Jejunal Varices Research Articles

Jejunal varices with extra hepatic portal vein obstruction: A case report.

Introduction and importanceExtrahepatic portal vein obstruction (EHPVO) with portal hypertension is rare in children. Intestinal varices as new collaterals accompanying portal hypertension are very rare.Presentation of caseWe report an unusual case of a 12-year-old boy with EHPVO with gastrointestinal bleeding from ectopic jejunal varices, without any gastroesophageal varices.DiscussionPortal hypertension is the most common cause of EHPVO. Among various ectopic varices, intestinal varices are found distal to the duodenum and present with complaints of hematochezia, melena, or intraperitoneal bleeding. The diagnosis of the EHPVO is aided by imaging investigations like Doppler ultrasound, computed tomography, or magnetic resonance imaging. A multidisciplinary team including gastroenterologists, interventional radiologists, surgeons, and intensivists is crucial in the management of ectopic varices.ConclusionJejunal varices must be considered in the differential diagnosis of gastrointestinal (GI) hemorrhage in patients with a negative source of bleed on upper and lower GI endoscopy.

Jejunal variceal rupture in a patient with myelofibrosis: a case report

An 80-year old man with myelofibrosis and chronic renal disease was admitted to our hospital because of severe anemia and gastrointestinal bleeding. Although no bleeding was observed by upper or lower endoscopy, contrast-enhanced computed tomography revealed an enhanced area in the small intestinal wall that was suspected of being the bleeding site, and was confirmed by double-balloon endoscopy. Based on endoscopic findings, it was difficult to differentiate between variceal rupture and collapse of a submucosal tumor. We performed segmental resection of the small intestine to make a definitive diagnosis and achieve reliable hemostasis. The gross findings confirmed a variceal rupture from the small intestine. His gastrointestinal bleeding stopped and his anemia improved following surgery. Although some cases of portal hypertension in association with myelofibrosis have been reported, we are aware of no prior reports of variceal rupture in the small intestine. To our knowledge, this is the first reported case of ectopic jejunal varices in a patient with myelofibrosis.

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

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Bleeding from jejunal varices formed at the Roux-en-Y jejunum site caused by the compression of the left renal vein after living donor liver transplantation with renoportal anastomosis

BackgroundRenoportal anastomosis is an option for the portal vein reconstruction of a liver transplantation with grade 4 portal vein thrombosis and a splenorenal shunt. Here, we report the case of gastrointestinal bleeding who underwent living donor liver transplantation (LDLT) with renoportal anastomosis.Case presentationSix-year-old female patient who underwent LDLT with renoportal anastomosis at 1 year of age had severe anemia with normal liver function during the follow-up period. The varices at the Roux-en-Y jejunum were considered the source of bleeding, and the compression of the left renal vein, which is known as a cause of Nutcracker syndrome, seemed to induce venous hypertension through the splenorenal shunt, which might induce the formation of the varices. She underwent percutaneous transhepatic sclerotherapy of the varices, and the anemia improved at her last follow-up, 6 months after sclerotherapy. This is the first reported case of Roux-en-Y jejunal varices bleeding related to the compression of the left renal vein after LDLT was performed with renoportal anastomosis.ConclusionsAlthough renoportal anastomosis should be cautiously performed when there are no options for severe portal vein thrombosis, the status of the left renal vein and new collateral formation should be observed carefully during the follow-up period in pediatric cases of renoportal anastomosis.

