Jejunal Varices Detected on Capsule Endoscopy as the Cause of Recurrent GI Bleed

Abstract

Purpose: We present a case of a 45 year old male with history of abdominal gunshot wound in 1980's and small wedge resection of the liver for laceration. Patient developed GI hemorrhage in 2004, and workup revealed hepatic hemangiomas as the likely source. Patient reportedly had embolization with coils without success and continued to have bleeding episodes. Several months later, he had right hepatectomy and Roux-en-Y hepaticojejunostomy since hepatic hemangiomas were still the suspected etiology of his GI bleed. However, he continued to have bleeding. At some point around this time, he was diagnosed with portal vein thrombosis and portal hypertension, though the exact details of this diagnosis are not known. He had extensive evaluations including multiple endoscopies at two teaching medical centers with no definitive conclusion. Patient was then seen at a different hospital for a massive GI hemorrhage in 2006. During that admission, EGD/enteroscopy showed grade I esophageal varices, questionable gastric varices, and mild portal gastropathy. Colonoscopy showed mild portal colopathy and small internal hemorroids. Tagged RBC scans and angiogram did not locate the source of bleed. CT scan suggested the possibility of varices within jejunum. This is when the patient was referred to our facility for capsule endoscopy, which demonstrated four clusters of varices in jejunum with fresh blood approximately 2 hours and 40 minutes into the study. The patient was not a candidate for TIPS because of his extensive portal vein thrombosis and underwent surgery for splenorenal shunt with an associated splenectomy. He currently remains stable without any further episodes of gastrointestinal bleeding. Bleeding from jejunal varices is an uncommon manifestation of portal hypertension. Recently, capsule endoscopy has been used in the workup of obscure-overt GI bleed as in our case. Our case represents one of the first reports of jejunal varices detected on capsule endoscopy as the cause of GI hemorrhage.[figure1]Figure