P0783 - An Interesting Case of a Descending Colonic Varix Unresponsive to Transjugular Intrahepatic Portosystemic Shunt Placement

Phillip Leff, DO¹, Elvis J. Arteaga, MD², Xue Jing Li, MD³, Kenneth S. Zurcher, MD⁴, Steve Chen, MD⁵, Moises Nevah Rubin, MD^5
1Creighton University School of Medicine, Scottsdale, AZ; ²University of Arizona College of Medicine, Phoenix, AZ; ³University of Arizona College of Medicine, Phoenix VA Medical Center, Phoenix, AZ; ⁴Vascular & Interventional Partners, Scottsdale, AZ; ⁵Banner University Medical Center, Phoenix, AZ

Introduction: Portal hypertension can lead to various complications, including ascites, hepatic encephalopathy, and variceal bleeds. The most common variceal bleeds occur in the esophagus. The prevalence of colonic varices is roughly 0.07% and is found in 1% to 8% of patients with cirrhosis.¹

Colonic varices, though rare, are another manifestation of portal hypertension, typically found in the rectum and cecum.^{1, 2} Due to their rarity, there is a general lack of guidelines for treatment.¹ This case discusses a patient with descending colonic varix treated with transjugular intrahepatic portosystemic shunt (TIPS) and embolization.

Case Description/Methods: A 45-year-old male with decompensated alcoholic cirrhosis presented to the hospital after an outpatient paracentesis revealed spontaneous bacterial peritonitis. Upon admission, he reported intermittent hematochezia. Initial labs showed a hemoglobin level of 7.1 g/dL. On the fourth day of hospitalization, he developed abdominal pain and bright red blood per rectum, with Hgb dropping from 7.0 g/dL to 5.4 g/dL. He received four units of pRBCs, raising his Hgb to 6.5 g/dL. A flexible sigmoidoscopy revealed a submucosal mass in the descending colon and blood in the descending and sigmoid colon, but no bleeding source was identified.

A CT angiogram of the abdomen indicated large varices in the descending colon. The patient underwent a TIPS procedure with a pre-TIPS gradient of 16 mmHg and a post-TIPS gradient of 9 mmHg. During angiography, an inferior mesenteric varix was identified and subsequently treated with coil embolization. Despite this intervention, the patient continued to experience hematochezia. A second coil embolization was performed, which successfully resolved the issue.

Discussion: Treatment options for colonic varices include sclerotherapy, cyanoacrylate injection, TIPS, embolization, and BRTO.³ Our patient developed hematochezia from colonic variceal bleeding while being treated for spontaneous bacterial peritonitis and was treated with TIPS and embolization. The persistence of hematochezia despite initial interventions underscores the complexity of managing colonic varices. Though rare, providers should consider colonic varix in the differential diagnosis for any cirrhotic patient presenting with lower gastrointestinal bleeding.



Disclosures:


Phillip Leff, DO¹, Elvis J. Arteaga, MD², Xue Jing Li, MD³, Kenneth S. Zurcher, MD⁴, Steve Chen, MD⁵, Moises Nevah Rubin, MD⁵. P0783 - An Interesting Case of a Descending Colonic Varix Unresponsive to Transjugular Intrahepatic Portosystemic Shunt Placement, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.