Woman With Hematochezia

Abstract

As a consequence of cirrhosis, portal hypertension causes resistance to blood flow and leads to the formation of varices. However, colonic variceal hemorrhages are rarely reported but could be a lethal cause of lower gastrointestinal hemorrhage. Currently, there is no consensus on the management of colonic variceal hemorrhage. Variceal ligation, injection sclerotherapy, transjugular intrahepatic portosystemic shunt placement, and balloon-occluded retrograde transvenous obliteration or a combination of the above therapies have been reported with inconsistent success rates. We advocate considering colonic variceal bleeding as a crucial differential diagnosis of lower gastrointestinal bleeding in cirrhotic patients and initiating time-sensitive, definite operative treatment or combination therapy as soon as possible in colonic variceal patients with life-threatening bleeding events, which are often refractory to conservative treatment.

Keywords: cirrhosis; colonic varices; ectopic varices; exploratory laparotomy; portal hypertension.

Figure 1. Computed tomography angiography of the abdomen (axial view) demonstrating enhanced and engorged vascular lesions (arrows), compatible with ascending colonic varices

Figure 2. Computed tomography angiography of the abdomen (coronal view) demonstrating ascending colonic varices (arrows) with wall edema of the colon (arrowhead)

Figure 3. Gross specimen of the resected colon, measuring up to 15 X 9 cm, with attached ileum, measuring up to 2 X 2 cm and appendix, measuring up to 4.0 X 0.6 X 0.5 cm. Edematous changes were noted in the whole colon. An area with dilated vessels is noted 10 cm from the distal cut end. Sections show colonic tissue with dilated, tortuous, and congested veins in the submucosa. The picture is consistent with varicose veins due to portal hypertension. The bilateral cut ends and appendix were unremarkable except for mild congestion. There is no evidence of malignancy identified in the specimen examined.

Figure 4. Flow diagram for management of acute colonic variceal bleeding in the patients with liver cirrhosis

ICU: intensive care unit; LGI: lower gastrointestinal series; TIPS: transjugular intrahepatic portosystemic shunt; UGI: upper gastrointestinal series.