Risk Factors Regarding Portal Vein Thrombosis in Chronic Liver Disease

Abstract The portal vein thrombosis (PVT) is one of the most frequent vascular diseases of the liver, with a high rate of morbidity and mortality. The most common causes of the PVT are hepatic cirrhosis, hepatobiliary neoplasms, inflammatory and infectious abdominal diseases, and myeloproliferative syndromes.(1,2) The natural progress of the PVT has as a result portal hypertension which leads to splenomegaly and the formation of portosystemic collateral vessels, as well as gastroesophageal, duodenal and jejunal varices. Ultrasonography, especially Doppler ultrasound, is the most widely used imaging method to asses, supervise and diagnose PVT in patients with hepatopathies. The purpose of acute PVT treatment is to re-permeabilize the obstructed vessels; the endoscopic ligature of the varices in the eventuality of their rupture is safe and extremely efficient in chronic PVT. To conclude, PVT is the most common hepatic vascular disorder, and its prevalence has increased particularly among the patients with chronic hepatopathies.(3)

Outcomes of Double Balloon Enteroscopy for Managing Overt Small Bowel Bleeding

Abstract Background The commonest therapeutic indications for double balloon enteroscopy (DBE) includes removal of retained video capsules, dilatation of strictures, polypectomy, and managing obscure small bowel bleeding. We review our experience in managing active small bowel bleeding with DBE. Methods A retrospective review was done for all the cases undergoing DBE from August 2017 to July 2019. Patient follow-up data was collected. Results Among 25 cases with a median age of 46.8 (range 25–65 years), 17 males (68%) underwent DBE for suspected small bowel bleeding. The commonest presenting complaint was melena 19 (76%). The findings were positive (diagnostic yield) in 18 (72%) patients with an antegrade approach. Active bleeding was associated with Dieulafoy's lesion (n = 6), gastrointestinal stromal tumors (GIST) (n = 4), jejunal varices (n = 3), angioectasia (n = 3), and ulcer (n = 2), who then underwent successful intervention. The rest of the patients underwent both antegrade and retrograde approach but failed to immediately identify an alternative diagnosis. Mean (standard deviation [SD]) time taken for antegrade enteroscopy was 96.7 (15.3) mins and 67.8 (13.6) mins for retrograde enteroscopy. The median duration between the last bleeding episode and timing of DBE was 9 (range 6–15 hours). No major complications were seen during or immediately postprocedure. Conclusion DBE is useful in identifying and treating active small bowel bleeding. Being invasive and time-intensive, it is easy to miss lesions and, therefore, needs appropriate expertise. DBE does appear to be relatively cheaper, with better patient acceptance and time saving.

2011 Jejunal Varices: A Diagnostic and Therapeutic Nightmare!

INTRODUCTION: Gastrointestinal hemorrhage is a common complication among cirrhotic patients with portal hypertension, due to the development of bleeding varices. While esophagus and stomach are the most common location for development of varices, it can also rarely occur in ectopic locations, such as the jejunum, ileum, rectum and duodenum. Here, we report a case of a patient with severe gastrointestinal hemorrhage due to a bleeding jejunal varix. CASE DESCRIPTION/METHODS: A 55-year-old male with a history of hypertension, splenectomy, and alcoholic cirrhosis had presented initially to an outside ED with complaints of bright red blood per rectum. At admission, he required multiple infusions of pRBCs, and several upper endoscopies due to refractory bleeding with unclear source. Initial endoscopies showed non-bleeding esophageal varices, for which he underwent ligation banding. However, he continued to deteriorate, developing recurrent melena, hypotension, and syncope. On admission to our hospital, he had a repeat upper endoscopy, lower endoscopy, CT angiography and tagged red blood cell study; but we were unable to localize the source of the bleeding. He continued to deteriorate, and also developed a PEA arrest in the setting of a profuse bright red blood per rectum, requiring massive transfusion protocol. After successful resuscitation, he underwent a small bowel enteroscopy, which finally revealed a bleeding jejunal varix. However, the varix was not amenable to any endoscopic intervention. Subsequently, he underwent a successful balloon-occluded retrograde transvenous obliteration (BRTO) of varix. Patient’s condition stabilized and after adequate recovery, he was extubated. DISCUSSION: Early diagnosis of ectopic varices is difficult to achieve due to low likelihood of presentation and low sensitivity to various diagnostic tests. Due to its low prevalence, there are no protocols for its management. As in our patient, endoscopic intervention such as sclerotherapy and band ligation can be difficult due to the narrow lumen of the small bowel. Alternatively, BRTO and TIPS are also considered effective therapeutic options. However, due to his poor liver function, BRTO was a better alternative. In conclusion, through this case report, we want to emphasize the importance of early recognition and appropriate management of ectopic varices due to its potential for massive, even fatal hemorrhage.

