The ileal conduit is one of the most commonly performed urinary diversion procedures for muscle-invasive bladder cancer, and among the various complications, bleeding from an ileal conduit is rare. In patients with recurrent stomal haemorrhage, one must consider the possibility of atypical varices and assess for liver cirrhosis if it has not been previously established. Here, we describe a case of bleeding ectopic varices at the ileal conduit site in a patient in his 50s who underwent surgery for urinary bladder carcinoma, which was successfully managed through percutaneous transhepatic glue embolisation. Selective embolisation of these ectopic varices with coils or glue produces impressive results, offering the benefit of being minimally invasive, and can be considered an initial treatment option for stomal variceal bleeding. Other techniques, such as transjugular intrahepatic portosystemic shunt or antegrade and retrograde variceal occlusion using balloon or plug assistance, can also be attempted to eliminate varices.

Bleeding ectopic varices at hepaticojejunostomy.

This case study reports the diagnostic and clinical features and offers management strategies for duodenal variceal bleeding in patients with portal hypertension. Particular attention is given to the potential development of ectopic varices in the duodenum, where bleeding is a highly dangerous and life-threatening complication. The report outlines available diagnostic tests used to identify the source of bleeding. The anatomical characteristics of duodenal varices and the high rate of bleeding recurrence are emphasized as special treatment challenges. The case described highlights the importance of early detection of duodenal varices and of comprehensive management of patients with portal hypertension and its complications of different severity.

Occlusion of the portal system in pancreatic cancer patients occurs due to tumour invasion or compression, leading to segmental portal hypertension and the formation of portosystemic collaterals or varices at gastro-oesophageal or ectopic sites. Ectopic duodenal varices represent a rare and potentially life-threatening cause of upper gastrointestinal bleeding, associated with significantly high mortality rates. Herein, we describe a case of bleeding ectopic duodenal varices caused by occlusion of the splenoportal confluence, attributable to unresectable pancreatic cancer in a patient in his late 50s, who presented with multiple episodes of haematemesis and melaena over 3 days. This was successfully managed through variceal glue embolisation, followed by recanalisation of the portal system using a percutaneous transhepatic approach, after an unsuccessful endoscopic intervention. Endovascular recanalisation of the portal system through stent placement, along with ectopic variceal embolisation, may be considered a safe and effective alternative treatment option for managing ectopic varices in cases of inoperable pancreatic cancers with failed endoscopic treatment.

Endovascular Management of Bleeding Ectopic Varices.

Red Dichromatic Imaging (RDI) is an advanced endoscopic technology designed to enhance the visualization of gastrointestinal bleeding. While RDI with Mode 2 has demonstrated significant efficacy in the detection and management of esophageal varices, its role in treating anastomotic varices remains underexplored. We report a challenging case of anastomotic variceal rupture, highlighting the advantages of RDI in precise localization and treatment. A woman in her 70s with a history of pancreaticoduodenectomy for pancreatic head cancer and liver metastasis, presented with melena, fever, and suspected cholangitis during chemotherapy. Laboratory findings revealed anemia, leukocytosis, and elevated biliary enzymes. Blood transfusion and antibiotic therapy were initiated. CT revealed portal vein stenosis and contrast extravasation into the jejunum. Endoscopy showed a white plug at the gastrojejunal anastomosis, but no visible varices on white light imaging. RDI with Mode 2 identified subtle color changes, enabling successful N-butyl-2-cyanoacrylate injection. Accumulation of lipiodol confirmed variceal obliteration. No further bleeding occurred, and the patient was discharged in stable condition on hospital day 19. This case suggests that RDI may improve the detection and therapeutic precision of ectopic varices and serve as a valuable adjunct in their management.

Abstract Extrahepatic portal vein occlusion (EHPVO) is a primary vascular condition characterized by chronic obstruction of the extrahepatic portal vein and is a significant cause of ectopic varices, variceal bleeding, and morbidity. Transjugular intrahepatic portosystemic shunt is a critical procedure in decompressing the portal system. An unfortunate cohort of patients with refractory variceal bleeding who suffer from coexistent chronic portal vein thrombosis, often have limited treatment options. We present a case of EHPVO, complicated with hepatitis C virus infection and cirrhosis with refractory variceal bleed in which percutaneous mesocaval shunt was performed.

Ectopic varices represent 1–5% of variceal bleeding and carry a high mortality rate. Duodenal varices are more frequent in extrahepatic portal hypertension, often related to prior abdominal surgery. Diagnosis requires high suspicion and use of imaging when endoscopy is inconclusive. Treatment involves endoscopy, interventional radiology, or surgery, depending on the case. We report the case of a 37-year-old woman who presented with upper gastrointestinal bleeding due to ectopic duodenal varices, revealing extrahepatic portal hypertension with a portal cavernoma. Diagnosis was made through endoscopy and imaging. Despite endoscopic and surgical treatment, the outcome was fatal. This case highlights the severity and management challenges of ectopic varices. This case illustrates the severity and diagnostic difficulty of ectopic varices and the need for a multidisciplinary, tailored approach to improve outcomes. Early diagnosis and timely treatment are critical to reduce mortality.

