Gastrointestinal Bleeding in a Patient with Pancreatico-Jejunostomy Diagnosed and Treated with Double-Balloon Endoscopy

Abstract

Purpose: Diagnosis and therapy of gastrointestinal bleeding in post-surgical patients can be very challenging due to their altered anatomy. We describe a patient who developed massive GI bleeding after a Roux-en-Y procedure and was diagnosed and treated successfully with double-balloon endoscopy (DBE). Methods: Case report. Results: A 50 year old female with history of Roux-en-Y pancreatico-jejunostomy (Puestow procedure) for chronic pancreatitis four years earlier, presented with recurrent massive gastrointestinal bleeding, requiring multiple units of blood transfusions. Standard endoscopies, push enteroscopy, as well as bleeding scans and mesenteric angiography failed to reveal an etiology. An urgent capsule endoscopy study, performed during one of the bleeding episodes, showed blood in the distal small bowel without a clear source. At DBE, the pancreatico-jejunal anastomosis including the remnant of the pancreatic duct openings were clearly seen. Active bleeding ensued about probing the blind end of the jejunal pouch. The bleeding was controlled after injecting epinephrine and the application of two endoscopic clips. Post-procedural angiography revealed a possible minute anurysm on a branch of the dorsal pancreatic artery in the area of the endoscopic clips. The patient's hemoglobin normalized over the following weeks and no further bleeding occurred at 9 months follow-up. Conclusion: In conclusion, we are presenting a case of delayed bleeding related to pancreatico-jejunostomy. This report illustrates the constantly expanding spectrum of applications for DBE both in the diagnosis and treatment of patients with altered bowel anatomy following complex surgical procedures.