Endoscopic sclerotherapy under balloon-assisted enteroscopy for hemorrhagic jejunal varices after choledocho-jejunostomy.

Endoscopic sclerotherapy under balloon-assisted enteroscopy for hemorrhagic jejunal varices after choledocho-jejunostomy.

P4.38: Bleeding episodes following intestinal transplantation- think outside the box

Introduction: In intestinal transplantation (ITx), bleeding from the intestinal tract is a rare complication and the differential diagnosis include infection, rejection, and PTLD. We report on a case series with bleeding from ectopic varices Methods: Case 1: 15 year old girl (intestinal pseudo-obstruction) presented with bleeding from the stoma, 8 years after Liver ITx. Graft biopsies excluded rejection and PTLD. An upper GI endoscopy (UGIE) showed no evidence of active bleeding. Repeat UGIE 3 wks later showed a cluster of varices at the upper graft anastomosis. ATIPPS was performed which stopped the bleeding. Two mths after TIPPS, she had recurrent bleeding from the jejunal varices, despite an patent TIPPS. She developed multi-organ failure and she eventually died. Case 2: A 8 year boy (MVID), presented with malaena & splenomegaly 4 years after isolated ITx. CT Angio revealed a patent portal vein & intra-abdominal varices in small bowel. A further UGIE revealed varices at upper graft anastomosis and were injected with thrombin. A TIPPS was performed, which stopped bleeding. He developed multiorgan failure and subsequently died. Case 3: 3 year old girl (gastroschisis) presented with recurrent intermittent bleeding from the stoma 1 year after Liver ITx. A initial UGIE showed no bleeding point and graft biopsies were normal. Video-capsule endoscopy done showed no varices. CT angio could not pinpoint the location of bleeding, but demonstrated occlusion of porta-caval shunt. Due to ongoing blood transfusion requirements, a further UGIE showed varices at the junction of the upper graft anastomosis. The child continues to have intermittent episodes of bleeding but the family has declined a definitive surgical option. Discussion: The bleeding episodes in our children originated from the ectopic varices that developed at level of the upper graft anastomosis due to altered hemodynamics following portacaval shunt blockage in two liver ITxgrafts. In the child with isolated ITx, it was due to progression of liver disease and possibly because of adhesions from repeated abdominal surgeries, which then predisposes to the development of collaterals at the upper graft anastomosis. Conclusion: Ectopic varices should be in the differential diagnosis of children presenting with bleeding episodes following ITx especially when the graft biopsies are normal.

Massive obscure GI bleeding from Idiopathic Jejunal varices identified using single balloon enteroscopy

