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Variceal Hemorrhage of Ascending Colon

2011; Elsevier BV; Volume: 10; Issue: 2 Linguagem: Inglês

10.1016/j.cgh.2011.08.024

1542-7714

Won Sohn, Hang Lak Lee, Kang Nyeong Lee,

Systemic Lupus Erythematosus Research

A 33-year-old woman with a history of systemic lupus erythematosus was admitted to the hospital with melena, hematochezia, and syncope. Upper endoscopy did not demonstrate any bleeding source. Colonoscopy revealed varices between mid and distal ascending colon and blood clots at colonic mucosa (Figure A). Therefore, variceal hemorrhage in ascending colon was suspected. To find a cause of ascending colonic varices, abdominal computed tomography (CT) angiography (Figures B and C) was performed. CT angiogram demonstrated development of collateral vessels at retroperitoneum (black arrow, Figures B and C), abdominal wall (white arrow, Figure B), and drainage of both renal veins to the mentioned collateral vessels (4 white lightning arrows, Figure C), but liver cirrhosis, portal vein obstruction, and splenomegaly were not found. Therefore, we thought that the long segmental portion of infrahepatic inferior vena cava was occluded (arrowhead, Figure C). In addition, acute thrombosis at left iliac vein with distention of left common iliac vein and external iliac vein was found (white arrow, Figure C). In her history, lupus anticoagulant and anticardiolipin antibody were positive. According to the clinical and laboratory findings, ascending colonic variceal hemorrhage caused by inferior vena cava occlusion by antiphospholipid syndrome was diagnosed. Melena and hematochezia were stopped by use of octreotide and β-blocker. After 2 weeks, anticoagulation was started with warfarin.Colonic varices are an uncommon cause of lower gastrointestinal bleeding. In general, esophageal and gastric varices are common in advanced liver disease with portal hypertension. The causes of colon varices other than portal hypertension are congestive heart failure, mesenteric vein thrombosis, pancreatitis with splenic vein thrombosis, mesenteric vein compression, and idiopathic.1Weingart J. Höchter W. Ottenjann R. Varices of the entire colon—an unusual cause of recurrent intestinal bleeding.Endoscopy. 1982; 14: 69-70Crossref PubMed Scopus (37) Google Scholar, 2Shrestha R. Dunkelberg J.C. Schaefer J.W. Idiopathic colonic varices: an unusual cause of massive lower gastrointestinal hemorrhage.Am J Gastroenterol. 1995; 90: 496-497PubMed Google Scholar Antiphospholipid syndrome is characterized with venous, arterial, small vessel thrombosis, thrombocytopenia, and repeated fetal losses. Antiphospholipid syndrome might develop primarily or in association with autoimmune diseases (eg, lupus), infectious diseases, and neoplastic disorders.3Gezer S. Antiphospholipid syndrome.Dis Mon. 2003; 49: 696-741Crossref PubMed Scopus (54) Google Scholar Colonic varices are considered as one of the sources for lower gastrointestinal bleeding under hyperthrombosis state including antiphospholipid syndrome. A 33-year-old woman with a history of systemic lupus erythematosus was admitted to the hospital with melena, hematochezia, and syncope. Upper endoscopy did not demonstrate any bleeding source. Colonoscopy revealed varices between mid and distal ascending colon and blood clots at colonic mucosa (Figure A). Therefore, variceal hemorrhage in ascending colon was suspected. To find a cause of ascending colonic varices, abdominal computed tomography (CT) angiography (Figures B and C) was performed. CT angiogram demonstrated development of collateral vessels at retroperitoneum (black arrow, Figures B and C), abdominal wall (white arrow, Figure B), and drainage of both renal veins to the mentioned collateral vessels (4 white lightning arrows, Figure C), but liver cirrhosis, portal vein obstruction, and splenomegaly were not found. Therefore, we thought that the long segmental portion of infrahepatic inferior vena cava was occluded (arrowhead, Figure C). In addition, acute thrombosis at left iliac vein with distention of left common iliac vein and external iliac vein was found (white arrow, Figure C). In her history, lupus anticoagulant and anticardiolipin antibody were positive. According to the clinical and laboratory findings, ascending colonic variceal hemorrhage caused by inferior vena cava occlusion by antiphospholipid syndrome was diagnosed. Melena and hematochezia were stopped by use of octreotide and β-blocker. After 2 weeks, anticoagulation was started with warfarin. Colonic varices are an uncommon cause of lower gastrointestinal bleeding. In general, esophageal and gastric varices are common in advanced liver disease with portal hypertension. The causes of colon varices other than portal hypertension are congestive heart failure, mesenteric vein thrombosis, pancreatitis with splenic vein thrombosis, mesenteric vein compression, and idiopathic.1Weingart J. Höchter W. Ottenjann R. Varices of the entire colon—an unusual cause of recurrent intestinal bleeding.Endoscopy. 1982; 14: 69-70Crossref PubMed Scopus (37) Google Scholar, 2Shrestha R. Dunkelberg J.C. Schaefer J.W. Idiopathic colonic varices: an unusual cause of massive lower gastrointestinal hemorrhage.Am J Gastroenterol. 1995; 90: 496-497PubMed Google Scholar Antiphospholipid syndrome is characterized with venous, arterial, small vessel thrombosis, thrombocytopenia, and repeated fetal losses. Antiphospholipid syndrome might develop primarily or in association with autoimmune diseases (eg, lupus), infectious diseases, and neoplastic disorders.3Gezer S. Antiphospholipid syndrome.Dis Mon. 2003; 49: 696-741Crossref PubMed Scopus (54) Google Scholar Colonic varices are considered as one of the sources for lower gastrointestinal bleeding under hyperthrombosis state including antiphospholipid syndrome.