Absent inferior mesenteric vein as a cause of lower gastrointestinal bleeding: The first reported case in the literature

Abstract

a b s t r a c tTo date, absent inferior mesenteric vein (IMV) has not been reported in the literature as a cause of or being associated with lower gastrointestinal (GI) bleeding. We describe a case of 13 year-old girl who presented with hematochezia and was subsequently found to have widespread colonic varices involving the ascending, transverse and proximal descending colon. The upper GI tract, small bowel, and rectum were not involved. Delayed venous phase of mesenteric angiography revealed an absent inferior mesenteric vein. The patient underwent laparoscopic extended right hemicolectomy with ileosigmoid anastomosis. No bleeding from recurrent varices occurred during a 1-year period of follow up. We conclude that extended right hemicolectomy is a potential curative surgical option in patients presenting with lower GI bleeding from colonic varices caused by absent IMV. Upper GI and small intestinal involvement should be excluded to prevent future bleeding from missed varices these sites.Ó 2014 The Authors. Published by Elsevier Inc. All rights reserved. BackgroundLower gastrointestinal (GI) bleeding can be caused my many etiologies in pediatric patients, a fact that makes the diagnosis challenging in this age group. Colonic varices have been described as a causative etiology in many case reports [1e9], none of these reports described the congenital absence of inferior mesenteric vein (IMV) as an underlying cause of these varices. We describe the first case of lower GI bleeding associated with colonic varices secondary to a congenital absence of the inferior mesenteric vein. Case reportA 13 year-old female with no significant past medical history presented to her local emergency department with a five-day history of intermittent rectal bleeding, urgency, and tenesmus which was thought to be gastroenteritis on initial evaluation. She was admitted to our facility after she passed a loose bloody bowel movement followed by a syncopal attack. Her hemoglobin level was 5.9 g/dl (10 g/dl prior to admission). Her initial physical exam was remarkable for minimal left lower quadrant pain. Meckel's diverticulum scan was negative. Esophagogastroduodenoscopy excluded the Upper GI as a potential cause of her bleeding. Subsequent flexible sigmoidoscopy revealed thick, sticky, tenacious, melanotic stool throughout the rectum and sigmoid colon with some fresh blood under the melanotic stool. Computed tomography (CT) scan of the abdomen revealed moderate thickening and edema of the wall of the ascending colon with multiple small prominent vessels in the region of the hepatic flexure. Abdominal ultrasonography with Doppler study excluded portal venous flow obstruction and hypertension.Repeat colonoscopy after bowel preparation identified multiple varices in the ascending colon, hepatic flexure, transverse colon, and splenic flexure [Figs. 1e4], with stigmata of recent hemorrhage in ascending colon and hepatic flexure. The distal and proximal extent of the varices was endoscopically tattooed.In an attempt to identify the cause of co...