Bleeding ileal varices: a rare cause of chronic anemia in liver cirrhosis

Abstract

A 70-year-old man was admitted to our hospital for severe microcytic anemia (Hb 5.9 g/dL, MCV 74 fl). The medical history included hepatic cirrhosis due to previous alcohol abuse with known portal hypertension, hemorrhoids and oesophageal varices. During the prior year, he had been admitted three times to the hospital due to ascites, treated with evacuative paracentesis for his microcytic anemia with low ferritinemia, each time he was transfused with blood and treated for 2 months with oral iron for an improvement in the hemoglobin level and in iron metabolism parameters. Two esophagogastroduodenoscopies (EGDs) and two colonoscopies did not show bleeding lesions, and even faecal occult blood testing was negative on multiple samples.He was on treatment with canrenoate 400 mg/die, furosemide 25 mg/die, and propranolol 80 mg/die. During immediate prior weeks, he reported general malaise, heart palpitations and weakness. He did not report any blood loss with stool, nor hematuria or hematemesis. He was afebrile, and the other vital signs were normal. He was pale, and there was no jaundice. Abdominal ultrasonography (US) showed slight free peritoneal fluid. He was initially transfused with two units of packed red blood cells and an intravenous administration of iron was started. The faecal occult blood test on three samples was negative, a new EGDs showed oesophageal varices without signs of recent bleeding; colonoscopy revealed a normal mucosa with hemorrhoids.In order to study the entire intestine, capsule endoscopy (CE) was performed; it revealed severe hyperemia of jejunoileal mucosa with multiple big blue varices in the ileum, without active bleeding (Fig. 1).Due to the persistence of anemia, and the need for frequent blood transfusion, along with a lack of response to betablockers, a transjugular intrahepatic portosystemic shunt (TIPSS) procedure was performed with no complications. The patient underwent a CE 5 days after showing the disappearance of the multiple varices (Fig. 2); the anemia improved quickly, and no further blood transfusion has been necessary up to the present. DiscussionPortal hypertensive enteropathy (PHE) is present in 5-11% of patients with portal hypertension and chronic active bleeding [1]; the presence of varices and of areas of mucosa with a reticulate pattern should be considered manifestations of portal hypertension in the small bowel. Ectopic varices are an unusual cause of gastrointestinal hemorrage and can account for up to 5% of variceal bleeding; acute bleeding is associated with a high mortality. These varicescan occur at different sites in the gastrointestinal tract, including the duodenum, small bowel, colon and peristomal locations.Endoscopic diagnosis of ileal PHE and ileal varices is impossible to achieve with a standard endoscope, and

Small Intestine Varices in Cirrhosis at a High-Volume Liver Transplant Center: A Retrospective Database Study and Literature Review

“…Our initial search yielded 395 case reports of SIV in patients with cirrhosis, of which 76 (19.2%) reported SIV bleeding and were included for collation and analysis (9–20,21–30,31–40,41–50,51–60,61–78). Mean age was 52.4 years (range 40–68), 32 were women, and 44 were men.…”

Ectopic gastrointestinal variceal bleeding with portal hypertension

“…Surgical resection was performed in 76.1% (16/21) of all patients. Some recent patients underwent interventional radiology (IVR) treatment methods such as transjugular intrahepatic portosystemic shunt (TIPS)[ 8 - 10 ] and balloon-occluded retrograde transvenous obliteration (BRTO)[ 11 , 12 ].…”

A Review on Clinical, Pathophysiological, and Diagnostic Hematological Features in Children With Liver Cirrhosis

“…14 In addition, anemia in cirrhotic children can follow a multivariate etiological approach encompassing gastrointestinal blood loss, hemolysis due to hypersplenism and splenomegaly, disrupted erythropoiesis due to iron or folate deficiencies, and autoimmune destruction of red cells. 7,15,16 Further, macrocytic anemia may be observed in cirrhotic children due to either folate or cyanocobalamin deficiencies in those patients with malnutrition. 6,17,18 Both folate and cyanocobalamin are stored in the liver and require intact enterohepatic cycle and sufficient intestinal absorption in order to take part in hematopoiesis.…”