Small Intestine Varices in Cirrhosis at a High-Volume Liver Transplant Center: A Retrospective Database Study and Literature Review

Abstract

INTRODUCTION: Esophageal varices are a well-characterized sequela of portal hypertension; however, less is known about varices arising in ectopic locations. We aimed to describe bleeding small intestine varices (SIV) in patients with cirrhosis and compare characteristics and outcomes to published case reports. METHODS: We performed an institutional chart review using billing codes and natural language processing between 2008 and 2019. Inclusion criteria were adult patients with cirrhosis and SIV verified by endoscopy, video capsule, or imaging. Patients with noncirrhotic portal hypertension and stomal varices were excluded. We examined demographic and clinical factors, characteristics of SIV, bleeding, intervention, and outcomes in our series and collated data from published cases identified during a literature review. RESULTS: We identified 71 patients with cirrhosis and SIV (18 bled). The literature search yielded 76 cases with bleeding SIV. Our series and published cases were matched for age, sex, liver disease etiology, and SIV location. Length of stay and transfusion requirements were similar. Aggregate initial treatments (number, hemostasis rate) included medical (n = 7, 57%), endoscopic (n = 48, 56%), interventional radiology (n = 31, 77%), and surgery (n = 8, 87%). Hospital and overall mortality rates were higher in our series (22% and 38%) compared with the published cases (5.3% and 18.4%), respectively (P = 0.02 and P = 0.07). DISCUSSION: A quarter of patients with cirrhosis and SIV experience bleeding, with high transfusion requirements, frequent need for secondary interventions, and high mortality. These findings highlight the need for a multidisciplinary approach and second-line therapeutic modalities in the timely management of bleeding SIV in cirrhosis.

Massive hematochezia due to jejunal varices successfully treated with coil embolization

“…Small bowel varices‐related bleeding was reported to be massive in several cases with patients presenting with hemodynamic instability and hemoglobin levels of 6 g/dL or lower 2,5,8,11,12 . The bleeding‐related mortality was estimated in a recent study to range from 5.3% to 18.4% 10 …”

“…Although their role has not yet been established in small intestine bleeding, somatostatin analogs have been used as a temporizing measure by several authors as well as ourselves. 10,14 To date, no evidence-based guidelines dealing with jejunal varices treatment have been published. Difficult to localize and reach with limited published data, management of small bowel varices remains challenging.…”

“…9 Small bowel varices are reported to bleed in 25% of cases. 10 The clinical presentation of small bowel varices is typically characterized by a triad: history of abdominal surgery, PHT and hematochezia without hematemesis. Yet, several authors have reported cases similar to ours, where patients had not been operated on.…”

“…When it comes to clinical management, the first step usually consists in resuscitation measures and correction of anemia. Although their role has not yet been established in small intestine bleeding, somatostatin analogs have been used as a temporizing measure by several authors as well as ourselves 10,14 . To date, no evidence‐based guidelines dealing with jejunal varices treatment have been published.…”

“…2,5,8,11,12 The bleeding-related mortality was estimated in a recent study to range from 5.3% to 18.4%. 10 Exploring the small bowel can be performed with contrast imaging, nuclear studies, angiography or with endoscopic procedures such as capsule endoscopy or push enteroscopy. In this context, CT scan or angiography are thought to be the most suitable as they can be immediately performed with no required preparation which make them appropriate for emergency cases.…”