Abstract
Vallecular varix can be a rare, potentially life-threatening source for Upper Gastrointestinal Bleeding. It is often a diagnostic dilemma and can present as persistent Hematemesis, Haemoptysis, or Malena. We describe a case of Vallecular varix, highlighting the presentation, diagnosis, management, along with the post-operative follow-up.
Keywords: Vallecular varix, Upper gastrointestinal bleeding, Hematemesis, Dieulefoy lesion
Introduction
Haemoptysis, Hematemesis, and Post-nasal bleeding can be confounding complaints. By itself, bleeding from the mouth can be a very distressing presentation and can arise from a source in the nasal cavity, nasopharynx, oral cavity, oropharynx, upper airway, oesophagus, stomach. Distinguishing between them can cause some amount of diagnostic difficulty. The vallecula is one such area from where bleeding can originate and be considerably difficult to identify on routine evaluation [1]. Hence an uncommon cause such as the vallecular varix is often missed due to a lack of its awareness. We here present one such case where it can be seen how missing such a diagnosis can cause significant morbidity.
Case History
A 27-year-old male presented to the emergency department of the district hospital with a presenting complaint of bloody vomitus of which he had 8 episodes over 3 days. The vomitus was a mixture of fresh blood, clots and food particles. This was of sudden onset, varying from a few drops to about a cup in amount with no prior history of the same. While there he vomited approximately 750 ml of blood. He was then referred to the tertiary care center after being admitted overnight in the district hoospital. He had no other significant complaints. He had a history of consuming alcohol for the past 3 years (3–9 units per week) and had his last drink 10 days ago. There were no other co-morbid conditions, prior admissions, or surgeries.
Upon evaluation, he had tachycardia and pallor but his vitals were otherwise stable. Per abdomen examination was unremarkable and Per rectal examination showed no melena. Nasogastric tube aspirates showed coffee grounds. For further evaluation, he was admitted under the Department of General Surgery. Blood investigation showed his Haemoglobin (Hb) to be 6 and Liver functions were normal. There was no occult blood in stools. He received 2 units of packed cells after which his Hb rose to 8.6. He underwent Flexible Upper Gastrointestinal endoscopy, which was unremarkable. He also underwent a CT(Computed tomography) angiography which showed no leak of contrast. Due to persistent bleeding, and no evident cause it was decided that an exploratory laparotomy be performed. He was found to have an ectatic lesion that was suspected to be a Dieulefoy anomaly in the stomach but could not be confirmed. Underrunning of this was done. Despite this, the patient had blood in vomitus and his Hb began to drop again. In view of this, an ENT consultation was sought to rule out any source of bleeding from the upper aerodigestive tract.
Indirect Laryngoscopic examination and subsequently laryngeal telescopy demonstrated a varix-like lesion in the left vallecula close to the base of the tongue (see Fig. 1). Active bleeding, while the procedure was being performed, reaffirmed that this could be the probable cause of the bleeding and it was decided to cauterize the lesion. The patient underwent direct laryngoscopy and electrocautery of the varix under general anaesthesia with orotracheal intubation. Postoperatively he received ceftriaxone, analgesics(low-dose opioids), cold saline and betadine gargles, cold antacid, and a Proton pump inhibitor(Pantoprazole). Subsequently, there were no further episodes of bleeding and the patient was discharged on post-op day 7. He followed up at post-op day 14(see Fig. 2) and subsequently one month later showed good mucosal healing and no recurrence of the varix or his bleeding complaint.
Fig. 1.
Bleeding Vallecular varix noted in left vallecula
Fig. 2.
Post op day 14 of direct laryngoscopy and cautery
Discussion
Bleeding from the mouth can be a very dramatic and perplexing problem. This is because the source could be anywhere from the upper aerodigestive tract, down to the gastroesophageal junction thereby making it a diagnostic challenge. As in all cases, there is no substitute for a good history aided by a detailed clinical examination. In most cases this will point the most likely etiology and the most likely source. Post nasal bleeding is more often than not associated with nasal complaints. It is also evident on a simple oral and oropharyngeal examination as a postnasal trickle. Oral cavity sources are similarly easily seen on examination. Oropharyngeal and hypopharyngeal causes may sometimes be picked up on an indirect laryngoscopy. Hemoptysis presents usually with cough, history of lung disease, and frothy sputum, while hematemesis is frequently associated with nausea, a history of gastroesophageal disease, and usually coffee-grounds in vomitus [2].
Hematemesis can have numerous etiologies. The most common causes of hematemesis are summarized in the below Table 1: [3]
Table 1.
Common Causes of Hematemesis
| Cause | Prevalence |
|---|---|
| Peptic Ulcer disease | 35–50% |
| Esophagitis | 20–30% |
| Esophageal varices | 5–12% |
| Tumors | 2–5% |
| Mallory Weiss tears | 2–5% |
| Vascular lesions e.g. Arterio Venous malformation, gastric antral ectasia, Dieulafoy | 3% |
While Lingual varices are more common in elderly populations, as well as those with a history of smoking and cardiovascular disease [3], the vallecula is an unusual site for varicosities with very few cases reported in the literature. Wetherill and Gandhi [4] described bleeding from these abnormal vessels in 1967, and Booton and Jacob [5] in 2002. These cases both had infective exacerbations of chronic obstructive lung disease. They theorized that since brachiocephalic and internal jugular veins drain the pharyngeal and laryngeal venous plexuses, chronic pulmonary hypertension causing increased right heart pressure could result in varicosities in this location [6]. Jassar et al. [7] described the base of tongue varices in an 82-year-old woman with portal hypertension. To explain the association, he proposed an unrecognized anastomotic connection between lingual venous drainage and portal circulation.
Because of the unique location of this lesion, it can present as either hemoptysis or hematemesis or even epistaxis and melena. Sometimes it may also present as a combination of the above. Its size, location, and frequency of bleed along with presenting complaint make it a diagnostic dilemma because it may not be readily identified even after extensive investigations.
This is why early, thorough and detailed endoscopy can help diagnose it early. Flexible nasopharyngoscopy, Laryngeal telescopy, Bronchoscopy, and Flexible upper gastrointestinal endoscopy are important diagnostic tools that can assist early diagnosis.
The major source of mortality is shock and organ failure due to exsanguination. There is in fact a reported case after a traumatic intubation where a patient required transfusion of 25 units of blood before the site of bleeding was identified and controlled by diathermy coagulation [8].
While we have successfully managed this lesion with electro-cautery, other successful treatment modalities documented in the literature include injection sclerotherapy [9] and ablation with continuous carbon dioxide laser [7].
Conclusion
Vallecular varices are a rare, potentially life-threatening source of bleeding with very few documented cases in the literature. Indirect laryngoscopy, laryngeal telescopy, laryngoscopy are fast and easily performed and should be used early to prevent unnecessary testing and decrease healthcare costs and patient morbidity associated with a delay in diagnosis. It is also prudent to not forget uncommon sites such as the vallecula during the evaluation of a common complaint such as hemoptysis or hematemesis.
Funding
There is no source of funding.
Declarations
Conflict of interest
The authors declare that there are no conflicts of interest.
Ethics approval and consent to participate
The case report is in accordance with the ethical standards and due permission from the ethical committee was taken prior to the submission of this publication.
Consent for publication
The case report data and images have been furnished only after obtaining an informed consent from the patient.
Footnotes
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