CASE 14410 Published on 09.02.2017

Massive lower gastrointestinal bleeding from caecal varices diagnosed by using CT angiography

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Kristiina Langemets, Pilvi Ilves

Tartu University Hospital, Radiology Clinic, L. Puusepa 1A 50406 Tartu, Estonia Email:kristiina.langemets@gmail.com
Patient

45 years, male

Categories
Area of Interest Abdomen, Colon, Emergency ; Imaging Technique CT, CT-Angiography
Clinical History
A 45-year-old male with a history of cirrhosis, related to chronic alcohol abuse and hepatitis C, presented with massive lower gastrointestinal (GI) bleeding. He had had haematochezia for about two days and was haemodynamically unstable, requiring blood transfusions.
Imaging Findings
An urgent upper endoscopy revealed small subcardial varices without haemorrhage.
Emergency CT showed a distended large bowel filled with high-attenuating fluid, consistent with blood clots. CT-angiography demonstrated large collateral veins surrounding the caecum. In the portal-venous phase, contrast extravasation to the caecum lumen was visible. Additionally CT showed signs of liver cirrhosis (decreased attenuation, irregular contour). Varices in other locations were not seen.
The patient was sent for emergency laparotomy, the findings of which correlated with those of the previous CT-study. Right-sided hemicolectomy and ileostomy were performed. During the surgery the patient had an excessive blood loss of 6500ml and received massive blood transfusions. Postoperatively, the patient had slow recovery and was later transferred to a county hospital in good general condition.
Discussion
Varices in ectopic locations outside the gastro-oesophageal region are a known manifestation of portal hypertension. However, ectopic varices account for only up to 5% of all variceal bleeding episodes and are a very rare cause of lower GI bleeding [1].

Isolated caecal varices without pancolonic varices are extremely rare. Less than 20 cases of caecal varices have been reported. With one exception, all the reported cases have presented with massive lower GI haemorrhage [2-4].

Ectopic varices have been described to develop in the setting of portal hypertension, prior abdominal surgery, abdominal vascular thrombosis or anomalites of the venous outflow vessels [1]. For our patient, the only known risk factor for developing caecal varices was portal hypertension.

Diagnosing bleeding from caecal varices requires exclusion of more frequent causes of GI haemorrhage. Usually, a gastroscopy is performed to exclude active gastroesophageal bleeding as the most common cause of GI haemorrhage for a patient with liver cirrhosis [1]. Colonoscopy is often performed, but it is important to remember that over-insufflation of the colon can cause the collapse of varices, which may lead to under-diagnosis [4].

Unenhanced CT can reveal blood clots in the bowel lumen, with measured attenuation values of 30-45 Hounsfield units (HU), compared to usual attenuation values of intestinal contents of about 0-15 HU.

CT-angiography has been described as a preferred method before colonoscopy in acute haemorrhage [5]. For detecting active bleeding, it is recommended to compare the findings obtained in the arterial and venous phases [6]. CT-angiography may show the hyperattenuating extravasated contrast material in the bowel lumen, that has not been visible on a previous unenhanced CT study [7]. In the present case the bleeding originated from a varicose vein and so extravasation was only seen in the venous phase. CT-angiography also allows evaluation of the gastrointestinal vasculature, including its relationship to the portal vein and to the inferior vena cava. Vascular anatomy may be crucial in selection of the treatment method [7].

There are no specific guidelines for treating bleeding caecal varices. Endoscopic, radiological or surgical interventions have been described. Selection of the treatment method is made on a case-by-case basis taking account of locally available expertise [5].
In conclusion, although caecal varices occur very rarely, the possibility of ectopic variceal bleeding should never be forgotten in the setting of massive GI haemorrhage.
Differential Diagnosis List
Lower gastrointestinal haemorrhage from bleeding caecal varices
peptic disease
diverticular bleeding
angiodysplasia
colonic neoplasm
colitis
Final Diagnosis
Lower gastrointestinal haemorrhage from bleeding caecal varices
Case information
URL: https://www.eurorad.org/case/14410
DOI: 10.1594/EURORAD/CASE.14410
ISSN: 1563-4086