Vallecular Varix: An Uncommon Cause for a Common Clinical Scenario

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.

Tongue base varix as a source of oral bleeding: A case report

RATIONALE

Oral bleeding is usually diagnosed after by referral to other department for the differential diagnosis of hematemesis or hemoptysis. If a patient presents with blood in the oral cavity with no obvious source, generally upper airway, pulmonary, or gastroesophageal lesions are considered likely bleeding foci. The tongue base is an unusual site for laryngopharyngeal varices and only a few cases have been reported.

PATIENT CONCERNS

Although varix at the tongue base in patients with liver cirrhosis has been rarely described, physicians must consider variceal bleeding from the tongue base when presented with oral bleeding. In such cases, bleeding foci can be identified and controlled by laryngoscopy. We describe the case of a 42-year-old woman complaining of small amount of hemoptysis with variceal bleeding at the tongue base controlled by laryngoscopic excision and cauterization.

DIAGNOSIS

A diagnosis of tongue base varix was made based on medical history, clinical manifestations, laryngoscopic findings and pathologic features for the patient.

INTERVENTIONS

The successful laryngoscopic procedures were performed.

OUTCOMES

The patient has shown no recurrent oral bleeding during follow-up.

LESSONS

Variceal bleeding in the tongue base is likely to cause serious massive hemorrhage. We need to consider this possibility when presented with a patient with intraoral bleeding but no evidence of hemoptysis or hematemesis.

Diagnosis and Treatment of Hemoptysis

Hemoptysis is the expectoration of blood from the tracheobronchial tree. It is commonly caused by bronchiectasis, chronic bronchitis, and lung cancer. The expectorated blood usually originates from the bronchial arteries. When hemoptysis is suspected, it must be confirmed and classified according to severity, and the origin and cause of the bleeding determined. Lateral and AP chest X-ray is the first study, although a normal chest X-ray does not rule out the possibility of malignancy or other underlying pathology. Multidetector computed tomography (MDCT) must be performed in all patients with frank hemoptysis, hemoptoic sputum, suspicion of bronchiectasis or risk factors for lung cancer, and in those with signs of pathology on chest X-ray. MDCT angiography has replaced arteriography in identifying the arteries that are the source of bleeding. MDCT angiography is a non-invasive imaging technique that can pinpoint the presence, origin, number and course of the systemic thoracic (bronchial and non-bronchial) and pulmonary arterial sources of bleeding. Endovascular embolization is the safest and most effective method of managing bleeding in massive or recurrent hemoptysis. Embolization is indicated in all patients with life-threatening or recurrent hemoptysis in whom MDCT angiography shows artery disease. Flexible bronchoscopy plays a pivotal role in the diagnosis of hemoptysis in patients with hemoptoic sputum or frank hemoptysis. The procedure can be performed rapidly at the bedside (intensive care unit); it can be used for immediate control of bleeding, and is also effective in locating the source of the hemorrhage. Flexible bronchoscopy is the first-line procedure of choice in hemodynamically unstable patients with life-threatening hemoptysis, in whom control of bleeding is of vital importance. In these cases, surgery is associated with an extremely high mortality rate, and is currently only indicated when bleeding is secondary to surgery and its source can be accurately and reliably located.

Vallecular Varix: A Perplexing Cause of Oral Cavity Bleeding

Often discovered only after an extensive work up for hemoptysis and hematemesis, vallecular varices are a rare cause of oral bleeding that increase patient morbidity due to delay of diagnosis. We describe an 89-year-old male who presented with a week of intermittent oral blood production. A vallecular varix was identified on fiberoptic laryngoscopy after studies for hematemesis and hemoptysis had been performed, including negative esophagogastroduodenoscopy and bronchoscopy. Awareness of this pathology and key points in the patient history can direct the clinician toward the correct diagnosis, expediting treatment and limiting invasive diagnostic procedures for pulmonary or gastric etiologies of bleeding.