Management of portal hypertension (PHTN) in pediatric patients presents challenges due to the smaller anatomy and a lack of standardized protocols. While evidence for endovascular management of ectopic varices, maintenance of surgical shunts, portal venous recanalization, and percutaneous portosystemic shunt creation in children grows, adaptation requires specialized techniques and equipment. This review explores the etiologies of pediatric PHTN, including Budd-Chiari syndrome, congenital anomalies, extrahepatic portal vein obstruction, and transplant vascular occlusions, and examines radiologic interventions to address these conditions. Management strategies are divided into relieving the primary cause of PHTN at the level of portal obstruction and managing the secondary effects of PHTN. For each category, the discussion focuses on device selection, postprocedural care, imaging surveillance, and management of pediatric scenarios.

Duodenal varices (DVs) are a rare type of ectopic varices occurring in portal hypertension, for which no standardized treatment strategy has been established. This retrospective study analyzed the outcomes of DV treatments in 15 patients. All enrolled patients with DVs were treated at a single institution Hospital between 2011 and 2022. The treatment procedure and outcome were analyzed retrospectively. Six patients presented with hemorrhagic DVs. Endoscopic variceal ligation was used for initial hemostasis in five bleeding cases. Balloon-occluded retrograde transvenous obliteration was the initial treatment in nine cases, achieving curative obliteration in eight cases. Percutaneous transhepatic variceal obliteration was performed as the initial treatment in three cases for which balloon-occluded retrograde transvenous obliteration was difficult to perform for anatomical reasons, and all cases achieved curative obliterations. Splenectomy was performed as the initial treatment in three patients due to complicating gastroesophageal varices. DVs recurred in two cases with splenectomy after approximately 1 year, but balloon-occluded retrograde transvenous obliteration and percutaneous transhepatic variceal obliteration were curatively applied in each case, and no recurrence has been observed since then. Gastroesophageal varices aggravated after the initial DV treatment in eight of the 15 cases during the observation period, and the cumulative aggravating rate was 58.1% at 4 years. All 15 cases with DVs were preferably controlled by selecting appropriate treatment based on individual hemodynamics of varices. Because of the relatively high rate of aggravation of gastroesophageal varices, careful long-term follow-up may be important for the treatment of DVs.

BACKGROUNDBleeding ectopic varices located in the small bowel (BEV-SB) caused by portal hypertension (PH) are rare and life-threatening clinical scenarios. The current management of BEV-SB is unsatisfactory. This retrospective study analyzed four cases of BEV-SB caused by PH and detailed the management of these cases using enteroscopic injection sclerotherapy (EIS) and subsequent interventional radiology (IR).AIMTo analyze the management of BEV-SB caused by PH and develop a treatment algorithm.METHODSThis was a single tertiary care center before-after study, including four patients diagnosed with BEV-SB secondary to PH between January 2019 and December 2023 in the Air Force Medical Center. A retrospective review of the medical records was conducted. The management of these four patients involved the utilization of EIS followed by IR. The management duration of BEV-SB in each patient can be retrospectively divided into three phases based on these two approaches: Phase 1, from the initial occurrence of BEV-SB to the initial EIS; phase 2, from the initial EIS to the initial IR treatment; and phase 3, from the initial IR to December 2023. Descriptive statistics were performed to clarify the blood transfusions in each phase.RESULTSFour out of 519 patients diagnosed with PH were identified as having BEV-SB. The management duration of each phase was 20 person-months, 42 person-months, and 77 person-months, respectively. The four patients received a total of eight and five person-times of EIS and IR treatment, respectively. All patients exhibited recurrent gastrointestinal bleeding following the first EIS, while no further instances of gastrointestinal bleeding were observed after IR treatment. The transfusions administered during each phase were 34, 31, and 3.5 units of red blood cells, and 13 units, 14 units, and 1 unit of plasma, respectively.CONCLUSIONEIS may be effective in achieving hemostasis for BEV-SB, but rebleeding is common, and IR aiming to reduce portal pressure gradient may lower the rebleeding rate.

Ectopic varices bleeding around the choledochojejunostomy site, potentially caused by portal vein occlusion, is a rare complication following pancreatoduodenectomy. In this report, we present a case of ectopic varices around the choledochojejunostomy site after pancreatoduodenectomy. A 55-year-old man who underwent pancreatoduodenectomy with portal vein reconstruction for pancreatic ductal adenocarcinoma suffered from hematochezia. Contrast-enhanced computed tomography revealed total occlusion of the main portal vein and ectopic varices around the choledochojejunostomy anastomosis site. An attempt at endoscopic hemostasis using clipping was unsuccessful. Consequently, a main portal vein stent was inserted to eliminate the varices. We successfully restored blood flow in the portal vein and eradicated the varices. Additionally, endoscopic changes were directly visualized using double-balloon endoscopy. Therefore, portal vein stent placement may be an effective treatment option for ectopic variceal bleeding around the choledochojejunostomy site following pancreatoduodenectomy.

