Massive Gastrointestinal Bleeding Due to Isolated Jejunal Varices in a Patient With Extrahepatic Portal Hypertension: A Case Report

Mansoor, Emad; Singh, AK; Nizialek, Gregory; Veloso, Hazel Marie G.; Katz, Jeffry; Cooper, Gregory S.; Isenberg, Gerard

doi:10.1038/ajg.2016.191

Cited by 7 publications

(10 citation statements)

References 9 publications

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“…Ectopic varices most commonly develop secondary to portal hypertension, but it can also develop because of other causes such as abdominal surgical procedures, congenital anomalies in venous outflow, certain familial syndromes, and abdominal vascular thrombosis, with the former being an odd cause of ectopic varices. Portomesenteric vein thrombosis (PMVT) causing small bowel varices has been reported a few times in literature as it can also cause secondary portal hypertension [5–7].…”

Section: Introductionmentioning

confidence: 99%

Jejunal Varices Bleeding in a Patient with Extensive Portomesenteric Thrombosis Secondary to Factor V Leiden Mutation: A Management Dilemma

Ayash

Mushtaq

Qader

et al. 2019

Case Reports in Gastrointestinal Medicine

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Ectopic varices are portosystemic collaterals that occur away from the gastroesophageal junction and account for 1-5% of all variceal bleeding. Its occurrence in the jejunum is rare. Most common cause of ectopic jejunal varices is portal hypertension especially in those patients who have undergone prior abdominal surgery. Portomesenteric thrombosis is a rare cause of ectopic jejunal varices. Ectopic varices are rare cause of obscure GI bleeding and hence should be always suspected in patients with history of portal hypertension who present with GI bleeding and have negative upper and lower GI endoscopies. Management of patients with ectopic varices is often very challenging and requires multidisciplinary approach. Therapeutic options include endoscopic therapy, interventional radiologic procedures, surgically creating shunting, or surgical resection. We present the case of a 52-year-old patient who was on anticoagulation for extensive portomesenteric thrombosis secondary to factor V Leiden heterozygous mutation and presented with melena and symptomatic anemia. Investigations showed bleeding jejunal varices as the cause of anemia. We discuss the therapeutic options and dilemma in the management of such cases.

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Section: Introductionmentioning

confidence: 99%

Jejunal Varices Bleeding in a Patient with Extensive Portomesenteric Thrombosis Secondary to Factor V Leiden Mutation: A Management Dilemma

Ayash

Mushtaq

Qader

et al. 2019

Case Reports in Gastrointestinal Medicine

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“…3 The jejunal varices formed at choledochojejunostomy site can be treated by (a) obliteration of the varices that cause bleeding (by endoscopic sclerotherapy injecting N-butyl-2-cyanoacrylate, 2 balloon-occluded retrograde transvenous obliteration, reanastomosis, surgical ligation or embolization) or (b) portal decompression (by portal venous dilatation and stenting, shunt operation [surgical shunt or transjugular intrahepatic portosystemic shunt], and splenectomy). 1,3 Because the varices collapse after an episode of bleeding, the previous antegrade double balloon enteroscopy could not visualize them. Capsule endoscopy cannot visualize the anastomosis because this is in the afferent limb and the capsule cannot traverse upstream.…”

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confidence: 99%

An Unusual Cause of Recurrent Gastrointestinal Bleeding After Whipple’s Surgery

2017

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Question: A 55-year-old Caucasian woman was admitted to the hospital with recurrent melena and hematochezia. Her past medical history was significant for a well-differentiated neuroendocrine tumor of the head of the pancreas for which she had undergone Whipple's procedure 10 years ago. Her postoperative course was complicated by portal vein thrombosis. She also had a history of compensated liver cirrhosis secondary to nonalcoholic fatty liver disease. She was extensively evaluated in the past 2 years for recurrent gastrointestinal (GI) bleeding with upper and lower endoscopy, double balloon enteroscopy, video capsule endoscopy, and angiography. However, the underlying diagnosis was uncertain despite this extensive workup. She had received a total of 12 units of packed red blood cell transfusion over 2 years. There was no evidence of esophageal or gastric varices. She denied nonsteroidal anti-inflammatory drugs or anticoagulants and antiplatelet use. Physical examination revealed splenomegaly without jaundice. Rectal examination showed bright red blood in the rectal vault. Laboratory data showed normocytic normochromic anemia (hemoglobin 7.4 g/dL), platelet count of 114,000/mm 3 , and an International Normalized Ratio of 1. Magnetic resonance imaging of abdomen showed hepatic cirrhosis with portal hypertension and cavernous transformation of the portal vein. Push enteroscopy was performed and ruled out peptic ulcer disease, and esophageal and gastric varices. She had worsening hematochezia and melena with a persistent decrease in hemoglobin requiring 5 units of packed red cell transfusions. A Tc-99-labeled red cell scan failed to identify active bleeding. Colonoscopy showed fresh blood in the colon and terminal ileum. However, no area of active bleeding was visualized. Antegrade double balloon enteroscopy was performed next day to evaluate the persistent bleeding that revealed 2 lesions at the choledochojejunostomy site with stigmata of recent bleeding (Figure A, B). What is the diagnosis? How is this condition diagnosed and managed? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

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“…Jejunal varices are an uncommon manifestation of portal hypertension, which may be due to liver cirrhosis, portal vein thrombosis or postsurgery extrahepatic portal vein stenosis and are challenging in terms of diagnosis and treatment 1–5. Whereas bleeding due to portal hypertension mostly arises from gastro-oesophageal varices, jejunal varices as bleeding source in patients with portal hypertension are rare.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2019

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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.

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Massive Gastrointestinal Bleeding Due to Isolated Jejunal Varices in a Patient With Extrahepatic Portal Hypertension: A Case Report

Cited by 7 publications

References 9 publications

Jejunal Varices Bleeding in a Patient with Extensive Portomesenteric Thrombosis Secondary to Factor V Leiden Mutation: A Management Dilemma

Jejunal Varices Bleeding in a Patient with Extensive Portomesenteric Thrombosis Secondary to Factor V Leiden Mutation: A Management Dilemma

An Unusual Cause of Recurrent Gastrointestinal Bleeding After Whipple’s Surgery

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

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