Ectopic variceal bleeding from chronic superior mesenteric vein thrombosis after hemorrhagic pancreatitis

Abstract

Varices are a common cause of gastrointestinal (GI) bleed. When ectopic, there is often a delay in diagnosis as it is difficult to localize these varices. Ectopic small bowel varices usually arise from portal hypertension, which commonly develops in the setting of cirrhosis. This case presents a much rarer cause of bleeding ectopic varices with portal hypertension secondary to chronic superior mesenteric vein (SMV) thrombosis that developed after an episode of hemorrhagic pancreatitis. An 81‐year‐old man with a past medical history of a recent GI bleeds secondary to an arteriovenous malformation presented to the hospital with continued melena after a recent admission at another hospital for the same symptom. Upper endoscopy and colonoscopy showed no evidence of active bleeding. Subsequently computed tomography angiography (CTA) showed bleeding from collaterals in the third part of the duodenum, consistent with ectopic varices. The CTA also showed SMV thrombosis. The patient underwent an ultrasound‐guided transhepatic venogram with coiling and sclerosant embolization of SMV varices and distal SMV balloon angioplasty. Capsule endoscopy after showed no evidence of further bleeding. The patient was discharged 72 h after the intervention with stabilized hemoglobin and resolved melena. Ectopic varices should be on the differential diagnosis for patients presenting with a GI bleed that remains nonlocalized after endoscopy and colonoscopy. EGD or colonoscopy is the first‐line intervention for the treatment of bleeding ectopic varices. If unreachable by these means, percutaneous coil embolization is an alternative way to stabilize the patient. As no general management guidelines exist, treatment of bleeding ectopic varices should continue to be case‐dependent and involve a multidisciplinary team.

An Unusual Case of Isolated Duodenal Varices With Superior Mesenteric Vein Thrombosis

“…However, detecting DV may be challenging especially if isolated. The DV bulge may be subtle and mimic enlarged mucosal folds or its location in the third or fourth part of the duodenum may be beyond the reach of a routine EGD examination [ 7 , 8 ]. As exemplified in our case the isolated DV was located in the third part of the duodenum and was detected incidentally on careful endoscopic inspection by an astute endoscopist.…”

Clostridium paraputrificum Bacteremia and Ectopic Ileal Varices in Underlying Chronic Portal and Superior Mesenteric Vein Thrombosis: Report of a Rare Case

“…Chronic MVT may be an incidental finding or present with nonspecific abdominal symptoms delaying diagnosis [ 7 ]. Bleeding as a manifestation of chronic superior mesenteric vein thrombosis (SMVT) is a rare phenomenon and it should be considered in the differential diagnosis, when more common causes are excluded [ 8 ].…”