LAUSR

A 38-year-old man presented with intermittent episodes of hematochezia and one episode of syncope, without hematemesis, abdominal pain, weight loss, nausea, or fever. He was found to have thrombocytopenia (75 × 10/L platelets) of unknown cause over the last 6 months. He was pale and jaundiced on examination with palmar erythema and splenomegaly. Initial laboratory studies showed hemoglobin 8.6 g/dL, platelets 54 × 10/L, albumin 25.2 g/L, total bilirubin 43.3 μmol/L, direct bilirubin 15.1 μmol/L, blood urea nitrogen 4.98 mmol/L, hepatitis B surface antigen > 250 IU/mL, prothrombin time 19.7 s, and fibrinogen 1.2 g/L. After fluid resuscitation, acid suppressive therapy and four units of red blood cell transfusion were given. Contrast-enhanced abdominal computed tomography (CT) revealed a cirrhotic liver with tortuous varices around the lower esophagus, stomach, and ascending colon, splenomegaly, and a large amount of ascites (Fig. 1a,b). Thus, he was treated for suspected lower variceal bleeding from hepatitis B-induced liver cirrhosis. Despite octreotide infusion, the patient continued to have hematochezia and further drop in hemoglobin (to 78 g/ L). Colonoscopy was performed 17 h after admission found varices in the ascending colon with one varix showed stigmata of recent bleeding, and colonic cavity contained a large volume of residual blood (Fig. 1c). The rest of the colon was normal. As no endoscopic intervention was given to the ascending colonic varices, the patient continued to bleed and lost approximately 3000 mL over a 72-h period after admission. Transjugular intrahepatic portosystemic shunt (TIPS) was performed with a covered 8-mm stent, demonstrating high portal venous pressure (29.6 mmHg). Angiography via the splenic vein showed an enlarged short gastric vein and gastroesophageal varices. Angiography via the superior mesenteric vein showed that the direction of blood flow through the superior mesenteric vein was reversed away from the liver, and the ascending colonic vein was enlarged and refluent (Fig. 2a,b). Varices of the short gastric vein and ascending colonic veins were treated by coil embolization. The portal pressure reduced to 22 mmHg after the TIPS placement (Fig. 2b), and hematochezia ceased. The patient’s hemoglobin remained stable,and had no sings of hepatic encephalopathy. Both ascites and the varices in the upper and lower gastrointestinal tract disappeared on repeated CT scan (Fig. 2c). The patient did not have any further bleeding, and 3 months after discharge, he underwent liver transplantation without complications or signs of rejection. Variceal bleeding from the colon is a rare cause of lower gastrointestinal bleeding, with an overall prevalence of 0.07%, and the majority locates in either the rectum or cecum. As illustrated in this report, variceal bleeding from the colon can be fatal with a large amount of blood loss. Contrast CT scan is often the imaging modality of choice as it can identify both colonic varices and the underlying liver disease. Although colonoscopy can be considered, the large amount of blood often obscured the view and impaired detection rate to 69%. Furthermore, endoscopic therapy is not very effective and mainly limited the glue injection. TIPS and angiographic embolization, on the other hand, are highly effective in stopping the bleeding as it able to reduce or normalize the portal pressure, which is the key determinant of portal hypertensive bleeding. A meta-analysis written by Zheng et al. has shown that TIPS is superior to endoscopic therapy for the prevention of variceal rebleeding but TIPS may worsen encephalopathy.