title: Small bowel varices secondary to chronic superior mesenteric vein thrombosis in a patient with heterozygous Factor V Leiden mutation: a case report.
abstract: BACKGROUND
  Bleeding ectopic small bowel varices pose a clinical dilemma for the physician, given their diagnostic obscurity and the lack of evidence-based medicine to guide therapy. They often occur in the context of portal hypertension, secondary to either liver disease or extrahepatic causes. Rarely is their presence associated with chronic superior mesenteric vein thrombosis and hereditary coagulopathies.
  
  
  METHODS
  A 74-year-old white woman, with a heterozygous Factor V Leiden mutation and no underlying liver disease or portal hypertension, presented over the course of 13 months for recurrent episodes of melena and per rectal bleeding. An initial endoscopy showed a clean-based chronic gastric ulcer, while colonoscopies showed multiple, non-bleeding angioectasias which were treated with argon plasma coagulation. Subsequent video capsule endoscopy and double balloon enteroscopy revealed red wale marks overlying engorged submucosal veins in her distal ileum, consistent with ectopic varices. A chronic superior mesenteric vein thrombus, found via computed tomography venogram, was the cause of the ileal varices. She underwent curative surgical resection of the affected bowel, with no re-bleeding episodes 17 months post-surgery, despite needing lifelong anticoagulation for recurrent venous thromboembolisms.
  
  
  CONCLUSIONS
  Clinicians should consider ectopic varices in patients who present with obscure gastrointestinal bleeding, even in the absence of portal hypertension or liver disease. In those with a known thrombophilia, patients should be screened for splanchnic thrombosis, which may precipitate ectopic varices.
authors.affiliation: Sydney Medical School, Westmead Clinical School, University of Sydney, Sydney, NSW, Australia. mgar9863@uni.sydney.edu.au.
authors.forename: Maria C
authors.initials: MC
authors.lastname: Garcia
authors.affiliation: Department of Gastroenterology and Hepatology, University of Sydney at Westmead Hospital, Westmead, NSW, Australia. golo.ahlenstiel@sydney.edu.au.
authors.forename: Golo
authors.initials: G
authors.lastname: Ahlenstiel
authors.affiliation: Department of Anatomical Pathology, Westmead Hospital, Westmead, NSW, Australia. Hema.Mahajan@health.nsw.gov.au.
authors.forename: Hema
authors.initials: H
authors.lastname: Mahajan
authors.affiliation: Department of Gastroenterology and Hepatology, University of Sydney at Westmead Hospital, Westmead, NSW, Australia. david.vanderpoorten@sydney.edu.au.
authors.forename: David
authors.initials: D
authors.lastname: van der Poorten
mesh_terms: D020016:Activated Protein C Resistance / Q000150:complications*; D000368:Aged; D005165:Factor V / Q000235:genetics; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000209:etiology*; D006801:Humans; D007082:Ileum / Q000098:blood supply* / Q000601:surgery; D008642:Mesenteric Veins / Q000473:pathology / Q000601:surgery*; D009154:Mutation; D014057:Tomography, X-Ray Computed; D014648:Varicose Veins / Q000150:complications / Q000175:diagnosis*; D020246:Venous Thrombosis / Q000150:complications / Q000175:diagnosis* / Q000601:surgery
chemical_list: C095381:factor V Leiden; D005165:Factor V