Bleeding Jejunal Varices Research Articles

Current approaches to the management of jejunal variceal bleeding at the site of hepaticojejunostomy after pancreaticoduodenectomy.

Jejunal variceal bleeding at the site of hepaticojejunostomy after pancreaticoduodenectomy due to portal hypertension caused by extrahepatic portal vein obstruction is a life-threatening complication and is very difficult to treat. Pharmacotherapy, endoscopic methods, transcatheter embolization of veins supplying the jejunal afferent loop, portal venous stenting, and surgical procedures can be used for the treatment of jejunal variceal bleeding. Nevertheless, the optimal management strategy has not yet been established, which is due to the lack of randomized controlled trials involving a large cohort of patients necessary for their development.

Successful treatment using balloon-assisted enteroscopy for jejunal loop variceal bleeding after pancreaticoduodenectomy.

Management of jejunal variceal bleeding after pancreaticoduodenectomy can be difficult. Previously, these cases were treated by portal vein stenting or shunt operations, resulting in a high likelihood of rebleeding. Endoscopic management could provide an alternative to invasive surgery; however, few reports have demonstrated endoscopic treatment [1] [2] [3] [4]. We report a successful case of balloon-assisted enteroscopy for jejunal loop variceal bleeding.

Superior mesenteric vein to the right testicular vein shunt operation for jejunal varices bleeding associated with extrahepatic portal vein obstruction after pancreaticoduodenectomy: a case report

BackgroundCauses of extrahepatic portal vein obstruction include abdominal surgeries such as pancreaticoduodenectomy. We improved jejunal variceal bleeding due to extrahepatic portal vein occlusion after pancreaticoduodenectomy, by shunting of the testicular vein.Case presentationA 72-year-old man was diagnosed with extrahepatic bile duct cancer and underwent subtotal stomach-preserving pancreaticoduodenectomy 5 years ago. No postoperative complications occurred, adjuvant chemotherapy using gemcitabine hydrochloride was performed, and the patient remained recurrence-free. One year and 6 months post-operation, extrahepatic portal vein stenosis appeared, but no recurrence was noted. However, 4 years and 6 months later, recurrent gastrointestinal bleeding occurred, and the patient was diagnosed with an extrahepatic portal vein obstruction. Double-balloon enteroscopy showed capillary dilatation and varicose veins in the hepaticojejunostomy region, and venous bleeding from collateral blood vessels was diagnosed. A superior mesenteric vein to the right testicular vein shunt operation was performed, following which the gastrointestinal bleeding disappeared, and the anemia improved. Although transient hepatic encephalopathy occurred, conservative treatment relieved it. Double-balloon enteroscopy confirmed the disappearance of abnormal blood vessels.ConclusionsA portosystemic shunt operation using the right testicular vein effectively relieved refractory variceal bleeding around the hepaticojejunostomy site in the jejunum due to an extrahepatic portal vein obstruction after pancreaticoduodenectomy.

Treatment of jejunal variceal bleeding with portal vein thrombosis after bile duct cancer surgery by short single-balloon endoscope.

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PS01.080: A CASE REPORT OF JEJUNAL VARICEAL BLEEDING SUCCESSFULLY TREATED WITH PERCUTANEOUS TRANSHEPATIC OBLITERATION AFTER SURGERY OF ESOPHAGOGASTRIC JUNCTIONAL CARCINOMA

Abstract Background Varicose veins in the esophagogastric junction rarely occur after surgery of esophagogastric junctional carcinoma, because the collateral pathway of the left gastric vein and short gastric vein was sacrificed. We presented a case of jejunal variceal bleeding successfully treated with percutaneous transhepatic obliteration after surgery of esophagogastric junctional carcinoma. Methods Case report. Results A 50-year-old man with alcoholic liver cirrhosis (Child-B) was admitted for abdominal pain, three months after proximal gastrectomy for esophagogastric junctional carcinoma. After diagnosed with peritonitis due to jejunal perforation, emergency surgery was performed. The next day after surgery, he had developed a lot of black stool. Gastroduodenoscopy revealed the variceal bleeding at the anal side of the esophagojejunal anastomois. Although endoscopic clipping was performed, intermittent bleeding was observed for several days. Since the contrast-enhanced computed tomography scanning revealed jejunal vein dilation at the anal side of the esophagojejunal anastomois, we planned to perform percutaneous transhepatic obliteration. Percutaneous transhepatic portography revealed jejunal varices and drained to the inferior vena cava, and continuously obliterated by 5% EOI (Ethanolamine oleate iopamidol). He was discharged without re-bleeding on the 14th day after the obliteration. Conclusion Percutaneous transhepatic obliteration might be a useful treatment option for jejunal variceal bleeding after surgery of esophagogastric junctional carcinoma. Disclosure All authors have declared no conflicts of interest.

