Jejunal Variceal Bleeding in an Undiagnosed Cirrhotic: Detected on Capsule Endoscopy and Treated With Embolization

Abstract

Case Report: A 62-year-old woman presented with hematochezia for 2 days with acute blood loss anemia (drop in Hb from 12 to 7 gm/dL). The patient denied nausea, vomiting, abdominal pain, fever, or change in appetite or weight. She had no prior history of melena, hematemesis, or GI bleeding. Her past medical history was significant for HTN, DM, CHF, and dual renal-pancreas transplant complicated by failed renal graft now on chronic hemodialysis. Physical exam revealed orthostasis and tachycardia. After initial resuscitation, she underwent EGD and colonoscopy, which were unremarkable. Tagged-RBC nuclear scan localized bleeding in LLQ; however, subsequent angiography was unable to localize the bleed. Video capsule endoscopy (VCE) showed large ectopic varices in the jejunum without active bleeding. She underwent transjugular liver biopsy and HVPG measurement, confirming cirrhosis and portal HTN. Extensive work-up for etiology of cirrhosis was negative, and she was diagnosed with cryptogenic cirrhosis. A month later, she again presented with hematochezia. Transjugular intrahepatic porto-systemic shunt (TIPS) was not an option, given her history of ESRD on HD and CHF. She underwent percutaneous coil embolization of superior mesenteric artery branches with complete occlusion of the varices. Since then, she has not had further bleeding. Discussion: While esophagogastric varices are common manifestations of portal hypertension, jejunal variceal bleeding is a rare complication of liver cirrhosis. Jejunal varices account for 5% of all variceal bleeding and are found mostly in patients with prior history of abdominal surgery like our patient. The incidence of bleeding is low, but it can result in severe, life-threatening hemorrhage with in-hospital mortality rates approaching 40%. Endoscopic diagnosis and management is often limited by poor visualization of varices due to their distal location and relatively small size. VCE might show ectopic varices, mostly in the small intestine, along with other changes of portal hypertension such as portal enteropathy. Therapeutic options include endoscopic sclerotherapy, vasoactive drugs, surgery, and TIPS with or without focal variceal embolization. Unless the underlying portal hypertension is treated, suture ligation of varices and sclerotherapy have high rebleeding rates. Surgical portocaval shunts are effective with low rebleeding rates, but only recommended in patients who can tolerate a major surgical procedure. TIPS can effectively reduce portocaval gradient and consequently decrease the risk of rebleeding. Embolization should be considered for patients who are not good candidates for endotherapy, TIPS, or surgery.