Massive gastrointestinal bleeding from jejunal varices

Isolated ectopic jejunal varices in a patient with extrahepatic portal vein obstruction - A case report

Introduction and importance

Among the various causes for lower gastrointestinal bleeding, ectopic varices constitute a small chunk. Though rare, these can pose a diagnostic challenge with recurrent bleed leading to multiple admission and blood transfusions.

Case presentation

A 41-year-old male presented to our department with multiple episodes of melena. On further evaluation with CT angiography, a diagnosis of extrahepatic portal vein obstruction with moderate splenomegaly and ectopic jejunal varix was made. He underwent splenectomy with resection of involved jejunal segment with side to side anastomosis.

Clinical discussion

The diagnosis of ectopic varices remains elusive in a large number of cases in view of the varied etiology. Various newer endoscopic and imaging modalities can play a diagnostic as well as therapeutic role but this also further complicates the management as there is a lack of substantial guidelines directing the treatment protocol. As a result, we have to resort to a case by case approach for the optimal management in these cases.

Conclusion

The main modality of management for bleeding ectopic varices is percutaneous or endoscopic. Surgery is reserved for refractory cases, with decompressive shunts combined with segmental resection of involved intestine being at the forefront of surgical options.

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Ectopic varices are an unusual cause of lower GI bleeding caused by porto-systemic collaterals.

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Ectopic varices most commonly occur at jejuno-ileum, but duodenal varices are more prone to bleed.

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The optimal management varies with each case due to paucity of treatment guidelines.

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Decompressive shunt with splenectomy and segmental resection of intestine effectively prevents rebleeding.

Jejunal varices as a rare cause of recurrent gastrointestinal bleeding in a 74-year-old man with extrahepatic portal hypertension after pancreato-biliary surgery

A 74-year-old man presented to our hospital with recurrent lower gastrointestinal bleeding. His past medical history was remarkable for a duodenal papilla carcinoma and he underwent a pylorus-preserving pancreaticoduodenectomy 4 years before. During diagnostic work-up a severe portal vein stenosis after surgery and multiple dilated intramural jejunal varices, which formed as collateral pathways could be detected. Based on these findings, the recurrent haemorrhages were considered to be due to repeated rupturing and bleeding of jejunal varices. Therapeutically, the portal vein stenosis was treated with endovascular stent placement leading to a reduction in prestenotic portal pressure. During follow-up no further episodes of gastrointestinal bleeding were observed. Bleeding from jejunal varices is a very rare cause of gastrointestinal haemorrhages and represents a diagnostic and therapeutic challenge. However, it should be considered in differential diagnosis of obscure recurrent gastrointestinal haemorrhages in patients with a history of hepato-pancreato-biliary surgery.

Jejunal varices: an unconsidered cause of recurrent gastrointestinal haemorrhage

A 78-year-old woman presented with melaenic stool and severe anaemia 4 years after a pancreaticoduodenectomy for adenocarcinoma of the pancreas. Initial workup revealed haemorrhage from the choledochojejunostomy site. Despite multiple endoscopic clips to the region, bleeding reoccurred multiple times over a period of several months. Due to ongoing haemorrhage, her case was urgently presented at the hospital's multidisciplinary hepatobiliary conference. The contrast-enhanced abdominal CT revealed severe stenosis of the extrahepatic portal vein and large afferent jejunal varices at the choledochojejunostomy, suspected as the cause of her persistent bleed. The recommendation was a percutaneous transhepatic approach for stenting of the portal vein stenosis that resulted in rapid decompression of the jejunal varices and control of her haemorrhage.

Unusual bleeding from hepaticojejunostomy controlled by side-to-side splenorenal shunt: A case report

RATIONALE

Ectopic variceal bleeding due to hepaticojejunostomy (HJ) is unusual and difficult to manage. Reports on the use of side-to-side splenorenal shunt for severe bleeding from varices at HJ anastomosis are lacking.

PATIENT CONCERNS

A 43-year-old man was admitted to our hospital with repeated episodes of hematemesis. He has a history of right hemihepatectomy with HJ reconstruction to the left hepatic duct for hilar cholangiocarcinoma. Two years after surgery, he presented with repeated episodes of hematemesis and underwent blood transfusion.

DIAGNOSES

Imaging tests and endoscopic investigation failed to identify the bleeding source. When conservative management failed to control his bleeding, he underwent emergency laparotomy, which revealed hemorrhage from ectopic varices at the HJ anastomosis.

