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Small bowel varices secondary to chronic superior mesenteric vein thrombosis in a patient with heterozygous Factor V Leiden mutation: a case report.

Garcia MC, Ahlenstiel G, Mahajan H, van der Poorten D - J Med Case Rep (2015)

Bottom Line: Rarely is their presence associated with chronic superior mesenteric vein thrombosis and hereditary coagulopathies.A chronic superior mesenteric vein thrombus, found via computed tomography venogram, was the cause of the ileal varices.In those with a known thrombophilia, patients should be screened for splanchnic thrombosis, which may precipitate ectopic varices.

View Article: PubMed Central - PubMed

Affiliation: Sydney Medical School, Westmead Clinical School, University of Sydney, Sydney, NSW, Australia. mgar9863@uni.sydney.edu.au.

ABSTRACT

Introduction: Bleeding ectopic small bowel varices pose a clinical dilemma for the physician, given their diagnostic obscurity and the lack of evidence-based medicine to guide therapy. They often occur in the context of portal hypertension, secondary to either liver disease or extrahepatic causes. Rarely is their presence associated with chronic superior mesenteric vein thrombosis and hereditary coagulopathies.

Case presentation: A 74-year-old white woman, with a heterozygous Factor V Leiden mutation and no underlying liver disease or portal hypertension, presented over the course of 13 months for recurrent episodes of melena and per rectal bleeding. An initial endoscopy showed a clean-based chronic gastric ulcer, while colonoscopies showed multiple, non-bleeding angioectasias which were treated with argon plasma coagulation. Subsequent video capsule endoscopy and double balloon enteroscopy revealed red wale marks overlying engorged submucosal veins in her distal ileum, consistent with ectopic varices. A chronic superior mesenteric vein thrombus, found via computed tomography venogram, was the cause of the ileal varices. She underwent curative surgical resection of the affected bowel, with no re-bleeding episodes 17 months post-surgery, despite needing lifelong anticoagulation for recurrent venous thromboembolisms.

Conclusions: Clinicians should consider ectopic varices in patients who present with obscure gastrointestinal bleeding, even in the absence of portal hypertension or liver disease. In those with a known thrombophilia, patients should be screened for splanchnic thrombosis, which may precipitate ectopic varices.

No MeSH data available.


Related in: MedlinePlus

Video capsule endoscopy showing (a) prominent submucosal vessels in the distal ileum and (b) red wale markings in the distal ileum
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Fig1: Video capsule endoscopy showing (a) prominent submucosal vessels in the distal ileum and (b) red wale markings in the distal ileum

Mentions: Despite repeat gastroscopy showing resolution of her gastric ulcer, over the next 9 months she represented four times for symptomatic melena and per rectal bleeding, which required at least one unit of packed red blood cells for three of her presentations (Hb <70g/L). Repeat colonoscopies showed multiple, non-bleeding angioectasias which were treated with argon plasma coagulation. Subsequently, rapid active bleeding was demonstrated in her distal ileum with a technetium-99m red blood cell scan, which was concordant with subsequent findings of engorged submucosal veins with red wale marks on capsule endoscopy (Figs. 1a and 1b) and double balloon enteroscopy.Fig. 1


Small bowel varices secondary to chronic superior mesenteric vein thrombosis in a patient with heterozygous Factor V Leiden mutation: a case report.

Garcia MC, Ahlenstiel G, Mahajan H, van der Poorten D - J Med Case Rep (2015)

Video capsule endoscopy showing (a) prominent submucosal vessels in the distal ileum and (b) red wale markings in the distal ileum
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4589920&req=5

Fig1: Video capsule endoscopy showing (a) prominent submucosal vessels in the distal ileum and (b) red wale markings in the distal ileum
Mentions: Despite repeat gastroscopy showing resolution of her gastric ulcer, over the next 9 months she represented four times for symptomatic melena and per rectal bleeding, which required at least one unit of packed red blood cells for three of her presentations (Hb <70g/L). Repeat colonoscopies showed multiple, non-bleeding angioectasias which were treated with argon plasma coagulation. Subsequently, rapid active bleeding was demonstrated in her distal ileum with a technetium-99m red blood cell scan, which was concordant with subsequent findings of engorged submucosal veins with red wale marks on capsule endoscopy (Figs. 1a and 1b) and double balloon enteroscopy.Fig. 1

Bottom Line: Rarely is their presence associated with chronic superior mesenteric vein thrombosis and hereditary coagulopathies.A chronic superior mesenteric vein thrombus, found via computed tomography venogram, was the cause of the ileal varices.In those with a known thrombophilia, patients should be screened for splanchnic thrombosis, which may precipitate ectopic varices.

View Article: PubMed Central - PubMed

Affiliation: Sydney Medical School, Westmead Clinical School, University of Sydney, Sydney, NSW, Australia. mgar9863@uni.sydney.edu.au.

ABSTRACT

Introduction: Bleeding ectopic small bowel varices pose a clinical dilemma for the physician, given their diagnostic obscurity and the lack of evidence-based medicine to guide therapy. They often occur in the context of portal hypertension, secondary to either liver disease or extrahepatic causes. Rarely is their presence associated with chronic superior mesenteric vein thrombosis and hereditary coagulopathies.

Case presentation: A 74-year-old white woman, with a heterozygous Factor V Leiden mutation and no underlying liver disease or portal hypertension, presented over the course of 13 months for recurrent episodes of melena and per rectal bleeding. An initial endoscopy showed a clean-based chronic gastric ulcer, while colonoscopies showed multiple, non-bleeding angioectasias which were treated with argon plasma coagulation. Subsequent video capsule endoscopy and double balloon enteroscopy revealed red wale marks overlying engorged submucosal veins in her distal ileum, consistent with ectopic varices. A chronic superior mesenteric vein thrombus, found via computed tomography venogram, was the cause of the ileal varices. She underwent curative surgical resection of the affected bowel, with no re-bleeding episodes 17 months post-surgery, despite needing lifelong anticoagulation for recurrent venous thromboembolisms.

Conclusions: Clinicians should consider ectopic varices in patients who present with obscure gastrointestinal bleeding, even in the absence of portal hypertension or liver disease. In those with a known thrombophilia, patients should be screened for splanchnic thrombosis, which may precipitate ectopic varices.

No MeSH data available.


Related in: MedlinePlus