Colonic Varices: An Under-Recognized but Potentially Deadly Complication of Cirrhosis

Abstract

While esophageal varices are well-established sequela of portal hypertension, colonic varices are rare, with less than 100 published cases. Due to the paucity of data, there are no established clinical guidelines for treatment. We report a case of colonic varices associated with liver cirrhosis in a gentleman presenting with hematochezia. A 48 year old male with alcoholic liver cirrhosis and esophageal varices presented with profuse rectal bleeding resulting in shock. He was intubated and started on vasopressors for hemodynamic instability. Hemoglobin was 6.4 g/dL. The massive transfusion protocol was initiated for intractable bleeding. Urgent upper endoscopy revealed no active source of bleeding. Interventional Radiology was consulted for emergent embolization however his mesenteric angiogram showed a nonbleeding right colonic varix. Surgical intervention was deferred due to hemodynamic instability. Due to ongoing bleeding after his mesenteric angiogram, he underwent a CT angiogram which revealed bleeding in the cecum from colonic varices. Transjugular intrahepatic portosystemic shunt (TIPS) was performed for portal decompression and the varices were embolized controlling the bleeding transiently. He developed disseminated intravascular coagulation 7 hours later leading to recurrence of bleeding. The course was further complicated by acute respiratory distress syndrome. He eventually expired from his complications. Colonic varices can present with a variety of manifestations from abdominal pain to catastrophic gastrointestinal bleeding, as in our patient. The most accurate diagnostic modality is CT or mesenteric angiography, with varices identified on the venous phase. Unfortunately, due to scarcity of cases, there are no treatment guidelines. In cases of portal hypertension and severe bleeding, therapy targeted towards portal decompression can be effective, as seen in esophageal varices. Although our patient eventually passed away from complications, TIPS proved to be an effective temporizing measure to manage hematochezia. In rare cases of massively bleeding colonic varices, prompt diagnosis and treatment aimed to reduce portal hypertension is imperative in decreasing mortality.2017_A Figure 1. Varices seen to the right colon/hepatic flexure.2017_B Figure 2. Enlarged venous collateral (colonic varices) originating from the distal portal vein.2017_C Figure 3. TIPS extending from the right portal vein into the right hepatic vein.