INTERVENTIONS

To arrest the bleeding, a side-to-side venovenal anastomosis was created between the splenic and left renal veins to form a shunt for decompression of the varices at the HJ anastomosis.

OUTCOMES

After the surgery, the patient's symptoms ceased, and a no bleeding in the digestive tract was noted at 2-year follow-up.

LESSONS

The present patient is the first reported case of unusual bleeding from HJ controlled by a side-to-side splenorenal shunt. We believe this approach is a useful and effective surgical treatment for severe bleeding from varices at the HJ anastomosis.

Ectopic gastrointestinal variceal bleeding with portal hypertension

Massive gastrointestinal bleeding from gastrointestinal varices is one of the most serious complications in patients with portal hypertension. However, if no bleeding point can be detected by endoscopy in the predilection sites of gastrointestinal varices, such as the esophagus and stomach, ectopic gastrointestinal variceal bleeding should be considered as a differential diagnosis. Herein, we report a case of ectopic ileal variceal bleeding in a 57-year-old woman, which was successfully diagnosed by multi-detector row CT (MDCT) and angiography and treated by segmental ileum resection. To date, there have been no consensus for the treatment of ectopic ileal variceal bleeding. This review was designed to clarify the clinical characteristics of patients with ectopic ileal variceal and discuss possible treatment strategies. From the PubMed database and our own database, we reviewed 21 consecutive cases of ileal variceal bleeding diagnosed from 1982 to 2017. MDCT and angiography is useful for the rapid examination and surgical resection of an affected lesion and is a safe and effective treatment strategy to avoid further bleeding.

[Surgical Removal of Migrated Coil after Embolization of Jejunal Variceal Bleeding: A Case Report]

Jejunal variceal bleeding is less common compared with esophagogastric varices in patients with portal hypertension. However, jejunal variceal bleeding can be fatal without treatment. Treatments include surgery, transjugular intrahepatic porto-systemic shunt (TIPS), endoscopic sclerotherapy, percutaneous coil embolization, and balloon-occluded retrograde transvenous obliteration (BRTO). Percutaneous coil embolization can be considered as an alternative treatment option for those where endoscopic sclerotherapy, surgery, TIPS or BRTO are not possible. Complications of percutaneous coil embolization have been reported, including coil migration. Herein, we report a case of migration of the coil into the jejunal lumen after percutaneous coil embolization for jejunal variceal bleeding. The migrated coil was successfully removed using surgery.

Solitary Variceal Rupture in the Small Intestine

A 70-year-old man was referred to our hospital to undergo treatment for hepatocellular carcinoma. In hospital, he complained of hematochezia and a laboratory analysis revealed a decreased level of hemoglobin. Abdominal computed tomography revealed a tumor in the small intestine, with slow enhancement of the dorsal region. Double-balloon enteroscopy revealed a submucosal tumor with a depression in the jejunum. Partial enterectomy was performed and a pathological examination demonstrated the presence of a solitary varix. Solitary varix in the small intestine has not been reported previously. We herein report an extremely rare case of solitary varix in the jejunum.

Is it possible to predict the presence of intestinal angioectasias?

Background and Aim. Angioectasias are the most common vascular anomalies found in the gastrointestinal tract. In small bowel (SB), they can cause obscure gastrointestinal bleeding (OGIB) and in this setting, small bowel capsule endoscopy (SBCE) is an important diagnostic tool. This study aimed to identify predictive factors for the presence of SB angioectasias, detected by SBCE. Methods. We retrospectively analyzed the results of 284 consecutive SBCE procedures between April 2006 and December 2012, whose indication was OGIB, of which 47 cases with SB angioectasias and 53 controls without vascular lesions were selected to enter the study. Demographic and clinical data were collected. Results. The mean age of subjects with angioectasias (70.9 ± 14.7) was significantly higher than in controls (53.1 ± 18.6; P < 0.001). The presence of SB angioectasias was significantly higher when the indication for the exam was overt OGIB versus occult OGIB (13/19 versus 34/81, P = 0.044). Hypertension and hypercholesterolemia were significantly associated with the presence of SB angioectasias (38/62 versus 9/38, P < 0.001 and 28/47 versus 19/53, P = 0.027, resp.). Other studied factors were not associated with small bowel angioectasias. Conclusions. In patients with OGIB, overt bleeding, older age, hypercholesterolemia, and hypertension are predictive of the presence of SB angioectasias detected by SBCE, which may be used to increase the diagnostic yield of the SBCE procedure and to reduce the proportion of nondiagnostic examinations.

