Refractory ileocolic variceal bleeding in hemorrhagic shock: Endoscopy-negative stigmata, failed TIPS, and successful control with targeted embolization of an ectopic varix

Ectopic varices are portosystemic collaterals located outside the gastroesophageal region and represent a rare cause of variceal bleeding. They often pose diagnostic and therapeutic challenges due to their atypical locations and limited accessibility by conventional endoscopy. We report the case of a 68-year-old woman with a history of liver transplantation complicated by cirrhosis who presented with recurrent hematochezia and hemorrhagic shock. Endoscopic evaluation failed to identify the bleeding source. Computed tomography angiography (CTA) revealed varices in the distal superior mesenteric vein (SMV) territory involving the terminal ileum. The patient underwent transjugular intrahepatic portosystemic shunt (TIPS) placement, but bleeding persisted. Subsequent coil embolization of the ileocolic varix successfully controlled the hemorrhage. This case underscores the importance of recognizing ectopic varices as a rare source of gastrointestinal bleeding and highlights that TIPS alone may be insufficient, with adjunctive embolization often required for definitive management.