A 79-year-old man presented to the emergency department with bleeding from his anterior chest wall. He had a history of cirrhosis secondary to nonalcoholic steatohepatitis and coronary artery bypass grafting complicated by multiple revisions for wound dehiscence and sternal wall infections. Bleeding was refractory to a dermal adhesive applied in a plastic surgery clinic 2 days prior. The findings on physical examination included a ventral hernia with numerous superficial engorged veins (Figure 1). Chest and abdominal computed tomography and transhepatic portal venography demonstrated numerous vascular collaterals, originating from an enlarged portal vein, coursing through the ventral hernia (Figures 2 and 3). A subocclusive portal vein thrombosis was also noted, which likely engendered the ectopic variceal bleed in the setting of increased portal pressures. His hemoglobin was 11.1 g/dL, and he did not require any blood products. The patient underwent transjugular intrahepatic portosystemic shunt with plug-assisted antegrade obliteration of the venous collaterals and was started on oral anticoagulation for his portal vein thrombus. One month later, his examination had improved with a decrease in venous collateral size on interval imaging (Figure 1).
Although most clinically relevant varices involve the esophagus, ectopic varices can manifest at any communication between the portal and systemic venous circulation. Ectopic varices can be consequences of surgical interventions, such as stoma creation in patients with cirrhosis.1 This patient presentation was unusual because he had the appearance of caput medusa on his upper abdomen as opposed to surrounding his umbilicus. More unusual was his presentation of bleeding from these cutaneous varices. To the best of our knowledge, there are no reports of spontaneous bleeding from cutaneous varices such as these. The pathophysiology is similar to bleeding from stomal varices and likely the formation of these venous collaterals formed because of the multiple surgical interventions in his upper abdomen related to the prior wound dehiscence of his sternotomy. In contrast to initial management referring the patient to a surgery clinic, we found that a combination of reducing portal hypertension and direct embolization of the variceal complex similar to the management of other case reports of ectopic varices was the best option.2 This case is an excellent example of the heterogeneity with which ectopic variceal bleeding can present.
Author contributions: M.S.: created the original draft of the manuscript and literature review. B.R.: significant draft revisions and literature review. D.S.: obtained, annotated, and interpreted key images. Z.H.: draft revisions, literature review, and image and clinical interpretations. M. Shwetar is the article guarantor.
Financial disclosure: None to report.
Informed consent was obtained for this case report.
1. Henry Z, Uppal D, Saad W, Caldwell S. Gastric and ectopic varices. Clin Liver Dis. 2014;18(2):371–88.
2. Henry ZH, Caldwell SH. Management of bleeding ectopic varices. Tech Gastrointest Endosc. 2017;101-107:1096–2883.