Mesenteric Variceal Bleeding Presenting as Massive Gastrointestinal Bleeding

Abstract

SESSION TITLE: Critical Care Cases II SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Monday, October 26, 2015 at 03:15 PM - 04:15 PM INTRODUCTION: Mesenteric varices are an unusual cause of gastrointestinal (GI) bleeding, but associated with a high mortality. We describe a case, where massive GI bleeding was encountered in the setting of mesenteric varices. CASE PRESENTATION: A 68-year-old woman presented with complaint of passing blood per rectum for four days prior. She had known hepatitis C cirrhosis and grade 3 esophageal varices. Physical exam was remarkable for pallor. Initial laboratory tests were significant for refractory anemia. An esophagogastroduodenoscopy (EGD) was negative. A colonoscopy showed diverticula but no active bleed. A video-capsule study revealed bleeding from the right side of the colon. She had persistent hematochezia needing support with massive transfusion and octreotide infusion for suspected variceal bleeding. An aortogram combined with a celiac, superior mesenteric and inferior mesenteric arteriogram, was negative for a source of bleeding. A repeat EGD revealed a normal esophagus, but active bleeding was noted upon entering the third portion of the duodenum obscuring visualisation. She was taken for a computed tomographic angiogram (CTA) of the abdomen that demonstrated on the delayed phase sequence images, dilated mesenteric veins representing the source of bleeding (Figure 1). Portal hemodynamic measurement revealed portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) was created, achieving resolution of portal hypertension and hemostasis. DISCUSSION: Ectopic varices, consisting of mesenteric and duodenal varices, are rare, representing up to 5% of all variceal bleeding. It is associated with a high mortality of up to 40% and frequently diagnosed upon surgery or autopsy. The most common cause is portal hypertension, though mesenteric vein thrombosis, congenital malformations, arteriovenous fistulas and adhesions from prior surgeries represent other rare causes. Diagnosis involves EGD, though CTA has been reported increasingly useful. Treatment includes the use of vasoactive medication. TIPS with or without embolization of the bleeding varices has been reported to be successful in several case reports and case series. CONCLUSIONS: We present a case of mesenteric varices manifesting as massive lower GI bleeding, which was eventually diagnosed with the help of an EGD and a CTA and treated with TIPS. Reference #1: Lopera JE, et al. Bleeding duodenal:varices treatment by TIPS and transcatheter embolization. Cardiovasc Intervent Radiol.2008;31(2):431-434. Reference #2: Norton ID, et al. Management of ectopic varices. Hepatology.1998;28(4):1154-1158. DISCLOSURE: The following authors have nothing to disclose: Sumera Ahmad, Jonathan Holdorf, Paulo Oliveira No Product/Research Disclosure Information