packed red cells and fresh frozen plasma, vasopressor support, and mechanical ventilation. Esophagoduodenoscopy revealed mild non-bleeding esophageal varices. Colonoscopy revealed a few mild oozing sites of portal colopathy treated with cautery. Given the presence of chronic portal vein thrombus and extensive collaterals, there was concern for a small bowel ectopic varix. On review of initial imaging, a dilated varix was noted to track along a loop of small intestine in the ventral hernia. She underwent percutaneous puncture of the ectopic varix under ultrasound guidance, followed by extensive coiling and gel foaming of the superior mesenteric venous system. Following the procedure, the patient developed gastrointestinal bleeding necessitating massive transfusion. Repeat esophagoduodenoscopy demonstrated grade II esophageal varices with active bleeding treated with banding. Continued hemorrhage led to hemodynamic collapse, followed by the patient's demise. DISCUSSION: Small bowel varices can be challenging to diagnose; they may be treated with transjugular intrahepatic porto-systemic shunt (TIPS), enteroscopy, embolization, or surgery. Percutaneous embolization was chosen as the treatment modality in our patient due to profound hemodynamic instability and emergent need for homeostasis. This is usually carried out via a transjugular, transfemoral, or transhepatic approach. The serendipitous presence of a portion of the ectopic varix on a loop of small bowel in a ventral hernia afforded the unconventional approach employed here. There have only been a few cases managed via a similar approach based on our literature review. Embolization was carried out successfully, but was complicated by bleeding from other varices, perhaps due to increased pressure in the portal venous system. CONCLUSIONS: Direct percutaneous varix embolization may be employed in the critical care setting provided favorable anatomy is present. REFERENCE #1: Lim L, Lee Y, Tan L, et al. Percutaneous paraumbilical embolization as an unconventional and successful treatment for bleeding jejunal varices. World J Gastroenterol. 2009 Aug 14; 15(30): 3823–3826. DISCLOSURES: No relevant relationships by Ajinkya Buradkar, source=Web Response no disclosure on file for William Haas; No relevant relationships by Danish Haque, source=Web Response No relevant relationships by Pius Ochieng, source=Web Response no disclosure on file for Nikul Patel; No relevant relationships by Arooj Quadir, source=Web Response No relevant relationships by NISHANT SHARMA, source=Web Response