S2105 Isolated Cecal Varices: A Rare Cause of Hematochezia

Abstract

INTRODUCTION: Ectopic varices (outside gastro-esophageal region) are uncommon in patients with portal hypertension (PH) and account for 5 % of all variceal bleeding cases. Isolated cecal varices (ICV) without pancolonic varices are extremely rare with only handful of cases reported so far. Here we present a case of bleeding from ICV in patient with alcoholic cirrhosis. CASE DESCRIPTION/METHODS: A 55-year-old male with history of alcoholic cirrhosis (last alcohol use 1 y ago), CKD3 was admitted with 1 day history of hematochezia and dizziness. Hemoglobin on admission was 5.8 gm/dL, platelet 126 b/L and INR 1.4. After initial resuscitation, he underwent EGD which revealed non-bleeding grade 2 esophageal varices which were banded. He continued to have hematochezia. He subsequently underwent colonoscopy which revealed a 4 cm area of granularity in cecum. This area was biopsied following which sudden spurting of blood was seen. He was sent for emergent abdominal CT angiography, which came back negative for active arterial bleeding. Retrospectively, the area of granularity in cecum was thought to represent an ICV. There was spontaneous cessation of bleeding and the patient was discharged in next few days. Two months later, he presented to our hospital for similar episodes of lower GI bleeding. EGD showed non-bleeding grade 1 esophageal varices. Due to suspected bleed from ICV, patient was taken for emergent TIPS. Mesenteric angiogram showed contrast extravasation from a large cecal varix. TIPS and coil embolization of cecal varix was performed resulting in hemostasis. DISCUSSION: Ectopic varices occur in the small intestine, biliary system, colon, rectum, and surgical ostomy sites and can develop in the setting of PH, prior abdominal surgery, vascular thrombosis, or anomalies of the venous outflow vessels. ICV without pancolonic involvement are extremely rare as less than 20 cases have been reported so far in English literature. Almost all the reported cases have presented with massive lower GI bleeding. Usually EGD is performed to rule out more common upper GI bleeding from esophageal varices. CT angiography may be obtained but extravasation may only be seen in the venous phase. No- bleeding ICV can be missed on colonoscopy as over-insufflation can cause the collapse of such varices. Exsanguinating ICV are usually treated by performing emergent TIPS with or without adjunctive variceal embolization.Figure 1.: Colonoscopy showing area of granularity in cecum representing cecal varix (left). Active bleeding seen when this area was mistakenly biopsied (right).Figure 2.: Abdominal angiogram showing large isolated cecal varix with extravasation of contrast.Figure 3.: Fluoroscopic image showing coil embolization of the cecal varix.