Introduction

The most frequent underlying cause of portal hypertension is liver cirrhosis, followed by superior mesenteric vein (SMV) thrombosis, splenic vein thrombosis (often secondary to pancreatitis/malignancy), and extrahepatic portal vein obstruction. Some other underlying causes can be pancreatic or gastric malignancy, liver metastasis, congenital hepatic fibrosis, and biliary stricture. Ectopic varices may also develop at sites of adhesions in patients who have undergone prior abdominal surgery [1-3]. In Japan, colonic varices account for approximately 3.5% of all ectopic varices nationwide [4]. Owing to the limited research and frequent underdiagnosis of colonic varices, determining the prevalence of isolated right colonic varices in patients with pancreatic cancer is challenging. Here, we report a case of recently diagnosed pancreatic adenocarcinoma presenting with isolated right colonic varices, along with a literature review of colonic varices associated with pancreatic cancer.

Case

Ethical statements: This study was approved by the Institutional Review Board (IRB) of Keimyung University Dongsan Hospital (IRB No. 2025-03-008). Informed consent was waived with IRB approval.

A 72-year-old man underwent a medical check-up at the clinic. He reported no symptoms and completed the examination without any issues. Physical examination revealed unremarkable vital signs, no pallor in the conjunctiva, no icteric sclera, and a soft, flat abdomen. Laboratory findings were as follows: hemoglobin (Hb) 12.8 g/dL, aspartate aminotransferase (AST)/alanine aminotransferase (ALT) 61/65 IU/L, γ-glutamyl transpeptidase (γ-GTP) 195 IU/L, alkaline phosphatase (ALP) 217 IU/L, total protein 7.6 g/dL, and albumin 4.5 g/dL. A year ago, his laboratory findings were as follows: Hb 14.3 g/dL, AST/ALT 21/17 IU/L, γ-GTP 17 IU/L, ALP 99 IU/L, total protein 7.3 g/dL, and albumin 4.3 g/dL. A significant decrease in hemoglobin and increases in AST/ALT, γ-GTP, and ALP levels were observed. Esophagogastroduodenoscopy showed edematous pangastritis and raised erosive gastritis. Colonoscopy revealed an isolated colonic varix at the hepatic flexure (Fig. 1). The patient also underwent abdominal ultrasound (Fig. 2), which showed no abnormal findings. Owing to questionable laboratory findings, an additional abdominal computed tomography scan was performed, taking into account the combined results of the laboratory tests and colonoscopy. The scan revealed a low-density lesion in the pancreatic head and uncinate process (Fig. 3), with peri-pancreatic infiltrations abutting the distal SMV (Fig. 3). Multiple enlarged intra-abdominal lymph nodes and scanty ascites were identified at pelvic cavity. Endoscopic ultrasound-guided fine-needle biopsy (Fig. 4) confirmed the diagnosis of stage IV pancreatic adenocarcinoma. He was treated with seventh course of FOLFIRINOX for 5 months and expired.

Discussion

Stomach and esophageal varices are common complications of portal hypertension in individuals with advanced liver disease. However, varices in the right colon are very rare among these patients [4,5]. As far as I aware, colonic varices just in five cases associated with pancreatic cancer have been reported [6]. Among these, only one was an incidental finding, while the others presented with symptoms such as melena or hematochezia [7]. Colonic varices are generally managed with supportive treatment if they are not bleeding [8]. But intervention as transileocolic vein obliteration could be considered as management for bleeding colonic varices [4]. In this case, although the patient reported no symptoms, hemoglobin changes were identified, suggesting that cause of anemia might be due to chronic disease of pancreatic cancer. Isolated colonic varices, although rare, can lead to life-threatening gastrointestinal bleeding as a complication of pancreatic cancer. Here, the abdominal ultrasound was unable to detect the pancreatic cancer, highlighting the importance of interpreting routine medical check-up results critically. A multidisciplinary approach to the diagnosis of such cases is recommended, with guidance tailored by local expertise. All the clinicians should remain vigilant for potential gastrointestinal bleeding in similar patients.

Article information

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Funding

None.

Author contributions

All the work was done by Inmo Kang.

Fig. 1.

Endoscopic findings: an isolated colonic varix at the hepatic flexure.

Fig. 2.

Ultrasound sonography of the pancreas.

Fig. 3.

Computed tomography scan of low density lesions in the pancreatic head (blue arrow) and uncinated process and superior mesenteric vein (red arrow).

Fig. 4.

Endoscopic ultrasound-guided fine-needle aspiration.

References

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Figure & Data

References

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