Small Bowel Varices Research Articles

Embolization of Bleeding Ileal Varices post Adnexal Biopsy in Liver Cirrhosis without Gastroesophageal Varices

AbstractBleeding ileal varices are rare in liver cirrhosis, where the gastroesophageal varices frequently accompany ectopic varices. Small bowel varices usually develop in patients with a history of abdominal surgery. We report a case of bleeding ileal varices without accompanying gastroesophageal varices, managed by percutaneous embolization, in a case of liver cirrhosis with no history of laparotomy. Computed tomography–guided percutaneous adnexal biopsy had been undertaken a year before the onset of bleeding.

S374 Endoscopic Coiling of Mesenteric Varices Causing Stomal Bleeding Caused by Extensive Portal Vein and Superior Mesenteric Thrombus

Introduction: Ectopic varices are collateral vessels located outside the gastro-esophageal area. Small bowel varices, while an uncommon result of portal hypertension can be a life-threatening cause of gastrointestinal bleeding. We present a case of refractory stomal bleeding secondary to mesenteric varices, treated with endoscopic ultrasound (EUS) guided coiling. Case Description/Methods: A 54-year-old male presented with history of ulcerative colitis status post proctocolectomy and ileostomy, primary sclerosing cholangitis (PSC), and auto-immune hepatitis (AIH) overlap syndrome treated with a deceased donor liver transplant in 2019. This was further complicated by portal hypertension secondary to portal vein and superior mesenteric vein thrombus. The patient presented with refractory stomal bleeding at this ileostomy site requiring multiple blood transfusions. On CT imaging, prominent mesenteric varices extending to the area of the stoma were noted. An interventional radiology (IR) approach from the portal system was not feasible given thrombosis in the portal vein and superior mesenteric vein. Percutaneous IR approach was also felt to be suboptimal given the depth of the peri-stomal varices. After a multidisciplinary discussion, the patient underwent ileoscopy with EUS guided coiling of the terminal/culprit branches of the mesenteric varices. The linear echoendoscope was introduced through the ileostomy and advanced approximately 5-10cm. Multiple tubal anechoic structures consistent with varices were noted with flow seen on doppler examination. This was confirmed on pulse wave doppler. A large feeding variceal vein towards the patient’s left side was punctured with a 22G needle. Saline was injected and it was visualized on EUS to confirm location. Next, embolization coils (8mm x 2, 10mm x1) were inserted for varix eradication. Reduced flow downstream of the coiling site was confirmed on doppler exam after embolization. Brief fluoroscopic images showed appropriate placement of coils in the patients right lower quadrant, without any migration. There was no significant flow toward the lumen on EUS after coiling. Since this procedure, the patient’s stomal bleeding resolved. (Figure) Discussion: Small bowel varices in the setting of significant portal hypertension are a rare but clinically significant cause of gastrointestinal bleeding. EUS-guided interventions such as coil embolization can be an effective treatment modality, especially in patients who are poor interventional radiology candidates. Watch the video at https://tinyurl.com/ACGAbstractS374Figure 1.: (1a) Prominent mesenteric varices extending into the ostomy (1b) EUS-guided coil embolization (1c) Status post successful endoscopic coil embolization

A SERENDIPITOUS DETOUR: DIRECT PERCUTANEOUS EMBOLIZATION OF ECTOPIC VARIX

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Variceal bleeding can be a devastating complication of cirrhosis; a minority of varices develop at sites apart from the esophagus or the stomach. We present the case of an ectopic variceal bleeding complicated by hemorrhagic shock, managed by direct percutaneous embolization of an ectopic small bowel varix in a ventral hernia. CASE PRESENTATION: A 47-year-old woman with a history of decompensated alcoholic cirrhosis presented with sudden onset profuse bright red bloody output per rectum. She was hypotensive, tachycardic, and had a ventral hernia. Labwork was notable for anemia (hemoglobin 2.9 mg/dL). Computed tomography (CT) angiography of the abdomen and pelvis did not reveal a source of hemorrhage, but did show a large ventral hernia containing small bowel without signs of strangulation. She was treated with pantoprazole, octreotide, transfusions of packed red cells and fresh frozen plasma, vasopressor support, and mechanical ventilation. Esophagoduodenoscopy revealed mild non-bleeding esophageal varices. Colonoscopy revealed a few mild oozing sites of portal colopathy treated with cautery. Given the presence of chronic portal vein thrombus and extensive collaterals, there was concern for a small bowel ectopic varix. On review of initial imaging, a dilated varix was noted to track along a loop of small intestine in the ventral hernia. She underwent percutaneous puncture of the ectopic varix under ultrasound guidance, followed by extensive coiling and gel foaming of the superior mesenteric venous system. Following the procedure, the patient developed gastrointestinal bleeding necessitating massive transfusion. Repeat esophagoduodenoscopy demonstrated grade II esophageal varices with active bleeding treated with banding. Continued hemorrhage led to hemodynamic collapse, followed by the patient's demise. DISCUSSION: Small bowel varices can be challenging to diagnose; they may be treated with transjugular intrahepatic porto-systemic shunt (TIPS), enteroscopy, embolization, or surgery. Percutaneous embolization was chosen as the treatment modality in our patient due to profound hemodynamic instability and emergent need for homeostasis. This is usually carried out via a transjugular, transfemoral, or transhepatic approach. The serendipitous presence of a portion of the ectopic varix on a loop of small bowel in a ventral hernia afforded the unconventional approach employed here. There have only been a few cases managed via a similar approach based on our literature review. Embolization was carried out successfully, but was complicated by bleeding from other varices, perhaps due to increased pressure in the portal venous system. CONCLUSIONS: Direct percutaneous varix embolization may be employed in the critical care setting provided favorable anatomy is present. REFERENCE #1: Lim L, Lee Y, Tan L, et al. Percutaneous paraumbilical embolization as an unconventional and successful treatment for bleeding jejunal varices. World J Gastroenterol. 2009 Aug 14; 15(30): 3823–3826. DISCLOSURES: No relevant relationships by Ajinkya Buradkar, source=Web Response no disclosure on file for William Haas; No relevant relationships by Danish Haque, source=Web Response No relevant relationships by Pius Ochieng, source=Web Response no disclosure on file for Nikul Patel; No relevant relationships by Arooj Quadir, source=Web Response No relevant relationships by NISHANT SHARMA, source=Web Response

