Small Bowel Variceal Bleeding Secondary to Gyno-Enteric Shunt

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Introduction: A 70-year-old woman with a history of cirrhosis secondary to hemochromatosis and prior alcohol abuse (with long-term abstinence) was admitted for large-volume hematochezia. She had a history of esophageal variceal bleeding in the past, which was effectively treated with esophageal variceal band ligation. Her last EGD and banding was performed 4 years prior to presentation with obliteration of esophageal varices. Two years prior to admission, she had a negative surveillance colonoscopy for a personal history of colon polyps. A bleeding scan was performed shortly after admission. Accumulation of radiotracer was noted in the right lower quadrant, suggesting active hemorrhage from the distal small bowel or right colon. Mesenteric angiography was performed with the intention of hemostasis following the positive bleeding scan. A clear bleeding site was not identified. At this point, the patient had received 20 units of red blood cells, several units of FFP, and vitamin K. The platelet count remained above 60 K/μL. She did not receive platelet transfusion. Her fibrinogen level was normal. As the site of bleeding remained unclear, a colonoscopy was performed to the distal 30 cm of ileum. This demonstrated blood clots and fresh blood to the proximal extent of the exam. EGD was performed using a pediatric colonoscope. The proximal 80 cm of small bowel was examined. EGD-enteroscopy did not demonstrate a clear bleeding source. No esophageal or gastric varices were seen. To further define the bleeding site, abdominal and pelvic CT angiography was performed. A portosystemic shunt between the parametrial veins and the superior mesenteric vein was identified (Figure 1). A partial portal venous thrombosis was also seen. The patient was taken to the operating room for exploratory laparatomy. The involved segment of small bowel was resected and suture ligation of the shunt was performed. Following surgery, there was no further hematochezia.Figure 1: Small bowel varices with communication to the superior mesenteric vein and parametrial veins.