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Imaging findings before variceal rupture. (a-c) Contrast-enhanced computed tomography scan of the abdomen: (a) 6 months after surgery, (b) 1 year after surgery, and (c) 11 years after surgery (January 2022). With the development of collateral vessels, vasodilatation around the ascending colon and vascular structures on the mucosal surface were apparent (yellow arrowhead). (d) Colonoscopy revealed F3-equivalent tortuous varices, but no red color signs.
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After surgery, contrast-enhanced computed tomography (CE-CT) revealed venous dilatation in the ascending colon, which gradually increased (Figure 1a-c). When colonoscopy was performed in March 2022 to check for chronic diarrhea, ectopic varices equivalent to F3 were found on the distal side of the ascending colon, but there were no bleeding and red color signs (Figure 1d).
Abdominal contrast-enhanced computed tomography at the time of variceal rupture. (a) Axial section: Although fluid collection and varices were present in the ascending colon, no leakage of contrast medium was seen at the varices (yellow arrowhead). (b) Coronal section: Large mosaic-like fluid collection was seen on the left side of the colon, including the distal colon (red arrowhead). (c) 3D vascular image: The middle colonic vein as well as the inferior vein are connected to the resected splenic vein (yellow round circle). Dilated veins were seen in the route, the middle colonic vein (yellow arrowhead) varices (red arrowhead) the ileocecal vein (white arrowhead). (d) Schema of vascular anatomy (created with BioRender.com): For an anatomic anomaly of the middle colonic vein, originally should return to the superior mesenteric vein (blue dotted line), leading to the splenic vein (red dotted line), blood flow from the inferior mesenteric vein back to the splenic vein was flowing into the middle colonic vein and forming varices. PV, portal vein; SV, splenic vein; SMV, superior mesenteric vein; IMV, inferior mesenteric vein; LCV, left colic vein; MCV, middle colic vein; ICV, ileocolic vein; SGV, short gastric vein.
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CE-CT showed a mosaic-like fluid accumulation from the ascending colon to the rectum (Figure 2a,b). But a shunt was formed following splenic vein resection as shown in the figure, the feeding vein of varices was the middle colonic vein, and the draining vein was the ileocolic vein (Figure 2c,d).
Imaging findings during endoscopic treatment. (a-c) Emergency colonoscopy. (a) Fibrin plug in the erosion was observed at the anorectal end of the varices (black arrowhead). (b) After puncturing the same site, injecting 2 ml of N-butyl-2-cyanoacrylate (NBCA), and removing the needle, active bleeding occurred from the puncture site (black arrowhead). (c) After injecting another 1.6 ml of NBCA, the bleeding stopped. (d) Simple computed tomography (3D image) after treatment: the contrast medium was retained in the varix area, and no leakage into other vessels was observed.
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Tokyo, Japan) was used, without a tip cap. The emergency colonoscopy showed large amounts of fresh blood in the colon and a visible fibrin plug with blood oozing at the top of varix in the ascending colon, which was indicative of colonic varix with recent bleeding (Figure 3a). 75% NBCA was injected into varix with a 20-g needle (Endoscopic Puncture Needle; TOP, Tokyo, Japan), resulting in the initial active spurting bleeding from the sites of the fibrin plug and injection (Figure 3b), which resolved after additional injection (Figure 3c). Subsequent simple CT confirmed that the contrast media remained in the same site (Figure 3d).