Small Bowel Hemorrhage Due to Ectopic Varices Between the Inferior Mesenteric Vein and the Left Gonadal Vein

Abstract

Ectopic varices account for only 3-5% of all varices, but they have a 4-fold increased risk of bleeding when compared to esophageal varices. Endoscopic treatment of ectopic varices is often hindered by the difficulty in reaching some of these locations, and oftentimes alternative means of hemostasis will need to be pursued. Here we discuss a case of hemorrhage arising from ectopic varices between the inferior mesenteric vein (IMV) and left gonadal vein (LGV). A 62-year-old female with a history of alcoholic cirrhosis, decompensated by bouts of severe hepatic encephalopathy, and laparoscopic sigmoid colectomy for diverticular disease, presented to the Emergency Department with symptomatic anemia in the setting of maroon stools, found to have a hemoglobin level of 6.2 g/dL. Following resuscitation, the patient underwent esophagogastroduodenoscopy (EGD) and colonoscopy, which failed to identify a culprit lesion. In the ensuing days, the patient continued to have maroon stools and daily blood transfusion requirements. Further evaluation with capsule endoscopy and double-balloon enteroscopy were inconclusive. Tagged RBC scan and CT angiography were likewise negative, though CT angiogram did note prominent venous collaterals associated with the IMV and LGV, concerning for ectopic varices (Figure 1). An interdisciplinary meeting between Gastroenterology, Hepatology, Hepatobiliary Surgery, and Interventional Radiology was held to discuss potential options. Transjugular intrahepatic portosystemic shunt was contraindicated due to the degree of liver decompensation. Given the lack of other identifiable lesions, it was felt reasonable to attempt direct embolization of the varicosities between her IMV and LGV. Pre-embolization venogram did demonstrate a large shunt with extensive varices between the IMV and LGV (Figure 2). Amplatzer plugs and embolization coils were successfully deployed into 3 branches of the distal IMV (Figure 3). The patient was monitored in the hospital for a few days with stability of her hemoglobin, and she was discharged home. The patient followed up 1 month post-hospitalization with no recurrence of bleeding. Case Highlights: This case illustrates the difficulty that may be encountered in the identification and treatment of ectopic varices. In this case, the unusual location of her varices is postulated to have been related to her post-surgical state. A multi-disciplinary approach was needed in order to properly manage and treat this patient.2008_A Figure 1. CT angiogram demonstrating large venous collateralization between the IMV and left gonadal vein.2008_B Figure 2. Pre-embolization venogram demonstrating extensive network of varices with drainage by the left gonadal vein.2008_C Figure 3. Post-embolization venogram demonstrating complete occlusion of flow after deployment of Amplatzer plugs and coils into branches of the IMV.