Less Could Be More: Rethinking the Unexpected Deterioration of Variceal Bleeding After Endoscopic Occlusion of Gastroesophageal Varices

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.