Fallbericht: Massive untere gastrointestinale Blutung aus ilealen Varizen

Abstract

Acute gastrointestinal bleeding in patients with liver cirrhosis is associated with a high mortality. Ileal varices and collaterals from ectopic vessels are extremely rare, encountered in less than 5% of the cirrhotic patients. The diagnosis is frequently delayed because the regular diagnostic methods such as gastroscopy or colonoscopy are unsuccessful in accurate the source of bleeding in the majority of the cases. We report an unusual case of massive and uncontrollable lower intestinal bleeding from ileal varices with right ovarian vein anastomosis in a 56 year-old female patient with liver cirrhosis and previous history of abdominal and pelvic surgery. The accurate angiographic and computed tomography diagnosis allowed fast decompression of the portal venous system using a transjugular intrahepatic portosystemic shunt.

Clinicopathological Features and Treatment of Ectopic Varices with Portal Hypertension

“…Several cases of bleeding jejunal [54–59] and ileal varices have been reported [60–68]. A triad of portal hypertension, hematochezia without hematemesis, and previous abdominal surgery characterizes small intestinal varices [69].…”

“…Surgical approaches such as segmental resection and ligation generally control bleeding from ileal varices successfully [64, 65, 70, 71]. In patients with a poor condition, interventional radiologic treatments, such as insertion of a TIPS for ileal varices, have been performed as a nonsurgical treatment option [3, 66, 68]. Because B-RTO can obliterate not only varices but also the afferent and efferent veins, it is practical for treating ileal varices [72], as described here.…”

Ileal Varices Treated with Balloon-Occluded Retrograde Transvenous Obliteration

“…Whereas esophagogastric varices are the most common complication in patients with portal hypertension, ectopic varices defined by large portosystemic venous collaterals occurring anywhere in gastrointestinal tract except in the esophagogastric region are less common and account for between 1% and 5% of all variceal bleeding [6, 7]. Several cases of bleeding ileal varices have been reported [8-16]. …”

“…In patients with poor condition, interventional radiologic treatment such as insertion of a transjugular intrahepatic portosystemic shunt (TIPS) for ileal varices have been performed as a non-operative treatment option [7, 14, 16]. Although TIPS is a relatively safe and effective means of decompressing the portal pressure, it may not prove effective in patients with severe liver atrophy or complications such as encephalopathy and cerebral embolization.…”

Portosystemic shunt via the superior mesenteric and right ovarian vein leading to small intestine bleeding in alcoholic liver cirrhosis

“…There are different therapeutic option in bleeding ectopic varices, such as balloon occluded retrograde transvenous obliteration,2 transcatheter embolisation or sclerotherapy, with or without portosystemic TIPS 3. Thus, a multidisciplinary approach (intensivists, gastroenterologist, interventional radiologist and surgeons) is needed to define the optimal treatment strategy for patients with ectopic varices.…”