Portal Vein Stenting for Delayed Jejunal Varix Bleeding Associated with Portal Venous Occlusion after Hepatobiliary and Pancreatic Surgery.

ObjectiveThe study aimed to describe portal stenting for postoperative portal occlusion with delayed (≥ 3 months) variceal bleeding in the afferent jejunal loop.Materials and MethodsEleven consecutive patients (age range, 2–79 years; eight men and three women) who underwent portal stenting between April 2009 and December 2015 were included in the study. Preoperative medical history and the postoperative clinical course were reviewed. Characteristics of portal occlusion and details of procedures were also investigated. Technical success, treatment efficacy (defined as disappearance of jejunal varix on follow-up CT), and clinical success were analyzed. Primary stent patency rate was plotted using the Kaplan-Meier method.ResultsAll patients underwent hepatobiliary-pancreatic cancer surgery except two children with liver transplantation for biliary atresia. Portal occlusion was caused by benign postoperative change (n = 6) and local tumor recurrence (n = 5). Variceal bleeding occurred at 27 months (4 to 72 months) and portal stenting was performed at 37 months (4 to 121 months), on average, postoperatively. Technical success, treatment efficacy, and clinical success rates were 90.9, 100, and 81.8%, respectively. The primary patency rate of portal stent was 88.9% during the mean follow-up period of 9 months. Neither procedure-related complication nor mortality occurred.ConclusionInterventional portal stenting is an effective treatment for delayed jejunal variceal bleeding due to portal occlusion after hepatobiliary-pancreatic surgery.

An “Obscure” Presentation of Early Cirrhosis: Bleeding Jejunal Varices as Initial Presentation of Cryptogenic Cirrhosis

Introduction: Isolated small intestinal varices are an uncommon manifestation of portal hypertension. Although uncommon, small intestinal variceal hemorrhage can be life-threatening. We report a case of isolated small bowel variceal hemorrhage in a man with previously undiagnosed cirrhosis. Case: An 82 year-old man presenting with 5 weeks of melena and anemia (hemoglobin 5.7 g/dL) was admitted to the hospital. Two months prior, he had undergone coronary artery bypass graft surgery. His post-operative course was complicated by new-onset atrial fibrillation; he was started on therapeutic anticoagulation with apixaban. His past medical history was otherwise notable for a history of chronic kidney disease secondary to hypertension requiring kidney transplant fourteen years prior. Inpatient EGD was normal. Colonoscopy with examination of ileum was normal except for colonic diverticulosis without active or stigmata of recent bleeding. A CT of the abdomen and pelvis without contrast revealed no abnormalities of the liver or spleen. The patient was instructed to stop apixaban and was discharged with stable hemoglobin level of 8.0 g/dL and platelet count 158,000. He had no further episodes of melena while inpatient. An outpatient capsule endoscopy revealed the presence of blue tinged nodules in the distal jejunum. Double balloon enteroscopy confirmed the presence of jejunal varices without evidence of active bleeding or other high-risk stigmata (Figure 1). The patient underwent liver ultrasound, which showed liver contour nodularity and mildly enlarged splenic vein and spleen. There was normal flow through hepatic and portal veins and hepatic arteries.Figure 1Discussion: We present a case of small intestinal varices in a patient with no previous diagnosis or manifestations of portal hypertension. Small intestinal varices are uncommon and are rarely reported to cause gastrointestinal hemorrhage, but can cause significant blood loss when hemorrhage does occur. Small intestinal variceal bleeding can present subtly with occult gastrointestinal hemorrhage or dramatically with hypovolemic shock, hematochezia and/or hematemesis. Small intestinal varices are most often caused by portal hypertension in the setting of liver cirrhosis or portal vein thrombosis, but have also been associated with adhesions from previous abdominal surgeries or other vascular anomalies. Prompt identification and treatment, if necessary, are essential in the management of small intestinal varices.

