Trans-anastomotic porto-portal varices in patients with gastrointestinal haemorrhage

AIM: Porto-portal varices are commonly seen in patients with segmental extr a-hepatic portal hypertension and develop to provide a collateral circulati on around an area of portal venous obstruction. It is not well recognized t hat such communications may also develop across surgical anastomoses and be the source of gastrointestinal haemorrhage. The possible mode of developme nt of such communications has not been previously discussed. MATERIALS AND METHODS: Over a 3-year period between 1995 and 1998, porto-po rtal varices were demonstrated across surgical anastomoses in four patients who were referred for the investigation of acute (two), acute-on-chronic ( one) and chronic gastrointestinal bleeding (one). Their medical notes and t he findings at angiography were reviewed. RESULTS: Three patients had segmental portal hypertension due to extra-hepa tic portal vein (one) or superior mesenteric vein (two) stenosis/occlusion, One patient had mild portal hypertension due to hepatic fibrosis secondary to congenital biliary atresia. At angiography all patients were shown to h ave varices crossing previous surgical anastomoses. These varices were pres umed to be the cause of bleeding in three of the four patients; the site of bleeding in the fourth individual was not determined. CONCLUSIONS: Trans-anastomotic porto-portal varices are rare. They develop in the presence of extra-hepatic portal hypertension and presumably arise w ithin peri-anastomotic inflammatory tissue. Such varices may be difficult t o manage and their prognosis is poor when bleeding occurs. (C) 2000 The Roy al College of Radiologists.