Ascending Colon Variceal Bleeding in Cirrhotic Patient with Emergent Endoscopic Variceal Obturation with N-butyl-2-cyanoacrylate

Chang Lae Kim; Taehong Kim; Won Hyuk Lee; Joo Wan Seo; Seung Ha Park; Joon Hyuk Choi; Nae-Yun Heo

doi:10.4166/kjg.2018.72.1.37

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Kim, Kim, Lee, Seo, Park, Choi, and Heo: Ascending Colon Variceal Bleeding in Cirrhotic Patient with Emergent Endoscopic Variceal Obturation with N-butyl-2-cyanoacrylate

Case Report

Korean J Gastroenterol 2018;72(1):37-41.

Published online: 4 October 2018

DOI: https://doi.org/10.4166/kjg.2018.72.1.37

Ascending Colon Variceal Bleeding in Cirrhotic Patient with Emergent Endoscopic Variceal Obturation with N-butyl-2-cyanoacrylate

Chang Lae Kim, Taehong Kim, Won Hyuk Lee, Joo Wan Seo, Seung Ha Park, Joon Hyuk Choi, Nae-Yun Heo

Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea

Correspondence to: Nae-Yun Heo, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, 875 Haeun-daero, Haeundae-gu, Busan 48108, Korea. Tel: +82-51-797-0661, Fax: +82-51-797-0941, E-mail: nyheo@hanmail.net

Received 28 February 2018 Revised 17 April 2018 Accepted 17 April 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Ectopic varices are rare among patients with portal hypertension, especially in the ascending colon. It is difficult to evaluate massive lower gastrointestinal bleeding in patients with liver cirrhosis by colonoscopy due to hemodynamic instability and poor bowel preparation. In Korea, there has only been one case report about ascending colon variceal bleeding, in which hemostasis was performed by venous coil embolization. We report another rare case of ascending colon variceal bleeding in a patient with alcoholic cirrhosis, who was successfully treated via two sessions of N-butyl-2-cyanoacrylate injection through colonoscopy. This case suggests that the careful endoscopic approach and hemostasis with glue injection might be an option for treating massive bleeding in the lower gastrointestinal varix.

Keywords: Colon, ascending, Colonoscopy, Cyanoacrylates, Liver cirrhosis, Varix

References

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Fig. 1.

At proximal ascending colon, there was dilated vascular structure with shallow erosion (A). The endoscopic variceal obturation with N-butyl-2-acyanoacrylate was performed through colonoscopy (B).

Fig. 2.

Second session of endoscopic variceal obturation was done targeting the remnant dilated varix one week after 1st session (A). After 2nd injection, bloated varix with sclerosant was noted (B).

Fig. 3.

Simple abdomen after 2nd endoscopic variceal obturation (white arrow: lipiodol in the ascending colon varix).

Fig. 4.

A radiopague lipiodol attenuation with N-butyl-2-cyanoacrylate in the ascending varix was shown after hemostatic procedure (white arrow). The liver shows surface nodularity and blunting edge.

Table 1.

Previously Reported Colon Varices Presenting Lower Gastrointestinal Bleeding except Rectal Variceal Bleeding in Patients with Portal Hypertension since 2000

Author (year)	Age/gender	Cause	Location	Treatment
Chevallier et al. (2000)⁵	44/F	Alcoholic LC	Ascending colon	EVO, then rebleeding
				TIPS and embolization
Chen et al. (2000)⁶	64/M	HBV LC	Sigmoid colon	EVO, then rebleeding
Bernard et al. (2001)¹¹	40/M	HCV LC	Transverse colon	EIS with epinephrine and
				morrhuate, then rebleeding
Vangeli et al. (2004)⁷	37/F	Alcoholic LC	Cecum	TIPS & embolization
Vangeli et al. (2004)⁷	19/M	Autoimmune hepatitis	Non-specified colon	TIPS & embolization
Wiegand et al. (2006)⁸	43/M	Alcoholic LC	Ascending colon	TIPS, then rebleeding
				EVO & embolization
Anan et al. (2006)¹²	62/F	HCV LC	Splenic flexure	BRTO
Misra and Dwivedi (2006)⁴	32/M	HBV LC	Descending colon	EVL
Kim et al. (2008)¹⁰	43/M	Alcoholic LC	Ascending colon	Right hemicolectomy
Sato et al. (2008)¹³	75/F	HCV LC	Transverse colon	EIS with ethanolamine oleate
Watanabe et al. (2010)³	−	−^a	Non-specified	BRTO
Watanabe et al. (2010)³	−	−^a	Non-specified	PTO
Sohn et al. (2012)¹⁴	33/F	IVC occlusion by APS	Ascending colon	Octreotide and β-blocker
Jha et al. (2012)¹⁵	59/M	Alcoholic liver disease	Sigmoid colon	EVO
Ko et al. (2013)¹	38/F	Alcoholic LC	Ascending colon	Venous embolization
Christian et al. (2015)⁹	54/M	Alcoholic liver disease	Ascending colon	TIPS and embolization
Sousa et al. (2016)¹⁶	50/F	Alcoholic LC	Ascending colon	EVO
Rawal (2016)¹⁷	42/M	Alcoholic liver disease	Cecum	EVO
Zhou et al. (2017)¹⁸	38/M	HBV LC	Ascending colon	TIPS
Jindal and Philips (2017)¹⁹	58/M	LC	Sigmoid colon	Conservative therapy

F, female; LC, liver cirrhosis; EVO, endoscopic variceal obturation by N-butyl-2-cyanoacrylate; TIPS, transjugular intrahepatic portosystemic shunt; M, male; HBV, hepatitis B virus; HCV, hepatitis C virus; EIS, endoscopic injection sclerotharpy; BRTO, balloon-occluded retrograde transvenous obliteration; EVL, endoscopic variceal ligation; PTO, percutaneous transhepatic obliteration; IVC, inferior vena cava; APS, antiphospholipid syndrome.

^a Eighty percents among the mentioned ectopic varices was liver cirrhosis. There was no specific data for colon variceal bleeding.

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