Multifocal gastrointestinal varices: a rare manifestation of immunoglobulin G4-related disease
Multifocal gastrointestinal varices are uncommon and often associated with liver cirrhosis. They consist of varices at the gastroesophageal region and the other sites (i.e. ectopic varices) simultaneously. The etiology includes venous system anomalies or thrombosis (congenital or acquired), vascular injury (iatrogenic or traumatic), or portal hypertension (either intrahepatic or extrahepatic). The clinical manifestations vary from asymptomatic lesions to life-threatening variceal hemorrhage. The identification of bleeding foci, as well as the etiology of varices, can be challenging. The treatment necessitates a multidisciplinary approach. Here, we report a case with multifocal gastrointestinal varices involving the stomach, duodenum, and transverse colon. The patient presented with intermittent melena and has no history of liver or heart disease. Serial endoscopic examinations confirmed the multiple sites of the gastrointestinal varices. Abdominal computed tomography demonstrated that the liver parenchyma is normal, and the hepatic veins, intrahepatic portal system, as well as vena cava, are all unobstructed. Nevertheless, it revealed typical features of autoimmune pancreatitis, retroperitoneal fibrosis, and compromised splenic and superior mesenteric veins. After the pancreatic tissue sampling, we eventually confirmed the etiology as immunoglobulin G4-related disease. In addition to steroid treatment for immunoglobulin G4-related disease, we successfully treated variceal bleeding with band ligation and prevented rebleeding with propranolol. He had been convalescing and has received periodic follow-up in our outpatient clinic for more than 12 months uneventfully.