Jejunal varices: an unconsidered cause of recurrent gastrointestinal haemorrhage

Abstract

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.

Percutaneous transhepatic stent for chronic intestinal bleeding from jejunal varices in primary idiophatic superior mesenteric vein stenosis: A case report

“…This procedure can exactly define both the localization and the grade of stenosis. So operator is able to: a. measure venous pressure gradients before and after the stenotic tract; b. study blood flow direction of whole splanchnic venous system, discovering possible retrograde flows into portosystemic collaterals, as observed in the case reported, allowing direct endovascular recanalization [1 , 4 , 5 , [7] , [8] , [9] , [11] , [12] , [13] , [14] , [15] , [16] .…”

“…Similar to extra-hepatic portal vein occlusion, last but noy least the origin of small bowel varices could be a SMV stenosis which leads to thrombosis, either acute or chronic [8] , [9] , [10] , [11] .…”

“…Symptomatic jejunal varices can be treated with endoscopy or surgery, but it is always basic to treat the underlying splanchnic hypertension [1 , 5 , 8 , 11] .…”

Ectopic variceal bleeding after hepatobiliary surgery

“…There are still limited case reports on jejunal varices without liver cirrhosis that developed after abdominal surgery. [ 11 – 13 ] Unlike surgery involving the gall bladder, pancreas, and duodenum, this patient underwent surgery mainly in the liver, which would affect the portal vein thereafter, leading to jejunal varices and urgent bleeding. Portal venous stenosis may occur after hepatic surgery due to portal venous reconstruction and postoperative inflammation, which impedes blood flow into the liver and leads to portal hypertension.…”

Laparotomy-assisted transcatheter variceal embolization for bleeding jejunal varices formed at the site of choledochojejunostomy: Report of a case and review of the literature

“…Two treatment options are available for varices at the bilioenteric anastomosis: obliteration of the varices (by endoscopic sclerotherapy or ligation, embolization, surgical re-anastomosis) and portal decompression [by portal venous dilatation and stenting, splenectomy, and shunt operation (surgical shunt or transjugular intrahepatic portosystemic shunt)] [ 2 ]. Table 1 shows the various treatments for jejunal varices at the site of bilioenteric anastomosis [ 1 , 2 , [5] , [6] , [7] , [8] , [9] , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] , [23] ]. Portal vein stenting was performed for 9 cases, and laparotomy-assisted embolization was performed for 8 cases.…”