Ectopic varices are defined as portosystemic venous collaterals occurring in the gastrointestinal tract outside of the cardio-esophageal region. Duodenal varices are not routinely encountered by pediatric gastroenterologists. At the time of this case report, there are no consensus guidelines on the management of bleeding duodenal varices in pediatric patients. This is a case of a 14-year-old young woman with a history of multi-visceral transplantation due to short gut syndrome. The patient had developed duodenal varices near her transplant anastomosis, which were incidentally biopsied on endoscopy causing resultant bleeding that required endoscopic hemostasis. This case highlights the need for recognition of duodenal varices as a potential etiology of gastrointestinal bleeding in children and describes band ligation as an effective hemostatic modality.

Ectopic varices are dilated veins resulting from portosystemic venous collaterals that appear anywhere in the gastrointestinal mucosa except the gastroesophageal region. Gastrointestinal bleeding caused by this type of varices accounts for 5% of all variceal hemorrhages, making it an unusual cause with a high mortality rate. The optimal treatment for gastrointestinal bleeding due to ectopic duodenal varices has not been well established because of its rarity. Various treatment options have been analyzed for cases with active bleeding, with endoscopic treatment in its various modalities being the preferred choice for achieving initial hemostasis. Additionally, endoscopic treatment can be complemented with therapy guided by interventional radiology, which helps reduce the rate of rebleeding.

Ectopic varices account for 5% of variceal bleeding cases but carry high mortality due to their concealed nature and diagnostic challenges. A 46-year-old man with hepatitis C cirrhosis and prior gastroesophageal variceal bleeding presented with fatigue and dark red stools. Initial gastroscopy revealed moderate gastric-oesophageal varices without active bleeding, treated with preventive sclerotherapy and cyanoacrylate injection. Persistent bleeding and a worsening condition led to his transfer to our hospital. Clinical evaluation suggested lower gastrointestinal bleeding. Imaging and colonoscopy confirmed ascending colon ectopic varices with recent thrombotic bleeding, while a repeated gastroscopy showed evidence of prior therapeutic interventions for gastric-oesophageal varices, which were stable. A titanium clip was placed for temporary hemostasis, but further vascular embolization was halted due to extensive variceal involvement and risk of bowel necrosis. A multidisciplinary team recommended a transjugular intrahepatic portosystemic shunt, although the patient declined. This case underscores the importance of identifying the primary bleeding source to prevent exacerbation caused by unnecessary interventions. A stepwise diagnostic approach is put forward, highlighting that multidisciplinary care is crucial, with personalized, minimally invasive strategies to manage fragile vascular anatomy. Early detection and increased awareness of ectopic varices can facilitate timely and appropriate therapeutic interventions, ultimately improving patient care and outcomes.

In addition to its recognized efficacy, endoscopic band ligation (EBL) of esophageal varices can lead to a number of complications, among which post-banding ulcer bleeding (PUB) has a special place. Model of end-stage liver disease >18 index in combination with emergency EBL has been found to be the most likely predictor of PUB. The choice of effective endoscopic treatment for gastric variceal (GV) is often reduced to endoscopic interventional techniques. Here, the choice of intervention under the control of endoscopic ultrasound scanning (EUS) has shown its superiority over traditional endoscopic and X-ray endovascular methods of treating. Standard EBL and endoscopic sclerotherapy (ES) have a higher complication rate in the treatment of gastrointestinal ectopic varices (GEV). Bypass surgeries do not always achieve eradication or regression of GEV. The use of EUS allows delineation of afferent vessels for direct injection of sclerosant, which is not feasible with conventional endoscopic treatment. The main causes of non-variceal portal bleeding are portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE). New minimally invasive diagnostic methods allow to differentiate PGH and GAVE with high specificity, and can help in understanding the etiopathogenesis of GAVE and finding effective ways of its treatment.

Ectopic varices are dilated veins resulting from portosystemic venous collaterals that appear anywhere in the gastrointestinal mucosa except the gastroesophageal region. Gastrointestinal bleeding caused by this type of varices accounts for 5% of all variceal hemorrhages, making it an unusual cause with a high mortality rate. The optimal treatment for gastrointestinal bleeding due to ectopic duodenal varices has not been well established because of its rarity. Various treatment options have been analyzed for cases with active bleeding, with endoscopic treatment in its various modalities being the preferred choice for achieving initial hemostasis. Additionally, endoscopic treatment can be complemented with therapy guided by interventional radiology, which helps reduce the rate of rebleeding.

This article reports a rare case of upper gastrointestinal bleeding caused by an ulcerated varice in the duodenal bulb, associated with portal hypertension secondary to sarcoidosis. A 54-year-old patient was successfully treated with glue therapy without complications. Ectopic varices, such as those in the duodenal bulb, are rare but serious causes of gastrointestinal bleeding. Their management is complex due to their atypical location and the lack of standardized protocols. This case underscores the value of endoscopic techniques, such as glue therapy, combined with a multidisciplinary approach to optimize treatment and prevent recurrence.

An Extremely Rare Case of Spontaneous Hemoperitoneum Due to Rupture of Ectopic Varices in Cirrhosis of Liver

Endoscopic management of a life-threatening ectopic variceal bleed: A case report