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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

a Abnormal tortuous vessels (arrows) in submucosa, extending into muscularis propria (hematoxylin-eosin, ×2); and b tortuous vessel (arrow) extending into muscularis propria (hematoxylin-eosin, ×4)
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Fig2: a Abnormal tortuous vessels (arrows) in submucosa, extending into muscularis propria (hematoxylin-eosin, ×2); and b tortuous vessel (arrow) extending into muscularis propria (hematoxylin-eosin, ×4)

Mentions: Further investigation with a computed tomography (CT) venogram showed obscuration of her superior mesenteric vein (SMV) with surrounding collaterals, suggestive of chronic thrombosis. A surgical opinion was sought regarding therapeutic options, and the patient underwent an elective small bowel resection of 15cm of the distal ileum. At operation, marked varices were noted on her bowel wall, as well as thickened mesentery, which was consistent with SMV thrombosis. Histopathological findings were in keeping with a vascular lesion, as tortuous and collapsed venules and veins were present within the submucosa and muscularis propria (Figs. 2a and 2b).Fig. 2


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)

a Abnormal tortuous vessels (arrows) in submucosa, extending into muscularis propria (hematoxylin-eosin, ×2); and b tortuous vessel (arrow) extending into muscularis propria (hematoxylin-eosin, ×4)
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

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

Fig2: a Abnormal tortuous vessels (arrows) in submucosa, extending into muscularis propria (hematoxylin-eosin, ×2); and b tortuous vessel (arrow) extending into muscularis propria (hematoxylin-eosin, ×4)
Mentions: Further investigation with a computed tomography (CT) venogram showed obscuration of her superior mesenteric vein (SMV) with surrounding collaterals, suggestive of chronic thrombosis. A surgical opinion was sought regarding therapeutic options, and the patient underwent an elective small bowel resection of 15cm of the distal ileum. At operation, marked varices were noted on her bowel wall, as well as thickened mesentery, which was consistent with SMV thrombosis. Histopathological findings were in keeping with a vascular lesion, as tortuous and collapsed venules and veins were present within the submucosa and muscularis propria (Figs. 2a and 2b).Fig. 2

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