Background: Obscure gastrointestinal bleeding from idiopathic small bowel varices is both a diagnostic and management challenge for physicians. There are very few cases reported in the literature and there is no consensus on management recommendations.
 Aims: To present the case of a 34-year-old male patient with bleeding from idiopathic jejunal varices and to review similar cases in the literature. 
 Methods: A case of idiopathic jejunal varices is reported. A literature review was conducted and a total of 24 articles describing idiopathic small bowel varices were identified.
 Results: Case Report: A 34-year-old gentleman was referred for worsening obscure gastrointestinal bleeding and anemia. Anterograde single balloon enteroscopy revealed several petechial like lesions that were not classic for angiodysplasia. These lesions were initially treated with argon plasma coagulation and clipped, which did not resolve the patient’s persistent anemia. No venous abnormalities were identified on computed tomography of the abdomen and pelvis with contrast. The patient underwent an endoscopically assisted exploratory laparoscopy that was converted to a laparotomy upon finding of grossly abnormal distal jejunum. Dilated and tortuous varicosities were identified involving approximately 150 cm of small bowel. It was decided to resect the 40 cm segment of jejunum in which varices were visible endoscopically. There was no evidence of thrombosis in the resected specimen. The patient suffered a pulmonary embolism post-operatively, believed to be provoked by the surgery. The patient has had no re-bleeding 12 months post-resection.
 Literature Review: Both familial and non-familial accounts of small bowel varices in the absence of a primary cause have been reported in the literature. When supportive therapy is insufficient, the most common treatment modality chosen is surgical resection. Select cases have also demonstrated that sclerotherapy and varix dissection can be used for to treat these lesions.
 Conclusions: Idiopathic small bowel varices pose both diagnostic and therapeutic challenges for physicians. In the literature, several treatment modalities have been shown to be successful; these include surgical resection, varix dissection and sclerotherapy. There is no consensus on the preferred treatment strategy. This report demonstrates endoscopically assisted surgical resection as a viable management strategy for bleeding of idiopathic small bowel varices, an uncommon cause of occult GI bleeding.

EUS-Guided Coil and Glue Embolization of Jejunal Varices: Presidential Poster Award

Jejunal varices are uncommon and challenging to manage given their anatomical location. There is currently no standardized treatment. However, EUS-guided cyanoacrylate glue injection and coil embolization have been reported. We describe successful use of EUS-guided cyanoacrylate glue and coil embolization for non-bleeding jejunal varices. A 58-year-old male patient with history of Roux-en-Y gastrojejunostomy presented with hematemesis and hematochezia. On initial assessment via push enteroscopy, non-bleeding jejunal varices with high risk stigmata were identified 15-20cm distal to the gastrojejunostomy. A varix measuring up to 8 millimeters in diameter was identified sonographically with color Doppler. After accessing the varix with 19 gauge FNA needle, D5W was injected into the vessel to confirm the position. Coil embolization was chosen over glue injection alone due to the large size of the vessel and concern for glue migration. A 0.035-inch cone-shaped fibered coil was chosen for embolization. Coil size was chosen to be approximately 20 percent larger in diameter than the target vessel to create enough radial force to prevent migration. The coil contains thrombogenic fibers to promote clot aggregation and occlude the vessel. The coil was deployed into the varix using a stylet and was identified as hyper-echogenic expansion occupying the lumen of the varix on EUS. The needle was left in place after coil deployment to maintain access in case a second coil or glue injection was needed. Two minutes after coil placement, no further flow was seen within the vessel. Therefore, glue injection was not performed and the needle was retracted. For a smaller varix measuring 5 millimeters in diameter, glue injection was deemed sufficient for embolization. The varix was accessed with a 22 gauge FNA needle and 2 cubic centimeters of 100% n-butyl-cyanoacrylate glued was injected. After confirming no active flow in the vessel after glue injection, the needle was retracted. Enteroscopy was performed after embolization and no active bleeding was seen from the varices. EUS-guided intervention can be successfully used for embolization of small bowel varices. EUS-guided coil embolization may be used in larger varices to prevent glue migration. EUS-guided cyanoacrylate glue alone is often effective for embolization of smaller varices. Watch the video: https://goo.gl/cxrwTr1695_A Figure 1. Left: Coil with thrombogenic fibers was chosen. The fibers promote clot aggregation and occlude the vessel Right: A large varix measuring up to 8 millimeters in diameter on color Doppler is identified1695_B Figure 2. Left: Deployed coil is identified as hyper-echogenic expansion occupying the lumen of the large varix on EUS (marked with a red circle) Right: 2 minutes after the coil placement, no further flow is seen within the vessel on color Doppler1695_C Figure 3. Left: Smaller varix measuring up to 5 millimeters is identified with color Doppler Right: Diminished flow through the varix on color Doppler is noted after injection of 2 cubic centimeters of 100% n-butyl-cyanoacrylate glue

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.

