Bleeding ileal varices: a rare cause of chronic anemia in liver cirrhosis

Abstract

A 70-year-old man was admitted to our hospital for severe microcytic anemia (Hb 5.9 g/dL, MCV 74 fl). The medical history included hepatic cirrhosis due to previous alcohol abuse with known portal hypertension, hemorrhoids and oesophageal varices. During the prior year, he had been admitted three times to the hospital due to ascites, treated with evacuative paracentesis for his microcytic anemia with low ferritinemia, each time he was transfused with blood and treated for 2 months with oral iron for an improvement in the hemoglobin level and in iron metabolism parameters. Two esophagogastroduodenoscopies (EGDs) and two colonoscopies did not show bleeding lesions, and even faecal occult blood testing was negative on multiple samples. He was on treatment with canrenoate 400 mg/die, furosemide 25 mg/die, and propranolol 80 mg/die. During immediate prior weeks, he reported general malaise, heart palpitations and weakness. He did not report any blood loss with stool, nor hematuria or hematemesis. He was afebrile, and the other vital signs were normal. He was pale, and there was no jaundice. Abdominal ultrasonography (US) showed slight free peritoneal fluid. He was initially transfused with two units of packed red blood cells and an intravenous administration of iron was started. The faecal occult blood test on three samples was negative, a new EGDs showed oesophageal varices without signs of recent bleeding; colonoscopy revealed a normal mucosa with hemorrhoids. In order to study the entire intestine, capsule endoscopy (CE) was performed; it revealed severe hyperemia of jejunoileal mucosa with multiple big blue varices in the ileum, without active bleeding (Fig. 1). Due to the persistence of anemia, and the need for frequent blood transfusion, along with a lack of response to betablockers, a transjugular intrahepatic portosystemic shunt (TIPSS) procedure was performed with no complications. The patient underwent a CE 5 days after showing the disappearance of the multiple varices (Fig. 2); the anemia improved quickly, and no further blood transfusion has been necessary up to the present.