Laparotomy Assisted Injection of Jejunal Varices for Overt Small Bowel Bleeding: 2016 ACG Presidential Poster Award

Abstract

A 54 year old male was admitted to the hospital for management of asymptomatic anemia (hemoglobin 4.6 g/dL; baseline 11 g/dL). He had a history of orthotopic liver transplant with a roux-en-Y choledochojejunostomy in 2005 for primary sclerosing cholangitis mediated cirrhosis. His post-operative course was complicated by extensive mesenteric thrombosis leading to portal hypertension and esophageal varices. During his hospital stay, he developed multiple episodes of hematochezia and hypotension which required 18 units of blood products over 4 days. EGDs, push enteroscopy, flexible sigmoidoscopies, CT, and a bleeding scan did not identify a source of active bleeding. IR guided angiography and a repeat CT scan showed the presence of possible jejunal varices (figure 1). Since these varices were veins from cavernous transformation of the portal vein, balloon-occluded retrograde transvenous obliteration was not performed due to fear of vascular compromise to the allograft. A double balloon enteroscopy was done and the choledocho-enteral anastomosis was visualized along with varices with a small clot suggestive of recent bleeding. Doppler confirmed brisk venous flow. Prior to intervention the varix began to bleed. Due to the extensive loop formation and unstable position of the endoscope, intervention could not be safely performed. After appropriate resuscitation in the ICU, the patient was taken to the operating room for laparotomy, enterotomy and intra-operative endoscopic intervention. There was a column of grade II varix in the jejunum measuring 7 mm in largest diameter (Figure 2). Doppler assessment confirmed brisk venous flow. An initial injection of 2.5cc of cyanoacrylate was not successful in obliterating the doppler flow in the varix. A subsequent injection of 2 mL cyanoacrylate led to eradication of the varix which was confirmed by doppler assessment. Following intraoperative intervention he developed jaundice and had a prolonged hospital course with gradual recovery. The patient fully recovered and had no further bleeding or need for transfusion in 3 months of follow-up. Variceal injection of cavernous transformation of the portal vein at the choledocho-jejunal anastomosis have not been reported. We describe the first successful management of this type of varix in a post-transplant patient.Figure 1Figure 2