a 53-year - old caucasian male was evaluated for bright red blood per rectum with colonoscopy . the patient 's past medical history was significant for end - stage liver disease due to hepatitis c and hepatitis b , asthma , and erythropoietic porphyria . the patient had prior episodes of hematemesis which required multiple sessions of esophageal variceal rubber band ligation treatment . the patient complained of bright red blood per rectum for a four month period without clinical evidence of active or massive bleeding . family history was notable for colon cancer in the patient 's father at age 60 . his medications included propanolol , lasix , aldactone , lactulose , thiamine , and folate . pertinent review of symptoms was negative for fevers , chills , weight loss , diarrhea , constipation , melena , weakness , or loss of consciousness . physical examination revealed a well - developed , well - nourished male in no acute distress appearing his stated age . vitals signs were as follows : blood pressure 108/58 mm hg , heart rate 66/min , respiratory rate 18/min , and temperature 36.9c . in addition , abdominal examination revealed a 2  2 cm umbilical hernia and a right - sided inguinal hernia . recent complete blood count prior to colonoscopy revealed a hemoglobin of 11.5 g / dl , hematocrit of 34.6% , and a platelet count of 36,000 with a mcv of 81.3 . the patient had positive serologies proving both infection with hepatitis b and c. the patient 's hepatitis c viral load was undetectable . recent abdominal ultrasound was notable for hepatomegaly , nodular and heterogeneous in consistency , massive splenomegaly , and ascites . colonoscopy was significant for internal hemorrhoids as well as cecal and proximal ascending colon varices without any endoscopic evidence of bleeding ( fig . reported cases of varices have been found in the stomach , small bowel , biliary tree , colon , rectum , and even the site of a surgical ostomy . the stomach and the rectum are the most common sites of extraesophageal varices and up to 30% of variceal bleeding may originate from an extraesophageal location . a history of abdominal surgery may predispose a patient to develop varices of the lower gastrointestinal tract [ 5 , 6 ] . other causes include biliary atresia , biliary sclerosis , congestive heart failure , superior mesenteric vein thrombosis , and inferior mesenteric vein thrombosis . a smaller number are of idiopathic origin . due to the patient 's history of esophageal varices as a result of portal hypertensive gastropathy this case of cecal and ascending colon varices is presented because of the uniqueness of this anomaly within the colon and most notably the cecum . in the literature , a total of seventeen cases ( including this one ) of cecal varices have been reported [ 2 , 5 , 6 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 ] . the cases of cecal varices that have been reported have all presented clinically with massive lower gastrointestinal bleeding necessitating urgent management with blood products and surgical or endoscopic intervention . to our knowledge this is the first case of cecal varices reported that has not resulted in massive lower gastrointestinal bleeding . he did not demonstrate any episodes of massive gastrointestinal bleeding requiring immediate intervention as in the previous cases reported . given the colonoscopic finding , we believe that the internal hemorrhoids and not the cecal varices may have contributed to his clinical presentation . by reporting our experience we emphasize that cecal varices are very rare and may also be present in stable patients without massive lower gastrointestinal bleeding . because of the paucity of data , the proper management of patients with colonic varices is unknown . treatment of cecal varices has included colectomy as well as transjugular portal - systemic shunt in cases of varices attributed to portal hypertension . there are no established guidelines for the treatment of extraesophageal varices due to the scarcity of cases reported . he is clinically stable and has no clinical evidence indicating a history of active bleeding from those varices . however , further study is needed to determine whether sclerotherapy , band ligation , or even surgical treatment is effective for bleeding associated with cecal varices . careful patient follow - up should also be instituted for those who are incidentally noted to have cecal varices but have not bled .
since the original description of colonic varices in 1954 [ n engl j med 1954;250:434 - 438 ] , fewer than 100 cases have been reported in the literature . particularly , even fewer cases of cecal varices have been reported . 
 more than 75% of these cases have been due to portal hypertension . 
 our objective is to contribute a rare case with an uncommon presentation to the medical literature . 
 we present the case of a 53-year - old male with hepatitis c and hepatitis b liver cirrhosis who presented for outpatient colonoscopy . 
 the indication for colonoscopy was bright red blood per rectum and iron deficiency anemia . 
 a significant amount of varices were noted in the cecum and proximal ascending colon . 
 no endoscopic evidence of colonic bleeding was noted . 
 this is the first reported case of cecal varices not presenting with massive lower gastrointestinal bleeding .