Ryan Kahl1, Kruti Patel2, Khalid George3, Michael Piper3. 1. Department of Internal Medicine, St. John Macomb-Oakland Hospital, Warren, MI. 2. Department of Internal Medicine, Doctors Hospital, Columbus, OH. 3. Department of Gastroenterology, St. John Providence Hospital and Medical Center, Southfield, MI.
A 76-year-old man with a past medical history of hypertension and hypothyroidism was referred by his primary care physician due to recurrent, bright red, lower gastrointestinal bleeding without anemia. The patient denied family history of colon cancer, and he did not have a history of cirrhosis, portal hypertension, colon malignancy, or congestive heart failure.Colonoscopy was significant for diverticulosis, the presence of small nonbleeding colonic angioectasia, and a nonspecific mucosa vascular pattern in the rectosigmoid, transverse, and ascending colon consistent with varicosities (Figure 1). Biopsy revealed moderate congestion and inflammation without signs of angiodysplasia or colitis. Esophagogastroduodenoscopy did not reveal esophageal varices, gastric varices, portal hypertensive gastropathy, or congestion. Laboratory evaluation showed no anemia or abnormalities consistent with cirrhosis. Computed tomographic angiography of the abdomen and pelvis revealed an 0.8-cm distal splenic artery aneurysm. No signs of portal hypertension, fibrosis, cirrhosis, necrosis, or mesenteric artery or venous thrombosis were noted. Liver biopsy and hepatic vein pressure were not obtained due to low suspicion of liver involvement from history, imaging, and laboratory values.
Figure 1
Colonoscopy showing a nonspecific mucosa vascular pattern in the descending colon consistent with varicosities.
Colonoscopy showing a nonspecific mucosa vascular pattern in the descending colon consistent with varicosities.In the presence of advanced liver disease, colonic varices can be detected in up to 31% of patients.1 However, idiopathic colonic varices are extremely rare, with less than 40 cases to our knowledge being reported in the literature to date. Idiopathic varices can occur throughout the colon and can present as stable recurrent lower gastrointestinal bleeding or massive hemorrhage. Instances of vascular malformation and a familial component have been described in the literature.2 Currently, no guidelines exist for monitoring colonic varices or screening for varices in family members. There is no known association with development of malignancy reported in the literature.2 In patients with massive hemorrhage or refractory bleeding, surgical colectomy may be considered. In our patient, a conservative approach with annual endoscopic monitoring was deemed appropriate.
Disclosures
Author contributions: All authors contributed equally to the preparation of the manuscript. R. Kahl is the article guarantor.Financial disclosure: None to report.Informed consent was obtained for this case report.
Figure 1