A rare lethal ectopic bleeding site in a cirrhotic por...

In January, 2007, a 33-year-old man was undergone emergent exploratory laparotomy due to hepatic cirrhosis-portal hypertension related massive hematochezia with severe hypovolemic shock after no response from aggressive anti-shock measurements, without positive findings from endoscopy and angiography. A bleeding site was found inside a segment of jejunum which adhered to abdominal wall, where a varicose vein from the bowel mesentery penetrated into the abdominal wall through this jejunum segment. After this collateral vein was ligated and the affected jejunum segment was resected, hypovolemic shock was reversed immediately. Pathology showed widespread varicose veins inside the dissected jejunum wall (Figure). Four days prior to this severe hematochezia and the subsequent laparotomy, he was admitted with mild melena, followed by nausea, episodes of bilious vomiting, dizziness and palmus. Back to 20 months ago, he had been treated for hepatic cirrhosis and portal hypertension with splenectomy and de-vasculization of the stomach, with a 17-year history of HBV hepatitis. He was recovered from this jejunum anastomosis operation. When last seen in February, 2009, he was well.北京协和医院肝脏外科毛一雷

Varices due to portal hypertension usually develop in the lower esophagus, stomach, or rectum, and rarely in other parts of the digestive tract1. Ectopic varices are an unusual cause of gastrointestinal hemorrhage, accounting for up to 5% of all variceal bleeding2. In a review of 169 cases of bleeding from ectopic varices, 17% occurred in the duodenum, 17% in the jejunum or ileum, 14% in the colon, 8% in the rectum, and 9% in the peritoneum1. A key consequence of increased portal pressure is the development of porto-systemic collateral circulation that allows blood from the portal venous bed return to the systemic circulation. The ectopic varices with huge bleeding caused by adherence of intestine and abdominal wall due to surgery, to our knowledge, had not been reported. Since our patient had a history of abdominal surgery, his usual venous collaterals might have been disrupted.

Varices bleeding related mortality had been reported as high as 50%3. These patients are at an increased risk of complications and death4. Endoscopic or angiographic treatment is sometimes helpful in detection and control of the bleeding. A successful management of active variceal bleeding requires effective control of active bleeding and hemodynamic resuscitation. Therefore emergent surgery for treating bleeding from the ectopic varices is vital although it is at high risk.

Role of the funding source: CMB grant (06-837) supporting in the writing of the report.

Contributors

All authors contributed to the patient management. Shunda Du, Yilei Mao, and Jiefu Huang wrote the report.

Acknowledgments

We thank Hongbing Zhang for critical reading of this report and Quancai Cui, Tianyi Chi, Haitao Zhao, Yiyao Xu, Haifeng Xu, Huayu Yang, Baozhong Zhang for helping collecting clinical images and data.

Conflict of interest statement

All the authors do not have any financial and personal relationships with other people or organizations that could inappropriately influence (bias) our work.

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Peking Union Medical College: www.pumc.edu.cn

Reference:

1.    Norton ID, Andrew JC, Kamath PS. Management of ectopic varices. Hepatology 1998; 28: 1154-58.

2.    Kinkhabwala M, Mousavi A, Iyer S, et al. Bleeding ileal varicosity demonstrated by transhepatic portography. Am J Roentgenol 1977; 129: 514-16.

3.    Harry R, Wendon J. Management of variceal bleeding. Curr Opin Crit Care. 2002; 8: 164-70.

4.    Comar KM, Sanyal AJ. Portal hypertensive bleeding. Gastroenterol Clin N Am. 2003; 32: 1079-105.