S3905 Endoscopic Challenges in Familial Idiopathic Colonic Varices: A Case Report on Polypectomy Risk

Introduction: Colonic varices are an uncommon finding, typically associated with portal hypertension. Familial idiopathic colonic varices are extremely rare, with only a few reported cases. We present a case of familial idiopathic ileocolonic varices associated with significant post-polypectomy bleeding during multiple elective outpatient colonoscopies. This highlights a potential risk in colorectal cancer surveillance and polypectomy for patients with this vascular anomaly. Case Description/Methods: A 66-year-old man with a history of idiopathic ileocolonic varices. Alternative etiologies (ie portal hypertension, thrombotic disease) were excluded with fibroscan and contrasted cross-sectional imaging. Patient has family members with similar findings on colonoscopy including his twin brother, sister, and mother. His initial colonoscopy in 2012, prompted by a positive fecal immunochemical test, showed pancolonic varices and multiple small adenomas. Two <5 mm polyps removed with biopsy forceps resulted in significant bleeding, requiring epinephrine injection, hemostatic clips, and overnight observation. Hematology evaluation was unremarkable; low-dose aspirin was held prior to subsequent procedures. In 2018, during surveillance colonoscopy, 2 < 1 cm polyps were removed with hot snare and clips. He was hospitalized 7 days later with hematochezia and anemia, though no active bleeding was found on repeat colonoscopy. At his 2025 surveillance, 2 small polyps were removed, again with prolonged post-polypectomy bleeding managed with clips. A 25 mm pedunculated polyp was prophylactically clipped and resected with hot snare without bleeding. Due to persistent oozing, another small polyp was left unresected. The patient recovered well post-procedure. Discussion: Idiopathic colonic varices without portal hypertension are rare, and familial clustering is even less common. Literature review reveals several reports of idiopathic and familial colonic varices presenting with recurrent gastrointestinal bleeding, sometimes necessitating transfusion or surgery. Only 2 English-language case reports describe post-polypectomy hemorrhage in this setting. In our case, even small, low-risk lesions led to significant bleeding. This underscores the need for increased procedural caution and tailored approaches to polyp management in patients with idiopathic colonic varices.