Korean J Gastroenterol.  2018 Jun;71(6):349-353. 10.4166/kjg.2018.71.6.349.

Case of Bleeding Ileal Varices after a Colectomy Diagnosed by Capsule Endoscopy

Affiliations
  • 1Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea. bongsul@hanmail.net
  • 2Department of Surgery, Pusan National University School of Medicine, Busan, Korea.
  • 3Department of Pathology, Pusan National University School of Medicine, Busan, Korea.

Abstract

We report a case of bleeding ileal varices associated with intra-abdominal adhesions after colectomy which was successfully diagnosed using capsule endoscopy. A 77-year-old woman visited the emergency department for several episodes of melena. She had a medical history of neoadjuvant chemo-radiation therapy and subsequent surgery for rectal cancer 6 years previously. Conventional diagnostic examinations including upper endoscopy, colonoscopy, and abdominal computed tomography could not detect any bleeding focus, however, following capsule endoscopy revealed venous dilatations with some fresh blood in the distal ileum, indicating bleeding ileal varices. The patient underwent exploratory laparotomy and the affected ileum was successfully resected. No further gastrointestinal bleeding occurred during the 6 months follow-up. Small intestinal varices are important differential for obscure gastrointestinal bleeding especially in patients with a history of abdominal surgery in the absence of liver cirrhosis, and capsule endoscopy can be a good option for diagnosing small intestinal varices.

Keyword

Gastrointestinal hemorrhage; Capsule endoscopy

MeSH Terms

Aged
Capsule Endoscopy*
Colectomy*
Colonoscopy
Dilatation
Emergency Service, Hospital
Endoscopy
Female
Follow-Up Studies
Gastrointestinal Hemorrhage
Hemorrhage*
Humans
Ileum
Laparotomy
Liver Cirrhosis
Melena
Rectal Neoplasms
Varicose Veins*

Figure

  • Fig. 1. Colonoscopy showed dark blood retention in the entire colon, originating from oral side of the ileocecal valve. (A) Transverse colon. (B) Ileocecal valce. (C) Terminal ileum.

  • Fig. 2. Capsule endoscopy showed bluish venous dilation with bloody intestinal fluids in the distal ileum.

  • Fig. 3. Abdominal computed tomography revealed venous dilatation on the ileum (red arrows) adjacent to the uterus.

  • Fig. 4. Histopathology findings. (A, B) Gross findings of the resected ileum showed a well-defined tortuous, engorged vascular structure (red arrows) on the serosal (A) and mucosal (B) surface. (C, D) On a microscopic examination, submucosa (C, H&E, ×40) and subserosa (D, H&E, ×40) showed irregularly dilated venous structures (red arrows). (E) Fibrous bands (star) around the dilated tortuous varices were observed on the subserosa (H&E, ×40).


Reference

References

1. Lebrec D, Benhamou JP. Ectopic varices in portal hypertension. Clin Gastroenterol. 1985; 14:105–121.
Article
2. Helmy A, Al Kahtani K, Al Fadda M. Updates in the pathogenesis, diagnosis and management of ectopic varices. Hepatol Int. 2008; 2:322–334.
Article
3. Gerson LB, Fidler JL, Cave DR, Leighton JA. ACG clinical guideline: diagnosis and management of small bowel bleeding. Am J Gastroenterol. 2015; 110:1265–1287.
Article
4. Raju GS, Gerson L, Das A, Lewis B, American Gastroenterological Association. American Gastroenterological Association (AGA) institute technical review on obscure gastrointestinal bleeding. Gastroenterology. 2007; 133:1697–1717.
5. Zuckerman GR, Prakash C, Askin MP, Lewis BS. AGA technical review on the evaluation and management of occult and obscure gastrointestinal bleeding. Gastroenterology. 2000; 118:201–221.
Article
6. Iddan G, Meron G, Glukhovsky A, Swan P. Wireless capsule endoscopy. Nature. 2000; 405:417.
Article
7. Ohmiya N, Nakagawa Y, Nagasaka M, et al. Obscure gastrointestinal bleeding: diagnosis and treatment. Dig Endosc. 2015; 27:285–294.
8. Pasha SF, Leighton JA, Das A, et al. Double-balloon enteroscopy and capsule endoscopy have comparable diagnostic yield in small-bowel disease: a metaanalysis. Clin Gastroenterol Hepatol. 2008; 6:671–676.
Article
9. Pennazio M, Eisen G, Goldfarb N. ICCE. ICCE consensus for obscure gastrointestinal bleeding. Endoscopy. 2005; 37:1046–1050.
Article
10. Sato T, Akaike J, Toyota J, Karino Y, Ohmura T. Clinicopathological features and treatment of ectopic varices with portal hypertension. Int J Hepatol. 2011; 2011:960720.
Article
11. De Palma GD, Rega M, Masone S, et al. Mucosal abnormalities of the small bowel in patients with cirrhosis and portal hypertension: a capsule endoscopy study. Gastrointest Endosc. 2005; 62:529–534.
Article
12. Norton ID, Andrews JC, Kamath PS. Management of ectopic varices. Hepatology. 1998; 28:1154–1158.
Article
13. Philips CA, Arora A, Shetty R, Kasana V. A comprehensive review of portosystemic collaterals in cirrhosis: historical aspects, anatomy, and classifications. Int J Hepatol. 2016; 2016:6170243.
Article
14. Cappell MS, Price JB. Characterization of the syndrome of small and large intestinal variceal bleeding. Dig Dis Sci. 1987; 32:422–427.
Article
15. Kobayashi K, Yamaguchi J, Mizoe A, et al. Successful treatment of bleeding due to ileal varices in a patient with hepatocellular carcinoma. Eur J Gastroenterol Hepatol. 2001; 13:63–66.
Article
16. Sato T, Yamazaki K, Toyota J, Karino Y, Ohmura T, Akaike J. Ileal varices treated with balloon-occluded retrograde transvenous obliteration. Gastroenterology Res. 2009; 2:122–125.
Article
17. Castagna E, Cardellicchio A, Pulitanò R, Manca A, Fenoglio L. Bleeding ileal varices: a rare cause of chronic anemia in liver cirrhosis. Intern Emerg Med. 2011; 6:271–273.
Article
18. Iguchi T, Yabushita K, Sakaguchi K, et al. Percutaneous transhepatic sclerotherapy for bleeding ileal varices associated with portal hypertension and previous abdominal surgery. Jpn J Radiol. 2010; 28:169–172.
Article
19. Traina M, Tarantino I, Barresi L, Mocciaro F. Variceal bleeding from ileum identified and treated by single balloon enteroscopy. World J Gastroenterol. 2009; 15:1904–1905.
Article
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