Treatment of jejunal variceal bleeding with portal vein thrombosis after bile duct cancer surgery by short single-balloon endoscope

Usefulness of double-balloon endoscopy-assisted injection sclerotherapy for hemorrhagic varices in the jejunum reconstructed for liver transplantation in a pediatric case

A 10-year-old girl was admitted to our hospital for treatment of recurrent melena and severe anemia. Her treatment history comprised Kasai's portoenterostomy for biliary atresia as an infant, followed by liver transplantation and partial splenectomy for portal hypertension at 1 year old. Her medications comprised steroids, immunosuppressive agents, a β-blocker, and a potassium-competitive acid blocker. Since the age of 5 years, she had repeatedly visited a local hospital for melena, but the bleeding source had not been identified. She was referred to our hospital, and laboratory data revealed severe anemia. An enhanced computed tomography showed post-liver transplantation status, splenomegaly, and gastric varices, without extravasation. Esophagogastroduodenoscopy and colonoscopy did not identify the bleeding source. Double-balloon endoscopy (DBE) revealed variceal bleeding and serosanguinous fluid accumulated at the choledochojejunostomy site in the jejunum. After obtaining informed consent, our team and the radiologists cooperatively performed DBE-assisted endoscopic injection sclerotherapy with 75% n-butyl-2-cyanoacrylate through a 23- gage needle according to high-resolution varicerography in a hybrid emergency room. Subsequently, the patient was discharged and regularly monitored without any complications. We demonstrated the first pediatric case of successful DBE-assisted endoscopic injection for hemorrhagic jejunal varices after liver transplantation for biliary atresia and partial splenectomy.