Clip-Assisted Cyanoacrylate Injection for the Management of a Proximal Colonic Varix

Colonic varices are a rare manifestation of portal hypertension and an uncommon cause of lower gastrointestinal bleeding, particularly when involving the proximal colon. We report a case of bleeding hepatic flexure varices in a 23-year-old male with extrahepatic portal vein obstruction (EHPVO) and prior splenectomy with lienorenal shunt. The patient presented with recurrent hematochezia and severe anemia. Upper gastrointestinal endoscopy was negative for a bleeding source, while colonoscopy revealed large tortuous varices at the hepatic flexure with stigmata of recent hemorrhage. Contrast-enhanced CT confirmed cavernomatous transformation of the portal vein with extensive mesenteric collaterals, thrombosis of the prior shunt, and afferents to the varix arising from the superior mesenteric vein. Endoscopic therapy was performed using clip-assisted flow modulation of the afferent and efferent venous channels, followed by N-butyl-2-cyanoacrylate injection into the main variceal trunk. The procedure resulted in successful obliteration of the varices without complications, with no further bleeding on follow-up. This case highlights hepatic flexure varices as a rare cause of lower gastrointestinal bleeding in EHPVO and demonstrates the feasibility of clip-assisted cyanoacrylate injection as an effective endoscopic treatment strategy for high-flow colonic varices.