Management of bleeding ectopic varices

Ectopic varices (ECV) are a heterogeneous group of portosystemic shunts that occur in the presence of portal hypertension. The shunts occur throughout the abdomen and pelvis, including the gallbladder, the genitourinary system, and the retroperitoneal space, but they are most common within the bowel (small intestine and colon) and at the mucocutaneous junction of a stoma. Bleeding rates vary depending on the location, but overall, ECV account for 1%-5% of all variceal bleeding and can lead to significant morbidity and mortality. Management of these shunts can be very difficult owing to complex underlying vascular anatomy. Although there is a role for endoscopic intervention in these cases, definitive therapy by this modality is often unachievable, necessitating complex endovascular procedures to ultimately occlude the shunt. Understanding the anatomy, the reported success rates with various procedural interventions, and the complications of those interventions is of the utmost importance in the management of ECV and will be reviewed here in detail.