S2582 Colonic Adenocarcinoma-Induced Gastroenteropathic Varices Causing Massive GI Bleed: Rare but a Serious Manifestation to Consider

Abstract

Introduction: Varices located in other regions than the esophagogastric areas are called Ectopic Varices. Gastroenteropathic varices are a rare manifestation of severe portal hypertension (HTN) caused by cirrhosis. Malignancy can contribute to the pathophysiology of portal HTN which is less commonly seen. We present a case of a patient with profuse rectal bleeding requiring massive transfusions due to ectopic varices predominantly caused by Colonic Adenocarcinoma induced Portal HTN. Case Description/Methods: The patient is a 61-year-old male with a past medical history of significant colonic adenocarcinoma with widespread metastasis s/p chemotherapy and radiation who was admitted to the hospital for another round of chemotherapy but the course was complicated by profuse anemia secondary to gastrointestinal bleed (GI). Esophagogastroduodenoscopy (EGD) showed small varices with portal hypertensive gastropathy. Colonoscopy showed rectosigmoid arteriovenous malformation status post argon plasma coagulation, diverticulosis, and rectal clot with no active bleeding. The patient required massive transfusion of 11 units of packed red cells due to continued bleeding. Nuclear Medicine (NM) scan was positive for a small bowel bleed. It was presumed that portal HTN caused continued bleeding of possible small bowel telangiectasias. Computed tomography angiography revealed extensive umbilical varices with small jejunal varices pointing towards portal hypertensive gastroenteropathy as the cause of Gl bleed. The transjugular intrahepatic portosystemic shunt (TIPS) procedure was unsuccessful complicated by superior mesenteric artery embolization. The patient was managed with octreotide drip, proton pump inhibitor, and transfused as needed. Gl bleed was successfully contained and the patient was discharged home with close follow-up with gastroenterology and surgery. Discussion: Gastroenteropathic Varices is a distinct and rare manifestation of severe portal HTN. Cirrhosis is considered to be a common causative factor but colon malignancy can play a major role in it's pathophysiology which is unique to this case. Ectopic Varices cause massive GI bleed with mortality reaching up to 40%. Due to infrequent presentation with limited literature, guidelines on management are deficient and requires further investigation.