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

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.

Ectopic Ascending Colonic Variceal Bleeding Treated with Balloon-Occluded Retrograde Transvenous Obliteration in a Decompensated Liver Cirrhosis Patient—A Hepatology Perspective

Ectopic colonic varices development from liver cirrhosis and portal hypertension is uncommon. They are part of the spectrum of portal hypertensive colopathy. Colonic variceal bleeding remains a rare cause of lower gastrointestinal tract (GI) bleeding. Due to the paucity of cases, there are no well-established conventional treatments for bleeding colonic varices. Different treatments have been reported. Here, we report a case of a 55-year-old gentleman, with a history of alcoholic liver cirrhosis, presenting with severe lower GI bleeding and symptomatic anaemia. An esophagogastroduodenoscopy revealed large esophageal varices with high-risk bleeding stigmata requiring endoscopic variceal ligation. A cross-sectional computed tomography scan showed colonic portosystemic shunts. In light of this and that the severe lower GI bleeding seemed out of proportion to the esophageal varices seen on upper endoscopy, an urgent unprepped colonoscopy was performed which revealed possible bleeding diverticula disease which required endoscopic mechanical hemoclip therapy. However, despite this, patient had recurrence of lower GI bleeding prompting a second colonoscopy. This relook colonoscopy showed ectopic ascending colon varices with high-risk bleeding stigmata. High-dose intravenous vasoactive agent somatostatin (500 mcg/hour) and subsequently terlipressin (2 mg every 4 hours) were used. The patient subsequently underwent successful balloon-occluded retrograde transvenous obliteration (B-RTO) and sclerotherapy. The non-selective beta-blocker (NSBB) carvedilol was started and bridged together with the vasoactive agent until stabilisation of portal hypertension. This difficult case illustrates the dynamic nature of portal hypertensive bleeding. It also highlights the presence of confounding non-variceal pathology complicating diagnosis of portal hypertensive colonic variceal bleeding, and that ectopic ascending colonic variceal bleeding can be treated successfully with B-RTO and sclerotherapy, with meticulous titration of high-dose vasoactive agents and NSBB, in a decompensated alcoholic liver cirrhosis patient.

Duodenal giant stromal tumor combined with ectopic varicose hemorrhage:A case report

BACKGROUND Gastrointestinal stromal tumors(GISTs)are mesenchymal tissue tumors originating from Cajal cells,presenting diverse clinical manifestations due to the different sizes,locations,and growth patterns of the lesions.Duodenum is an uncommon site of GISTs,more with gastrointestinal obstruction and bleeding as the first symptoms.Ectopic duodenal varix,as a rare varix occurring outside the gastroesophageal region,is the main type of heterotopic varices and an unusual cause of gas-trointestinal hemorrhage.The etiology is mainly seen in liver cirrhosis,portal hypertension,vasculitis,portal vein embolism and obstruction caused by various factors.Reports of duodenal stromal tumor combined with ectopic variceal hemorrhage are rarely seen;however,when it occurs,the situation can sometimes be urgent and life-threatening,especially when traditional endoscopy and imaging fail to detect the lesion timely.CASE SUMMARY We report a 52-year-old female patient who had no obvious inducement to develop black stool.Gastroscopy in a local hospital revealed that the duodenal horizontal ectopic varices were ruptured and bleeding.After metal clamping hemostasis,she still had gastrointestinal bleeding and was transferred to our hospital.Gastroscopy showed that active bleeding was still seen in the horizontal part of duodenum,and suspicious submucosal eminence was seen in the bleeding part.Abdominal computed tomography showed a huge stromal tumor of duodenum,specimens were pathologically confirmed after surgery.After a 3-mo follow-up,no gastrointestinal hemorrhage and complications occurred.CONCLUSION Ectopic variceal hemorrhage is rare but sometimes fatal.It may be combined with stromal tumor,which can be diagnosed by multiple methods.Endoscopic and surgical treatment are effective.

Peristomal variceal bleeding treated by coil embolization using a percutaneous transhepatic approach

Peristomal variceal bleeding due to portal hypertension is an entity that has rarely been reported with 3%-4% risk of death.A 68-year-old woman who had undergone a palliative colostomy(colorectal carcinoma) presented with a massive hemorrhage from the colostomy conduit.Considering her oncological status with medial and right hepatic veins thrombosis due to liver metastasis invasion,an emergency transhepatic coil embolization was successfully performed.Standard treatment modality for these cases has not been established.Percutaneous transhepatic coil embolization of varices is a safe and effective choice in patients who present with life threatening bleeding and exhibit contraindications to transjugular intrahepatic portosystemic shunt.