A case of variceal bleeding from the jejunum in liver cirrhosis

While esophagogastric varices are common manifestations of portal hypertension, variceal bleeding from the jejunum is a rare complication of liver cirrhosis. In addition, ectopic variceal bleeding occurs in the duodenum and at sites of previous bowel surgery in most cases, including of stomas. We report a case of obscure overt gastrointestinal bleeding from jejunal varices in a 55-year-old woman who had not previously undergone abdominal surgery, who had liver cirrhosis induced by the hepatitis C virus. Emergency endoscopy revealed the presence of esophageal varices without stigmata of recent bleeding, and no bleeding focus was found at colonoscopy. She continued to produce recurrent melena with hematochezia and received up to 21 units of packed red blood cells. CT angiography revealed the presence of jejunal varices, but no active bleeding was found. Capsule endoscopy revealed fresh blood in the jejunum. The patient submitted to embolization of the jejunal varices via the portal vein, after which she had a stable hemoglobin level and no recurrence of the melena. This is a case of variceal bleeding from the jejunum in a liver cirrhosis patient without a prior history of abdominal surgery.

Jejunal variceal bleeding successfully treated with percutaneous coil embolization

A 52-yr-old male with alcoholic liver cirrhosis was hospitalized for hematochezia. He had undergone small-bowel resection due to trauma 15 yr previously. Esophagogastroduodenoscopy showed grade 1 esophageal varices without bleeding. No bleeding lesion was seen on colonoscopy, but capsule endoscopy showed suspicious bleeding from angiodysplasia in the small bowel. After 2 weeks of conservative treatment, the hematochezia stopped. However, 1 week later, the patient was re-admitted with hematochezia and a hemoglobin level of 5.5 g/dL. Capsule endoscopy was performed again and showed active bleeding in the mid-jejunum. Abdominal computed tomography revealed a varix in the jejunal branch of the superior mesenteric vein. A direct portogram performed via the transhepatic route showed portosystemic collaterals at the distal jejunum. The patient underwent coil embolization of the superior mesenteric vein just above the portosystemic collaterals and was subsequently discharged without re-bleeding. At 8 months after discharge, his condition has remained stable, without further bleeding episodes.

Jejunal varix bleeding with extrahepatic portal vein obstruction after pylorus-preserving pancreatoduodenectomy: report of two cases

We present 2 patients showing afferent jejunal varix bleeding around hepaticojejunostomy caused by extrahepatic portal vein obstruction after pylorus-preserving pancreatoduodenectomy (PPPD). The case 1 was a 58-year-old woman who had recurrent anemia and hematochezia 3 years after undergoing PPPD. On the portography, the main portal vein was obliterated and collaterals around hepaticojejunostomy were developed. After percutaneous transhepatic balloon dilatation and stent placement through the obliterated portal vein, jejunal varices had disappeared and thereafter no bleeding occurred for 32 months. The case 2 was a 71-year-old man who had frequent melena 7 years after PPPD. Portal stent insertion was first tried, but failed due to severe stenosis of the main portal vein. Therefore, meso-caval shunt operation was attempted in order to reduce the variceal flow. Although an episode of a small amount of melena occurred one month after the shunt operation, there was no occurrence of bleeding for the next 8 months. For the treatment of jejunal varices, a less invasive approach, such as the angiographic intervention of stent insertion, balloon dilatation, or embolization is recommended first. Surgical operations, such as a shunt or resection of the jejunal rim, could be considered when noninvasive approaches have failed.

Duodenal and jejunal varices due to superior mesenteric vein thrombosis presenting as a massive gastrointestinal tract bleeding: a case report

Duodenal and jejunal varices usually occur due to portal hypertension and are rare causes of gastrointestinal tract bleeding. We report the case of a patient with no clinically significant history of a coagulopathy disorder, cirrhosis, or portal hypertension who presented with duodenal and jejunal varices that resulted in lower gastrointestinal bleeding with superior mesenteric vein thrombosis. Mesenteric angiography revealed superior mesenteric vein thrombosis and varices at the fourth part of the duodenum and the proximal jejunum draining into the main portal vein, but no active bleeding source was recognized. The patient was hemodynamically unstable. Emergency laparotomy was performed and revealed duodenal and jejunal varices, with occlusion of the superior mesenteric vein. Partial resection of the duodenum and jejunum and end-to-end anastomosis were performed. After surgery, the patient was hemodynamically stable with no recurrence of bleeding.

