S4025 Colon Under Pressure: A Case of Colonic Varix

Introduction: Ectopic varices, large portosystemic venous collaterals located outside the gastroesophageal region (including colonic, rectal, and gonadal varices), pose a unique challenge. These account for 1%–5% of variceal bleeds. Colonic varices can present with lower gastrointestinal bleeding and are identified through endoscopic or imaging investigations. Definitive guidelines are lacking for ectopic varices due to the varied locations and presentations. Case Description/Methods: A 59-year-old man with alcohol cirrhosis, grade 1 esophageal varices presented with acute hematochezia and melena. Symptoms included a 40-pound weight loss over 3 years, dry heaving, and vague abdominal pain. Vitals stable. Physical exam notable for tender epigastric region to palpation. Laboratory findings hemoglobin of 6.5, platelets 111, total bilirubin 5.5, direct bilirubin 2.9, aspartate aminotransferase 71, alanine aminotransferase 23, and alkaline phosphatase 171, international normalized ratio 1.57, Creatinine 0.68. Model for End-Stage Liver Disease 21. CTAP showed cirrhosis, portal hypertension, esophageal varices, splenorenal shunt with a venous aneurysm, and additional portal venous collaterals (superior mesenteric vein draining to the gonadal vein) noted in the right side of the abdomen some of which are inseparable from the wall of the ascending colon. Upper endoscopy did not reveal source of bleeding. Colonoscopy revealed bright red blood with clots up to the transverse colon, large, grade 3 colonic varices were identified in the ascending colon, Non-bleeding rectal varices and hemorrhoids. Hospital course complicated by hematochezia and anemia, requiring 7 units of packed red blood cells (PRBCs). He was started on an octreotide drip and transferred to a liver transplant center for sclerotherapy and embolization of colonic varices prior to transjugular intrahepatic portosystemic shunt (TIPS) placement. Discussion: A review of 169 ectopic variceal bleeding cases revealed ectopic varices in the duodenum (17%), jejunum or ileum (17%), colon (14%), rectum (8%), and peritoneum (9%). Management of ectopic varices with medications like octreotide remains uncertain. Endoscopy management includes band ligation, endoscopic sclerotherapy, or glue injection. Other alternatives include Balloon-occluded retrograde transvenous obliteration (BRTO) and Percutaneous transhepatic obliteration (PTO). The recommended approach for effective bleeding management involves a combination of TIPS and embolization. In our patient, the management plan involved sclerotherapy and TIPS with a long-term goal of a liver transplant.