Idiopathic Colonic Varices and the Need for Polypectomy: A Rare and Unique Clinical Challenge

Abstract

Colonic varices are a rare finding on colonoscopy and are most commonly associated with portal hypertension. Idiopathic colonic varices (ICV) comprise a small subset of colonic varices and have been reported in only 45 cases in the literature. Most cases present with lower GI bleeding and require prompt diagnostic colonoscopy. We present a unique case of ICV found on diagnostic colonoscopy complicated by the need for polypectomy. A 62 year-old male with a history of HTN and CKD presented with a 25 lb weight loss, anorexia and normocytic anemia. Colonoscopy revealed large pan-colonic varices and multiple polyps, two of which were >1cm in size. Polypectomy was not performed due to proximity to the varices and risk of gastrointestinal hemorrhage; however a 1.5 cm sessile sigmoid polyp was sampled and confirmed to be a tubular adenoma. Work-up for underlying liver disease, vascular shunts, and portal hypertension was undertaken to identify an etiology for the colonic varices. Laboratory data revealed normal liver enzymes, an INR of 1.0, and negative serologic work-up. An MRI of the abdomen revealed a normal sized heart, no hepatosplenomegaly and patent intraabdominal vasculature. Direct mesenteric angiography and liver biopsy were normal with a HVPG of 5mmHg. Without evidence of portal hypertension, arteriovenous shunt, or chronic liver disease, these large pan-colonic varices were determined to be idiopathic. Given the rarity of the disease, there are no guidelines for the management of ICV and many cases of bleeding result in complete colectomy. Unlike varices due to portal hypertension, there are no conservative pharmacologic therapies for bleeding prophylaxis or diminution of ICV in part due to an unclear mechanism of formation. Previous cases have suggested congenital vascular anomalies but this remains uncertain. Furthermore, of the 45 cases of ICV reported none have been complicated by the need for polypectomy. Our patient has multiple large polyps, including an advanced adenoma adjacent to large colonic varices and a resultant unknown bleeding risk with polypectomy. We are thus led to consider if prophylactic total colectomy should be undertaken to reduce the risk of colon cancer and bleeding, versus attempted polypectomy with the possibility of significant GI bleeding. Given the ambiguity of proper management, the risks and benefits of the above therapies were discussed with the patient and he elected for polypectomy, which has been scheduled.Figure: Large diffuse varices seen on colonoscopy.Figure. 1: 5cm polyp adjacent to varix.