Mesenteric Varices: Preventing a Catastrophic GI Bleed

Abstract

Bleeding esophageal and gastric varices are serious and widely recognized complications of portal hypertension in cirrhotic patients. A subset of patients also develop life-threatening mesenteric varices, due to the development of engorged collateral vessels. These non-esophageal and non-gastric varices are termed “ectopic varices” (EcV) and are at a high risk for rupture and hemorrhage. EcV often go undiagnosed and untreated which highlights our case for early diagnosis and preemptive treatment. A 53 year old female with history of NASH cirrhosis (MELD-Na of 17) and grade 1 esophageal varices presented with lower extremity cellulitis and Citrobacter koseri bacteremia. CT abdomen was done to look for a source of bacteremia. Incidentally, the CT revealed worsening portal hypertension with large parasagittal mesenteric varices measuring up to 36 milimeters in diameter (Figure 1). The varices were secondary to mesenterogonadal shunting with a serious concern for impending rupture into the intestinal lumen. An urgent TIPS was placed followed by angiography (Figure 2) and sclerotherapy of the large shunt. At a four month follow up visit, no bleeding episodes were reported. Although EcV account for 5% of variceal bleeds, they carry a mortality rate of 40-50%, a fourfold increase risk of bleeding compared to gastric varices. Untreated, these patients are at a higher risk for death due to hemoperitoneum or brisk intraluminal gastrointestinal bleeding. They pose a challenge to clinicians, as they bleed sporadically and are difficult to locate. Diagnosis of EcV should be considered in patients with portal hypertension who present with bleeding despite negative endoscopic findings. Once identified, the interventional modality is unclear. Treatment options include somatostatin analogs, band ligation, TIPS placement, embolization, sclerotherapy, or any combination of the aforementioned. TIPS with embolization is effective in controlling acute bleeding EcV but TIPS carries the risk of encephalopathy and procedure complications. As in the case above, TIPS followed by angiography and sclerotherapy was effective in preventing a catastrophic hemorrhage and could be a bridge to possible transplantation. Clinicians should have a high index of suspicion for these patients as early identification of EcV could lead to life-saving measures.FigureFigure