Gastrointestinal bleeding 30 years after a complicated cholecystectomy

Gastrointestinal bleeding from small-bowel varices is a rare and difficult to treat complication of portal hypertension. We describe the case of a 79-year-old female patient with recurrent severe hemorrhage from small-bowel varices 30 years after a complicated cholecystectomy. When double balloon enteroscopy was unsuccessful to reach the site of bleeding, a rendezvous approach was favored with intraoperative endoscopy. Active bleeding from varices within a biliodigestive anastomosis was found and controlled by endoscopic injection of cyanoacrylate. Intraoperative endoscopy should be considered in the case of life-threatening gastrointestinal hemorrhage that is not accessible by conventional endoscopy.

Successful embolization therapy for bleeding from jejunal varices after choledochojejunostomy: report of a case

We report a case of successful embolization of jejunal varices that were the cause of massive gastrointestinal bleeding from a choledochojejunostomy site, resulting from obstruction of the extrahepatic portal vein. A 42-year-old man who had undergone choledochojejunostomy for intrahepatic and choledochal stones was readmitted after he started passing massive dark bloody stools. Gastrointestinal endoscopic examination and angiography could not identify the source of bleeding. Percutaneous transhepatic portography showed obstruction of the right branches of the portal vein. The formation of jejunal varices at the site of choledochojejunostomy was revealed by portography and by cholangioscopy, suggesting the varices as the cause of massive bleeding. Bleeding could not be controlled long-term by cholangioscopic sclerosing therapy. We finally stopped the bleeding by embolizing a jejunal vein to the afferent loop.

Successful embolization therapy for bleeding from jejunal varices after choledochojejunostomy: report of a case

We report a case of successful embolization of jejunal varices that were the cause of massive gastrointestinal bleeding from a choledochojejunostomy site, resulting from obstruction of the extrahepatic portal vein. A 42-year-old man who had undergone choledochojejunostomy for intrahepatic and choledochal stones was readmitted after he started passing massive dark bloody stools. Gastrointestinal endoscopic examination and angiography could not identify the source of bleeding. Percutaneous transhepatic portography showed obstruction of the right branches of the portal vein. The formation of jejunal varices at the site of choledochojejunostomy was revealed by portography and by cholangioscopy, suggesting the varices as the cause of massive bleeding. Bleeding could not be controlled long-term by cholangioscopic sclerosing therapy. We finally stopped the bleeding by embolizing a jejunal vein to the afferent loop.

Successful endoscopic sclerotherapy for cholecystojejunostomy variceal bleeding in a patient with pancreatic head cancer

Variceal bleeding outside the esophagus and stomach is rare but important because of its difficult diagnosis and treatment. Bleeding from cholecystojejunostomy varices has been reported to be a late complication of palliative biliary surgery for chronic pancreatitis. Such ectopic variceal bleeding has never been reported after palliative surgery for pancreatic cancer, probably because of the limited lifespan of these patients. Herein, we report our successful experience using endoscopic cyanoacrylate sclerotherapy to treat bleeding from cholecystojejunostomy varices in a 57-year-old man with pancreatic head cancer. To our knowledge, this is the first case report in the literature of this rare complication.

Successful treatment of mesenteric varices after living donor liver transplantation with retrograde transvenous obliteration via an abdominal wall vein

Balloon-occluded retrograde transvenous obliteration is an established treatment for gastric varices; it has been used more rarely to treat mesenteric varices. We report a 12-year-old girl who had received a living donor liver transplant and suffered melena due to ruptured mesenteric varices. We addressed treatment of the mesenteric varices by retrograde transvenous obliteration of an abdominal wall collateral vein detected by superior mesenteric arteriography.

Tratamento de hemorragia intestinal grave decorrente de hipertensão porta, por meio de esplenectomia subtotal e anastomose esplenorrenal proximal

