Abstract
Ectopic colonic varices development from liver cirrhosis and portal hypertension is uncommon. They are part of the spectrum of portal hypertensive colopathy. Colonic variceal bleeding remains a rare cause of lower gastrointestinal tract (GI) bleeding. Due to the paucity of cases, there are no well-established conventional treatments for bleeding colonic varices. Different treatments have been reported. Here, we report a case of a 55-year-old gentleman, with a history of alcoholic liver cirrhosis, presenting with severe lower GI bleeding and symptomatic anaemia. An esophagogastroduodenoscopy revealed large esophageal varices with high-risk bleeding stigmata requiring endoscopic variceal ligation. A cross-sectional computed tomography scan showed colonic portosystemic shunts. In light of this and that the severe lower GI bleeding seemed out of proportion to the esophageal varices seen on upper endoscopy, an urgent unprepped colonoscopy was performed which revealed possible bleeding diverticula disease which required endoscopic mechanical hemoclip therapy. However, despite this, patient had recurrence of lower GI bleeding prompting a second colonoscopy. This relook colonoscopy showed ectopic ascending colon varices with high-risk bleeding stigmata. High-dose intravenous vasoactive agent somatostatin (500 mcg/hour) and subsequently terlipressin (2 mg every 4 hours) were used. The patient subsequently underwent successful balloon-occluded retrograde transvenous obliteration (B-RTO) and sclerotherapy. The non-selective beta-blocker (NSBB) carvedilol was started and bridged together with the vasoactive agent until stabilisation of portal hypertension. This difficult case illustrates the dynamic nature of portal hypertensive bleeding. It also highlights the presence of confounding non-variceal pathology complicating diagnosis of portal hypertensive colonic variceal bleeding, and that ectopic ascending colonic variceal bleeding can be treated successfully with B-RTO and sclerotherapy, with meticulous titration of high-dose vasoactive agents and NSBB, in a decompensated alcoholic liver cirrhosis patient.
Highlights
Varices formation is a complication of portal hypertension, with liver cirrhosis being the most common cause
The non-selective beta-blocker (NSBB) carvedilol was started and bridged together with the vasoactive agent until stabilisation of portal hypertension. This difficult case illustrates the dynamic nature of portal hypertensive bleeding. It highlights the presence of confounding non-variceal pathology complicating diagnosis of portal hypertensive colonic variceal bleeding, and that ectopic ascending colonic variceal bleeding can be treated successfully with B-RTO and sclerotherapy, with meticulous titration of high-dose vasoactive agents and NSBB, in a decompensated alcoholic liver cirrhosis patient
We successfully treated a case of ascending colonic variceal bleeding using B-RTO and sclerotherapy, with high-dose vasoactive agents and NSBB
Summary
Varices formation is a complication of portal hypertension, with liver cirrhosis being the most common cause. Ectopic colonic varices remain a rare cause of lower GI bleeding in cirrhosis patients. Several therapies, including percutaneous transhepatic obliteration, colonic resection, portacaval shunt construction, transjugular intrahepatic portosystemic shunt (TIPSS), variceal embolization, and B-RTO, have been reported [4]. In this case, we successfully treated a case of ascending colonic variceal bleeding using B-RTO and sclerotherapy, with high-dose vasoactive agents and NSBB. We report an interesting and difficult case of ectopic ascending colonic variceal bleeding in an alcoholic cirrhosis patient treated successfully using B-RTO and sclerotherapy, with meticulous titration of high-dose vasoactive agents and NSBB
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