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Giant idiopathic pancolonic varices — a rare entity Armando Peixoto ∗, Marco Silva , Pedro Pereira , Guilherme Macedo Centro Hospitalar de São João, Gastroenterology Department, Faculty of Medicine, University of Porto, Porto, Portugal
The authors present the case of a 54-year-old Caucasian man, referenced to screening colonoscopy, showing no symptoms at that time, or history of visible blood loss. His clinical history was unremarkable, including risk factors for chronic liver disease. No significant family history. Colonoscopy showed giant tortuous varices along the entire colon from the rectum to the cecum (Fig. 1), including the ileocecal valve, without any friable areas, ulcerations, or features suggestive of hypertensive colopathy. In this context, other endoscopic examinations were performed, including upper endoscopy and capsule enteroscopy, which showed no changes. Imaging studies, including CT angiography and MRI were negative, therefore, excluding intra-abdominal vascular disorders. Liver function tests were normal, as well as the full screening for chronic liver diseases and hepatic transient elastography. Study of prothrombotic conditions revealed no abnormalities. Thus, in the absence of an underlying disorder, it was confirmed the diagnosis of idiopathic pancolonic varices. Colonic varices are a very rare cause of gastrointestinal bleeding. More commonly, colonic varices occur in the context of portal hypertension (from any cause, including pre-, intra-, or post-hepatic conditions) and usually involve only some segments of the colon. The idiopathic form has less than 40 cases reported in the literature and are mostly diagnosed after recurring hematochezia or other forms of sudden and severe gastrointestinal bleeding, so the prevalence might be higher than thought, although in an autopsy
∗
Corresponding author. E-mail address: [email protected] (A. Peixoto).
Figure 1
Varices in the transverse colon.
series it was only 0.0007% [1], revealing the rare nature of this condition. Colonic varices should only be considered ‘‘idiopathic’’ after other medical conditions have been ruled out [2]. In previously reported in the cases, the median age at diagnosis was 37 years, with a near 2:0 male-to-female ratio. Unlike the cases secondary to portal hypertension, in idiopathic cases, varicose veins tend to occur throughout the colon, which can help distinguish between the two entities [3]. In our case, we applied the necessary evaluations to rule in other pathologies that could predispose to colonic varices, such as portal hypertension, intra-abdominal mass, thrombosis of major vascular structures, or congestive heart
http://dx.doi.org/10.1016/j.clinre.2016.01.001 2210-7401/© 2016 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Peixoto A, et al. Giant idiopathic pancolonic varices — a rare entity. Clin Res Hepatol Gastroenterol (2016), http://dx.doi.org/10.1016/j.clinre.2016.01.001
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A. Peixoto et al.
failure. The imaging mapping is important to determine the extent of this vascular anomaly and to eventually consider the surgical approach, often a fallback solution in emergency situations. Due to the lack of data, the treatment of colonic varices is not well defined in the absence of bleeding [4]. In this case, as the patient remained completely asymptomatic, the adopted approach was to observe and recommend family members to screening colonoscopy by the existence of specific cases of familial association [5].
Disclosure of interest The authors declare that they have no competing interest.
References [1] Feldman MSr, Smith VM, Warner CG. Varices of the colon: report of three cases. JAMA 1962;179:729—30. [2] Dina I, Braticevici CF. Idiopathic colonic varices: case report and review of literature. Hepat Mon 2014;14(7):e18916. [3] Speicher MV, Keegan MT, Kirk KE. A case of idiopathic colonic varices. J Am Osteopath Assoc 2014;114(1):56—9. [4] Krishna RP, Singh RK, Ghoshal UC. Recurrent lower gastrointestinal bleeding from idiopathic ileocolonic varices: a case report. J Med Case Rep 2010;4:257. [5] Boland P, Leonard J, Saunders M, Bursey F. Familial idiopathic small-bowel and colonic varices in three siblings. Endoscopy 2014;46(10):893—7.