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

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

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.

Successful Coil Embolization Without Balloon Occlusion of Mesocaval (Jejunal) Varices - a Case of Obscure Gastrointestinal Bleeding in a Patient with NASH Cirrhosis and Portal Hypertension

Successful Coil Embolization Without Balloon Occlusion of Mesocaval (Jejunal) Varices - a Case of Obscure Gastrointestinal Bleeding in a Patient with NASH Cirrhosis and Portal Hypertension

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.

Refractory bleeding from ectopic varices stopped by percutaneous transhepatic portal vein recanalization and stenting

Ectopic varices is an uncommon cause of gastrointestinal bleeding. We reported a case of severe bleeding due to jejunal varices which arose as a complication of extrahepatic portal vein thrombosis. The patient was successfully treated by portal vein recanalization and percutaneous transhepatic stent placement.

Balloon-Occluded Retrograde Transvenous Obliteration of Jejunal Varices: A Case Report, Therapeutic Approach

Jejunal varices occur very rarely [1–5]. Moreover, unlike esophageal or gastric varices, they are difficult to treat with an endoscopic approach because of their anatomic location. While surgery is an option, it is invasive and risky, especially in patients with liver cirrhosis and poor hepatic function. Thus, endovascular intervention may be a better approach for jejunal varices. The endovascular treatments for gastric varices include balloon-occluded retrograde transvenous obliteration (BRTO), percutaneous transhepatic obliteration, and transjugular intrahepatic portosystemic shunt (TIPS). TIPS reduces portal pressure by diverting portal flow to a hepatic vein through an artificial shunt, thereby reducing variceal hypertension and risk of bleeding, but can worsen liver function and cause hepatic encephalopathy. In contrast, BRTO directly induces sclerosis of the varices. Therefore, hepatic encephalopathy is not associated with this procedure. BRTO also associates with a lower rate of variceal bleeding recurrence than TIPS [6, 7]. For these reasons, BRTO is currently considered to be the first endovascular treatment choice for gastric varices. BRTO is a minimal invasive radiologic procedure that gives the sclerosing agent while blocking the outflow by a balloon catheter [8]. This report describes a case of jejunal varices treated with BRTO.

Video capsule endoscopy as the initial examination for overt obscure gastrointestinal bleeding can efficiently identify patients who require double-balloon enteroscopy.

BackgroundBoth double-balloon enteroscopy (DBE) and video capsule endoscopy (VCE) have similar diagnostic yields for patients with overt obscure gastrointestinal bleeding (OGIB). However, the choice of initial modality is still controversial. The aim of this study was to show the clinical outcome of the strategy of initial VCE, followed by DBE.MethodsEighty-nine consecutive overt OGIB patients who had undergone VCE as the initial examination were analyzed. The interpreters of VCE evaluated the necessity of performing DBE, and the antegrade or retrograde route was chosen, depending on the transit time of the capsule.ResultsThirty-seven patients (42 %) underwent DBE depending on the findings of VCE. Of these, bleeding sites in the small bowel were identified in 29 patients with the initially selected route (21 antegrade and 8 retrograde). The remaining 8 later underwent DBE by the other route, but 7 had no bleeding lesion, which was confirmed by second-look VCE. One remaining patient had a jejunal varix found by VCE, but DBE from either side could not reach the lesion. The sensitivity and negative predictive value of VCE were 100 %, both for the presence of small bowel lesions and the requirement of hemostasis in the small bowel; this indicated that VCE never misses relevant findings in the small bowel, and that negative VCE findings correspond to the lack of necessity for further examination.ConclusionsVCE as the initial examination can efficiently identify overt OGIB patients who require DBE. The strategy of initial VCE for overt OGIB appears to be reasonable.