Correspondence

Vesical Varices in a Patient with Portal Hypertension

N Engl J Med 2001; 345:1503-1504November 15, 2001

Article

To the Editor:

Portal hypertension is a frequent consequence of cirrhosis and may lead to dilated venous collaterals. Usually, varices due to portal hypertension develop in the lower esophagus, stomach, or rectum and rarely in other parts of the digestive tract.1 Extraintestinal ectopic varices are very rare. We recently treated a patient with cirrhosis who had gross hematuria from vesical varices.

A 54-year-old woman with ongoing alcohol abuse had a sudden onset of profuse gross hematuria. She had a history of alcoholic liver cirrhosis, complicated by decompensated ascites and ruptures of esophageal varices, and chronic pancreatitis. She had undergone sclerotherapy and band ligation for the management of varices. Her history was also notable for cholecystectomy, radical left nephrectomy for renal-cell carcinoma, and hysterectomy. Her hematuria had stopped by the time she was admitted.

Abdominal ultrasonography showed multiple nonechogenic nodes in the superior and posterior wall of the bladder. Cystoscopy demonstrated large vesical varices (Figure 1Figure 1Cystoscopic Findings Demonstrating Varices on the Posterior Wall of the Bladder.). Selective angiography of the superior mesenteric artery revealed venous dilatations at the root of the mesentery, in the ileal and colonic region, which drained to large vesical varices and then to the right internal and external iliac veins. The patient was treated with propranolol, which is used to treat patients with cirrhosis and variceal hemorrhage. There was no recurrence of hematuria during one year of follow-up.

Vesical varices secondary to portal hypertension are rare, since the bladder wall is an unusual collateral route for the venous splanchnic blood. Vesical varices may appear when the usual splanchnic-bed collaterals cannot develop,2 thus allowing venous blood to flow through the venous system of the bladder. Since our patient had a history of sclerotherapy, band ligation, and abdominal surgery, her usual venous collaterals may have been interrupted.

Yves Gaspar, M.D.
Olivier Detry, M.D.
Jean de Leval, M.D., Ph.D.
University of Liege, B4000 Liege, Belgium
oli.detry@chu.ulg.ac.be

2 References

1. 1

   Norton ID, Andrews JC, Kamath PS. Management of ectopic varices. Hepatology 1998;28:1154-1158
   CrossRef | Web of Science | Medline

2. 2

   Sano K, Shuin T, Takebayashi S, et al. A case of vesical varices as a complication of portal hypertension and manifested gross hematuria. J Urol 1989;141:369-371
   Web of Science | Medline

Citing Articles (10)

Citing Articles

1. 1

   Ying Hou, YanSheng Xue, Yi Yang, Rong Guo Sun. (2011) Vesical Varices Causing Gross Hematuria in a Four-year-old Girl. Urology
   CrossRef

2. 2

   Shanthi Sivendran, Harold Harvey, Allan Lipton, Joseph Drabick. (2011) Treatment of Langerhans cell histiocytosis bone lesions with zoledronic acid: a case series. International Journal of Hematology 93:6, 782-786
   CrossRef

3. 3

   Athanasios D. Anastasilakis, Gregory A. Kaltsas, Georgios Delimpasis, Ludwig Wilkens, George Kanakis, Polyzois Makras. (2011) Distinctive growth pattern in a patient with a delayed diagnosis of Langerhans’ cell histiocytosis. Pituitary
   CrossRef

4. 4

   Takahiro Sato, Jun Akaike, Jouji Toyota, Yoshiyasu Karino, Takumi Ohmura. (2011) Clinicopathological Features and Treatment of Ectopic Varices with Portal Hypertension. International Journal of Hepatology 2011, 1-9
   CrossRef

5. 5

   Takahiro Sato. (2010) Transabdominal color Doppler ultrasonography for the diagnosis of small intestinal and vesical varices in a patient successfully treated with percutaneous transhepatic obliteration. Clinical Journal of Gastroenterology 3:4, 214-218
   CrossRef

6. 6

   Somashekar Krishna, James Rose, Kedar Jambhekar, Kevin Olden, Farshad Aduli. (2009) Cirrhosis of Liver and an Unusual Ectopic Site of Portosystemic Shunt: Left Adnexal Venous Varix Presenting With Hematuria. The American Journal of Gastroenterology 104:9, 2365-2366
   CrossRef

7. 7

   Ranjit Kaur, Basri Johan Jeet Abdullah, Norman Dublin. (2009) Vesical varices in neobladder secondary to portal hypertension. European Journal of Radiology Extra 69:1, e25-e27
   CrossRef

8. 8

   Uta Herden, Christian A. Seiler, Daniel Candinas, Stefan W. Schmid. (2008) Bladder tamponade due to vesical varices during orthotopic liver transplantation. Transplant International???-???
   CrossRef

9. 9

   Sandra L. Hallamore, Richard J. Grills, Greg Neerhut, Nathan Lawrentschuk. (2007) Submucosal vesical varicosities causing hematuria and retention of urine in pregnancy: cystovarix. American Journal of Obstetrics and Gynecology 196:5, e29-e30
   CrossRef

10. 10

    GREG VAN STIEGMANN. (2004) Diagnosis and management of ectopic varices. Journal of Gastroenterology and Hepatology 19:s7, S168-S173
    CrossRef