OBJETIVO: Um dos maiores desafios no tratamento da hipertensão porta é o sangramento de varizes intestinais. O objetivo deste artigo é apresentar um novo tratamento para hemorragia entérica grave provocada por hipertensão porta cirrótica, utilizando a esplenectomia subtotal combinada com derivação esplenorrenal proximal. TÉCNICA: Uma paciente de 64 anos apresentou sangramento intenso proveniente de varizes em alça jejunal em Y de Roux, para derivação biliodigestiva, após lesão coledociana, complicada com cirrose hepática. O procedimento consistiu em esplenectomia subtotal, preservando o pólo superior do baço, suprido apenas pelos vasos esplenogástricos, e anastomose término-lateral da veia esplênica, em sua extremidade proximal, à veia renal esquerda. RESULTADOS: Esse procedimento foi seguro, sem sangramento maior, dificuldade técnica ou complicação. No acompanhamento de 30 meses, a paciente não teve novos episódios de sangramento, a cirrose não avançou e, atualmente, encontra-se bem, sob controle. CONCLUSÃO: A esplenectomia subtotal combinada com derivação esplenorrenal proximal é uma boa alternativa operatória para tratar hemorragia proveniente de varizes intestinais, decorrentes de hipertensão porta.

Hemorrhage from varices in hepaticojejunostomy in the fifth and tenth year after surgery for hepatic hilar bile duct cancer: a case report

We report a case of a 64-year-old female patient who underwent a right lobectomy of the liver (including total resection of the caudate lobe), dissection of the group 2 lymph nodes, left hepaticojejunostomy (Roux-en-Y fashion), and reconstruction of the portal vein (end-to-end anastomosis between the main portal vein and the left portal branch) for treatment of hepatic hilar bile duct cancer in 1996. In 2001, the anastomotic site of the hepaticojejunostomy was dissected and re-anastomosed due to gastrointestinal bleeding caused by variceal rupture in the jejunal loop. In 2006, splenectomy was performed for recurrence of gastrointestinal bleeding due to another variceal rupture in the jejunal loop. Portal venography performed perioperatively showed a decrease in portal blood flow into the liver via the jejunal varices and an increase in portal blood flow into the liver via the left gastric vein. She had two jejunal variceal ruptures at five-year intervals after extrahepatic portal obstruction and underwent successful treatments.

Subtotal splenectomy and central splenorenal shunt for treatment of bleeding from Roux en Y jejunal loop varices secondary to portal hypertension

PURPOSE

To present subtotal splenectomy and splenorenal shunt as a surgical option to treat severe bleeding from a Roux en Y jejunal loop varices secondary to portal hypertension.

METHOD

A 64-year-old white woman presented severe episodes of bleeding from varices inside a Roux en Y jejunal loop secondary to portal hypertension due to cirrhosis. Subtotal splenectomy was performed with preservation of the upper splenic pole supplied by the splenogastric vessels. This procedure was combined with a central splenorenal shunt to divert part of portal blood to systemic flow.

RESULTS

This procedure was safely performed with no complications. A 2-year post-operative follow-up of the patient has been uneventful. No re-bleeding occurred during this period and she returned to her normal life.

CONCLUSION

Subtotal splenectomy combined with central splenorenal shunt seems to be a safe procedure useful for the treatment of enteral bleedings due to portal hypertension.

[A surgical approach to acute intestinal bleeding]

The estimated incidence of lower gastrointestinal bleeding (LGIB) is 20/100,000 patients per year. Of these cases, 70-80% are minor or stop spontaneously and do not present as emergency hospital admissions. Colonoscopy and angiography detect 80-90% of major LGIB, and subsequent endoscopic intervention or embolisation can control approximately 70%. Emergency surgical intervention is required in haemodynamically unstable patients with persistent bleeding. The surgical treatment of choice is directed to resecting the bleeding bowel segment. Subtotal colectomy is performed in patients with colonic bleeding that can not exactly be localized. Segmental colon resection is often associated with rebleeding and not recommended in this situation. Primary anastomosis can usually be performed; elderly patients in reduced condition, however, are candidates for stoma. In case of persistent or recurrent bleeding and differentiation between intestinal and colonic bleeding fails, loop ileostomy may be performed. If the bleeding appears to originate from somewhere in the small bowel, an additional loop jejunostomy may be performed for specification. The mortality from acute LIGB is approximately 5% but increases with emergency surgery. Risk factors are age, comorbidity, and shock on admission.

Novel bile duct repair for bleeding biliary anastomotic varices: case report and literature review

An unusual case of variceal bleeding at the site of a biliary enteric anastomosis is presented. This entity can occur when a high-to-low pressure gradient forms in a variceal field. In this case the anastomotic site was the location of the pressure gradient from the high-pressure small bowel varices to the low-pressure biliary tract. This was successfully treated by disconnection of the anastomosis. The resulting biliary defect was patched with small intestinal submucosa, which functioned successfully as a scaffold for biliary epithelial ingrowth.