Large Cecal Varices as Cause of Lower Gastrointestinal Bleeding
A woman in her early 60s with alcohol-related liver cirrhosis was admitted for investigation of peranal blood loss. Her hemodynamic and respiratory parameters were initially stable, with a serum hemoglobin concentration of 7.2 (normal range: 12.0 to 15.2) g/dL on admission.
Esophagogastroduodenoscopy revealed grade 1 esophageal varices with no signs of hemorrhage. Subsequent colonoscopy showed a large convolute of varicose veins (Figure) with a fibrin-covered hemocystic spot (arrow) at the cecal pole. Despite embolization of the varices (cyanoacrylate) and drug treatment (terlipressin) the patient suffered recurring hemorrhagic episodes requiring transfusion.
Because of this refractory variceal bleeding we decided to insert a transjugular intrahepatic portosystemic shunt, which succeeded in lowering the portosystemic pressure gradient to 4 mm Hg. During the course there was renewed massive bleeding with hemorrhagic shock. The interdisciplinary treatment team opted for surgical treatment. Right hemicolectomy with creation of an ileostomy put an end to the hemorrhages.
Gastrointestinal bleeding from ectopic varices is rare, but represents a challenging diagnostic and therapeutic conundrum. The various treatment options should be evaluated by a team including specialists in gastroenterology, interventional radiology, and visceral surgery.
PD Dr. med. Matthias Büchter, Universitätsklinikum Essen, Klinik für Gastroenterologie und Hepatologie, firstname.lastname@example.org
Dr. med. Nicola Gerhardy, Alfried Krupp Krankenhaus Essen, Klinik für Kardiologie, Elektrophysiologie, Gastroenterologie, Intensivmedizin
PD Dr. med. Axel Wetter, Universitätsklinikum Essen, Abteilung für diagnostische und interventionelle Radiologie und Neuroradiologie
Conflict of interest statement: The authors declare that no conflict of interest exists.
Translated from the original German by David Roseveare.
Cite this as: Büchter M, Gerhardy N, Wetter A: Large cecal varices as cause of lower gastrointestinal bleeding.
Dtsch Arztebl Int 2019; 116: 690. DOI: 10.3238/arztebl.2019.0690