Please cite this article in press as: Peixoto A, et al. Giant idiopathic pancolonic varices — a rare entity. Clin Res Hepatol Gastroenterol (2016), http://dx.doi.org/10.1016/j.clinre.2016.01.001
ARTICLE IN PRESS
CLINRE-853; No. of Pages 2
Clinics and Research in Hepatology and Gastroenterology (2016) xxx, xxx—xxx
Available online at
ScienceDirect www.sciencedirect.com
IMAGE OF THE MONTH
Giant idiopathic pancolonic varices — a rare entity Armando Peixoto ∗, Marco Silva , Pedro Pereira , Guilherme Macedo Centro Hospitalar de São João, Gastroenterology Department, Faculty of Medicine, University of Porto, Porto, Portugal
The authors present the case of a 54-year-old Caucasian man, referenced to screening colonoscopy, showing no symptoms at that time, or history of visible blood loss. His clinical history was unremarkable, including risk factors for chronic liver disease. No significant family history. Colonoscopy showed giant tortuous varices along the entire colon from the rectum to the cecum (Fig. 1), including the ileocecal valve, without any friable areas, ulcerations, or features suggestive of hypertensive colopathy. In this context, other endoscopic examinations were performed, including upper endoscopy and capsule enteroscopy, which showed no changes. Imaging studies, including CT angiography and MRI were negative, therefore, excluding intra-abdominal vascular disorders. Liver function tests were normal, as well as the full screening for chronic liver diseases and hepatic transient elastography. Study of prothrombotic conditions revealed no abnormalities. Thus, in the absence of an underlying disorder, it was confirmed the diagnosis of idiopathic pancolonic varices. Colonic varices are a very rare cause of gastrointestinal bleeding. More commonly, colonic varices occur in the context of portal hypertension (from any cause, including pre-, intra-, or post-hepatic conditions) and usually involve only some segments of the colon. The idiopathic form has less than 40 cases reported in the literature and are mostly diagnosed after recurring hematochezia or other forms of sudden and severe gastrointestinal bleeding, so the prevalence might be higher than thought, although in an autopsy
∗
Corresponding author. E-mail address: [email protected] (A. Peixoto).
Figure 1
Varices in the transverse colon.
series it was only 0.0007% [1], revealing the rare nature of this condition. Colonic varices should only be considered ‘‘idiopathic’’ after other medical conditions have been ruled out [2]. In previously reported in the cases, the median age at diagnosis was 37 years, with a near 2:0 male-to-female ratio. Unlike the cases secondary to portal hypertension, in idiopathic cases, varicose veins tend to occur throughout the colon, which can help distinguish between the two entities [3]. In our case, we applied the necessary evaluations to rule in other pathologies that could predispose to colonic varices, such as portal hypertension, intra-abdominal mass, thrombosis of major vascular structures, or congestive heart
http://dx.doi.org/10.1016/j.clinre.2016.01.001 2210-7401/© 2016 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Peixoto A, et al. Giant idiopathic pancolonic varices — a rare entity. Clin Res Hepatol Gastroenterol (2016), http://dx.doi.org/10.1016/j.clinre.2016.01.001
+Model CLINRE-853; No. of Pages 2
ARTICLE IN PRESS
2
A. Peixoto et al.
failure. The imaging mapping is important to determine the extent of this vascular anomaly and to eventually consider the surgical approach, often a fallback solution in emergency situations. Due to the lack of data, the treatment of colonic varices is not well defined in the absence of bleeding [4]. In this case, as the patient remained completely asymptomatic, the adopted approach was to observe and recommend family members to screening colonoscopy by the existence of specific cases of familial association [5].
Disclosure of interest The authors declare that they have no competing interest.
References [1] Feldman MSr, Smith VM, Warner CG. Varices of the colon: report of three cases. JAMA 1962;179:729—30. [2] Dina I, Braticevici CF. Idiopathic colonic varices: case report and review of literature. Hepat Mon 2014;14(7):e18916. [3] Speicher MV, Keegan MT, Kirk KE. A case of idiopathic colonic varices. J Am Osteopath Assoc 2014;114(1):56—9. [4] Krishna RP, Singh RK, Ghoshal UC. Recurrent lower gastrointestinal bleeding from idiopathic ileocolonic varices: a case report. J Med Case Rep 2010;4:257. [5] Boland P, Leonard J, Saunders M, Bursey F. Familial idiopathic small-bowel and colonic varices in three siblings. Endoscopy 2014;46(10):893—7.
Please cite this article in press as: Peixoto A, et al. Giant idiopathic pancolonic varices — a rare entity. Clin Res Hepatol Gastroenterol (2016), http://dx.doi.org/10.1016/j.clinre.2016.01.001