Portal vein stent placement with or without varix embolization of jejunal variceal bleeding after hepatopancreatobiliary surgery.

Background Extrahepatic portal hypertension after surgery involving the duodenum or jejunum might result in massive ectopic variceal bleeding. Purpose To report the results of portal vein stent placement with the addition of variceal embolization. Material and Methods Between January 2000 and June 2015, portal vein stent placement was attempted in 477 patients. Of these, 22 patients (age, 63 ± 10 years) with jejunal variceal bleeding caused by portal vein obstruction after surgery were included in this study. Computed tomography (CT) findings before and after treatment and the rates of technical and clinical success, complications, and clinical outcomes were retrospectively evaluated. Results Stent placement was successful in 19 of 22 patients. Additional variceal embolization was performed in five cases. Clinical success, defined as the cessation of bleeding without recurrence within 1 month, was achieved in 18 of 19 patients with technical success. One patient developed recurrent bleeding 4 days after stent placement and was successfully treated with additional variceal embolization. There were no procedure-related complications. A regression of the jejunal varices was noted in 14 of 19 patients on follow-up CT scans. During the follow-up period (258 days; range, 7-1196 days), stent occlusion and recurrent bleeding occurred in six and four patients, respectively, of the 19 patients who achieved technical success. Statistical analyses revealed no significant differences regarding stent patency between benign and malignant strictures. Conclusion Percutaneous, transhepatic, portal vein stent placement with or without jejunal variceal embolization appears to be a safe and effective treatment for jejunal variceal bleeding after surgery.

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

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.

Jejunal Variceal Bleeding Successfully Treated with Percutaneous Coil Embolization

A 52-yr-old male with alcoholic liver cirrhosis was hospitalized for hematochezia. He had undergone small-bowel resection due to trauma 15 yr previously. Esophagogastroduodenoscopy showed grade 1 esophageal varices without bleeding. No bleeding lesion was seen on colonoscopy, but capsule endoscopy showed suspicious bleeding from angiodysplasia in the small bowel. After 2 weeks of conservative treatment, the hematochezia stopped. However, 1 week later, the patient was re-admitted with hematochezia and a hemoglobin level of 5.5 g/dL. Capsule endoscopy was performed again and showed active bleeding in the mid-jejunum. Abdominal computed tomography revealed a varix in the jejunal branch of the superior mesenteric vein. A direct portogram performed via the transhepatic route showed portosystemic collaterals at the distal jejunum. The patient underwent coil embolization of the superior mesenteric vein just above the portosystemic collaterals and was subsequently discharged without re-bleeding. At 8 months after discharge, his condition has remained stable, without further bleeding episodes.

Percutaneous Retrograde Sclerotherapy for Refractory Bleeding of Jejunal Varices: Direct Injection via Superficial Epigastric Vein

Small-bowel varices are rare and almost always occur in cases with portal hypertension. We encountered a patient with bleeding jejunal varices due to liver cirrhosis. Percutaneous retrograde sclerotherapy was performed via the superficial epigastric vein. Melena disappeared immediately after treatment. Disappearance of jejunal varices was confirmed by contrast-enhanced computed tomography. After 24months of follow-up, no recurrent melena was observed.

Effective Portal Stent Placement Using "Kissing" Technique by Transileocolic Approach for Jejunal Variceal Bleeding in Afferent Loop Caused by Local Recurrence of Hilar Cholangiocarcinoma: A Case Report

Effective Portal Stent Placement Using "Kissing" Technique by Transileocolic Approach for Jejunal Variceal Bleeding in Afferent Loop Caused by Local Recurrence of Hilar Cholangiocarcinoma: A Case Report

Massive gastrointestinal bleeding from splenojejunal varices in a child: A complication of splenic-vein occlusion following near-total pancreatectomy for hyperinsulinemic hypoglycemia

Severe jejunal variceal bleeding occurred in a child with splenic-vein occlusion following a near-total pancreatectomy for hyperinsulinemic hypoglycemia. This rare sequela of splenic-vein occlusion required dismantling of the varices and splenectomy.