Percutaneous paraumbilical embolization as an unconventional and successful treatment for bleeding jejunal varices

Abstract

A 48-year-old Indian male with alcoholic liver cirrhosis was admitted after being found unresponsive. He was hypotensive and had hematochezia. Esophagogastroduodenoscopy (EGD) showed small esophageal varices and a clean-based duodenal ulcer. He continued to have hematochezia and anemia despite blood transfusions. Colonoscopy was normal. Repeat EGD did not reveal any source of recent bleed. Twelve days after admission, his hematochezia ceased. He refused further investigation and was discharged two days later. He presented one week after discharge with hematochezia. EGD showed non-bleeding Grade 1 esophageal varices and a clean-based duodenal ulcer. Colonoscopy was normal. Abdominal computed tomography (CT) showed liver cirrhosis with mild ascites, paraumbilical varices, and splenomegaly. He had multiple episodes of hematochezia, requiring repeated blood transfusions. Capsule endoscopy identified the bleeding site in the jejunum. Concurrently, CT angiography showed paraumbilical varices inseparable from a loop of small bowel, which had herniated through an umbilical hernia. The lumen of this loop of small bowel opacified in the delayed phase, which suggested variceal bleeding into the small bowel. Portal vein thrombosis was present. As he had severe coagulopathy and extensive paraumbilical varices, surgery was of high risk. He was not suitable for transjugular intrahepatic porto-systemic shunt as he had portal vein thrombosis. Percutaneous paraumbilical embolization via caput medusa was performed on day 9 of hospitalization. Following the embolization, the hematochezia stopped. However, he defaulted subsequent follow-up.

Collateral Pathways in Portal Hypertension

“…The tributaries of IMV can make a major contribution toward formation of rectal varices. 54,55 Jejunoileal varices are frequently associated with prior abdominal surgery. The development of these varices is often due to collateral circulation through postoperative adhesions between the jejunum or ileum and the abdominal wall.…”

Transabdominal color Doppler ultrasonography for the diagnosis of small intestinal and vesical varices in a patient successfully treated with percutaneous transhepatic obliteration

“…Portal hypertension causes venous [5][6][7][8][9][10][11][12][13][14][15][16][17], and most bleeding intestinal varices, generally detected by previous intraabdominal surgery, are serious due to the difficulty of early diagnosis. Bleeding from vesical varices is rare in patients with portal hypertension [4,[18][19][20][21], since the bladder wall is an unusual collateral route for venous splanchnic blood.…”

A Case of Overt GI Bleeding from a Obscured Source in a Cirrhotic Patient

“…Radiological techniques with embolization have been used successfully in the active bleeding of jejunal varices. 13 There is a case report of enteroscopic sclerotherapy being successfully carried out using cyanoacrylate to treat hemorrhage from jejuna and gallbladder varices. 14 The selection of possible therapeutic options for cirrhotic patients was made considering the risks additive benefits in the situation and the health of the patients In conclusion, bleeding from ectopic varices must be considered for patients with portal hypertension and obscure overt GI bleeding, and we described a case of variceal bleeding from the jejunum in a patient with liver cirrhosis who had not previously undergone abdominal surgery.…”