A 30-year-old man presented to a community emergency department because of intense abdominal discomfort, distention, and diarrhea. His past medical history was notable for a 10-year history of chronic diarrhea, bloating, occasional bloody stool, and no family history of gastrointestinal disease or complications. A computed tomographic (CT) scan of the abdomen revealed a possible partial obstruction in the terminal ileum. The patient was discharged to home with analgesics and instructed to follow up with a gastroenterologist.
Five days later, the patient presented to our office with continued mild to moderate abdominal discomfort and diarrhea. Family history, social history, and physical examination findings were unremarkable. After a review of the CT scan, which showed contrast material and some evidence of bowel wall thickening, an inflammatory process was suspected. Laboratory tests were ordered, and a colonoscopy was scheduled for the next day.
The colonoscopy revealed diffuse erythema and congestion in the terminal ileum and throughout the colon. Markedly dilated, tortuous veins were appreciated throughout the colon (
Figure 1) and rectum. From biopsies obtained throughout the colon, pathologic results revealed dilated thin-walled vessels in the lamina propria with vascular congestion and hemorrhage (
Figure 2) but did not reveal colitis. Because of the finding of varices throughout the colon, portal hypertension or liver disease was suspected.
The CT scan was reviewed again and discussed with the original reading radiologist, and it was determined that there was no sign of liver disease and that mesenteric arteries and veins appeared normal. All results from other laboratory tests, including liver enzyme levels, were also unremarkable.
Two weeks after initial presentation, Doppler ultrasonography was performed and results revealed normal flow in the hepatic and portal veins, as well as in the inferior vena cava. Ultrasonographic image showed diffusely increased echogenicity consistent with diffuse fatty change. A core liver biopsy was ordered to investigate a hepatic etiologic process in the varices.
Six weeks after initial presentation, an upper endoscopy was performed and revealed no esophageal varices or signs of venous congestion.
At 8 weeks from initial presentation, the core liver biopsy was performed and confirmed mild to moderate steatosis but no significant cirrhosis, necrosis, or bridging fibrosis. At the time of the biopsy, hepatic and portal vein pressure measurements were obtained and revealed a mean right atrial pressure of 10 mm Hg, a mean free hepatic vein pressure of 10 mm Hg, and a mean wedged hepatic vein pressure of 11 mm Hg. These measurements yield a hepatic vein pressure gradient of 1 mm Hg (normal, 1-5 mm Hg) and allowed us to rule out hepatic outflow obstruction and portal hypertension.
At the completion of the 8-week visit, the patient had already experienced a moderate improvement of symptoms, with 2 soft bowel movements per day and no associated pain. After an extensive workup, no clear explanation for his colonic varices emerged. We continue to follow up this patient for possible recurrence and monitor for signs of liver disease.