Transjugular intrahepatic portosystemic shunt for repeated bleeding of hemorrhoids caused by severe portal hypertension with ectopic varices: A case report

Abstract

Background: Severe portal hypertension is life-threatening and can bring adverse complications such as ascites, gastroesophageal varices, and edema. It can, even cause variceal hemorrhage, which may lead to a high risk of death. There is a rare incidence in bleeding of hemorrhoids caused by severe ectopic varices.

Case presentation: We report the case of a female patient with a 20-year history of hepatitis B virus infection who presented with repeated bleeding of hemorrhoids caused by severe portal hypertension with ectopic varices that is connection between the superior mesenteric vein and rectal venous plexus. Laboratory results revealed a hemoglobin level of 74 g/L. Finally, the patient was successfully treated with transjugular intrahepatic portosystemic shunt (TIPSS) placement without variceal embolization after a multidisciplinary comprehensive opinion. In the two-month follow-up period, the patient had failed to develop hepatic encephalopathy or hematochezia, and computed tomography venography (CTV) indicated that the stent was unobstructed and ascites disappeared.

Conclusions: TIPSS placement is effective for the case, and we hope this case can help improve clinicians' awareness of hemorrhoidal bleeding with severe portal hypertension. Portal hypertension should also be considered during the diagnosis and treatment, as opposed to hemorrhoidal bleeding alone. Moreover, abdominal CTV is recommended as an effective imaging examination method to determine the stent status after operation.

Keywords: Ectopic varices; Hemorrhoidal bleeding; Portal hypertension; Transjugular intrahepatic portosystemic shunt.

Fig. 1

A. Contrast-enhanced CT showed a nodular filling defect on the main portal vein trunk (black arrow), splenomegaly and a large amount of ascites. B. Hemorrhoid varicosity (red arrow).

Fig. 2

A. Direct portal vein angiography. B. Severe ectopic varices of superior mesenteric vein–rectal venous plexus. C. Hemorrhoid varicosity.

Fig. 3

A. The punctured channel expanded with an 8 ​cm ​× ​6 ​mm balloon. B. The portal blood flowed smoothly back into the inferior vena cava through stent.

Fig. 4

Two months after the operation, computed tomography venography showed that ascites disappeared and stent remained in its original proper position without blocking.