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Endoscopy
Endoscopy
10.1055/s-00000012
Endoscopy
Endoscopy
0013-726X
1438-8812
Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

10.1055/a-2408-9639
E-Videos-2024-03-4869-EV
E-Videos
Never say never: a novel approach to tackle a bleeding ectopic varix
http://orcid.org/0000-0001-5099-163X
Kulkarni Akshay DM
Nair Anup Dr.
Mehta Siddhant Dr.
Bhaware Bhushan Dr.
Mukewar Saurabh
Mukewar Shrikant
1 Gastroenterology, Midas Multi-speciality Hospital, Nagpur, India
Correspondence Akshay Kulkarni, DM Department of Gastroenterology, Midas Multi-speciality HospitalMidas Heights 07, Central Bazaar RoadRamdaspeth, Nagpur, Maharashtra 440010Indiaakshaykulkarni262@gmail.com
19 9 2024
12 2024
1 9 2024
56 Suppl 1 E801E802
The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).
2024
The Author(s).
https://creativecommons.org/licenses/by/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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pmc A 53-year-old woman with decompensated cirrhosis due to nonalcoholic steatohepatitis presented with hematochezia. An upper gastrointestinal endoscopy revealed small varices that were not amenable to endoscopic variceal ligation. A computed tomography (CT) scan with intravenous contrast revealed multiple large collaterals close to the terminal ileum ( Fig. 1Fig. 1 ; Video 1Video 1 ), but with no sign of portal or mesenteric thrombosis. The patient had continuous hematochezia with transfusion-dependent anemia. Colonoscopy revealed a large amount of fresh and altered blood in the terminal ileum ( Fig. 2Fig. 2 ) and the patient continued to have persistent bleeding, requiring transfusions and vasopressors. Angiography revealed no evidence of arterial bleeding ( Fig. 3Fig. 3 ); portal vein access with venogram was avoided owing to her ascites and thrombocytopenia. The patient’s relatives declined surgery on her behalf owing to the possibility of further decompensation, and therefore rectal endoscopic ultrasound (EUS) was planned.

Fig. 1 Fig. 1 Contrast-enhanced computed tomography image showing a large group of collaterals in close proximity to the terminal ileum.

Fig. 2 Fig. 2 Colonoscopic images showing fresh blood in the: a colon; b terminal ileum, suggesting a small-bowel bleed.

Fig. 3 Fig. 3 Digital subtraction angiography image showing no evidence of arterial bleeding, with direct portal vein puncture or cannulation via a transjugular intrahepatic portosystemic shunt avoided owing to the patient’s thrombocytopenia.

Ileal varices are seen on contrast-enhanced computed tomography and rectal endoscopic ultrasound (EUS), which also showed significant ascites. After paracentesis had been performed, coil insertion and glue injection were performed under EUS guidance, with subsequent Doppler examination showing obliteration of the varices.

Video 1

Video 1

The rectal EUS ( Fig. 4Fig. 4 ) was performed with the ME-3 scope (Olympus, Japan). It showed significant ascites and large juxta-ileal varices. After paracentesis had been performed, the EUS was repeated and a 19G needle (Boston Scientific, USA) was passed into the varices. After saline had been injected, a 15-mm metal coil (Nester; Cook Medical, USA) was passed into the varix, followed by 3 mL of glue (Endocryl, India) and a saline flush. Doppler ultrasound showed obliteration of the flow in the varix. The patient recovered uneventfully and was discharged in a stable condition.

Fig. 4 Fig. 4 Rectal endoscopic ultrasound image showing significant ascites with ileal varices floating in the fluid.

Ileal varices have been documented in a considerable proportion of cirrhotic patients and bleeding from these varices is not rare 11 . Such bleeding has previously been managed either with multiple radiologic interventions 22 33 or with surgical resection and anastomosis 44 . To the best of our knowledge, this is the first case describing transrectal EUS-guided coiling of ileal ectopic varices. This procedure may be safe, feasible, and effective in selected cases, where the anatomy allows direct transmural access to the collaterals without the presence of intervening structures.

Endoscopy_UCTN_Code_TTT_1AS_2AG

Endoscopy E-Videos https://eref.thieme.de/e-videos

E-Videos is an open access online section of the journal Endoscopy , reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high-quality video and are published with a Creative Commons CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission process. We grant 100% waivers to articles whose corresponding authors are based in Group A countries and 50% waivers to those who are based in Group B countries as classified by Research4Life (see: https://www.research4life.org/access/eligibility/ ). This section has its own submission website at https://mc.manuscriptcentral.com/e-videos .

Conflict of Interest The authors declare that they have no conflict of interest.
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References

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