S2176 Small Bowel Varices: A Covert Source of Overt Bleeding

INTRODUCTION: Alcoholic cirrhosis is one of the most common causes of liver failure, accounting for millions of hospitalizations each year. Although esophageal, gastric, and rectal varices are extensively described as a result of portal hypertension, small bowel varices (SBV) are rarely implicated as a source of GI bleeding. This report describes a unique case of isolated SBV resulting in overt GI hemorrhage. CASE DESCRIPTION/METHODS: A 54-year-old female with a history of alcoholic cirrhosis decompensated by esophageal varices, hepatic encephalopathy, and abdominal ascites (MELD-Na 19) presented to the ED after multiple episodes of melena and hematochezia. The patient had previously undergone transjugular portosystemic shunting (TIPS) for recurrent variceal bleeding. The patient underwent an EGD which showed mild portal hypertensive gastropathy but no gastric or esophageal varices. Her colonoscopy was unremarkable. Given ongoing bleeding, the patient underwent a capsule endoscopy which revealed fresh blood with clots two-thirds (65%) of the way through the jejunum. A CT angiography revealed a portosystemic shunt between the superior mesenteric vein and the common femoral vein near the jejunum. Interventional radiology performed a catheter guided coil and glue embolization of the venous malformation and created a new portosystemic shunt. The patient’s melena and hematochezia ceased, and she was safely discharged home. DISCUSSION: Caused by portal hypertension, SBV are rare and infrequently implicated in significant GI hemorrhage. This case is unique in that the patient had no gastric, esophageal, or rectal varices. Isolated SBV are described anecdotally in the literature and extremely unlikely to manifest clinically. In addition, this case highlights the potential utility for inpatient video capsule endoscopy (VCE). In a patient with persistent GI bleeding with normal endoscopy and colonoscopy should certainly be considered for a deeper luminal exam. Furthermore, the definitive management of SBV is not well defined. While the mainstay of treatment is supportive care, minimally invasive vascular interventions provide an exciting option for management.

Clinical characteristics and efficacy of endoscopic treatment of gastrointestinal ectopic varices: A single-center study.

Background:Ectopic varices (EcVs) may cause massive bleeding, which can be difficult to control, with a high rate of mortality. The purpose of this study was to analyze the clinical characteristics of EcVs and the efficacy of endoscopic treatment.Methods:From January 2008 to July 2017, the clinical data of 150 patients with EcVs in our center were retrospectively collected and analyzed.Results:One hundred and fifty patients with EcVs (male 74.7%), with a mean age of: 54.1 ± 14.6 years were included. The prevalence of EcVs was 0.92% in gastrointestinal varices. Cirrhosis was the most common cause of EcVs (67.0%). The rates of bleeding were 57.14%, 4.34%, 30.0%, 33.3%, and 100% in the duodenal varices rectal varices, colonic varices, anastomotic varices, and small bowel varices, respectively. An age under 55 years, varices in the duodenum, and erythema were considered risk factors for EcV bleeding. Endoscopic treatments were performed in 15 patients with EcV bleeding. The follow-up period of the patients who underwent endoscopic treatment ranged from 0.5 to 24 months. The overall rate of treatment success was 73.33% for endoscopic treatment of EcV bleeding. The overall rates of rebleeding and mortality during 2 years were as high as 53.3% and 26.7%, respectively.Conclusion:Age, erythema, and the location of EcVs are considered risk factors for EcV bleeding, and the rate of bleeding is higher in patients with duodenal varices than in those with other EcVs. Endoscopic treatment is safe, effective, and feasible for controlling EcV bleeding.

1536 An Uncommon Case of Small Bowel and Pan-Colonic Varices

INTRODUCTION: We present a case of idiopathic varices in the small bowel and colon discovered after extensive work up for iron-deficiency anemia and portal hypertension. CASE DESCRIPTION/METHODS: 41-year-old with no known medical history underwent esophagogastroduodenoscopy (EGD) and colonoscopy for evaluation of iron-deficiency anemia. EGD was normal. Colonoscopy revealed diffuse colonic varices extending from the cecum to the rectum (Figure 1). Computed tomography enterography showed numerous varices of the mid jejunum. Magnetic resonance imaging of the abdomen showed patent portal circulation and no other abnormalities. Echocardiogram did not show any evidence of right heart failure. Transjugular liver biopsy showed a portosytemic pressure gradient of 4 mm of Hg indicating the absence of portal hypertension. Liver biopsy only showed mild steatosis and no fibrosis. A direct measurement of portal pressure was 3 mmof Hg again indicating the absence of portal hypertension. DISCUSSION: Given the extensive workup with no evidence of portal hypertension, patient is thought have idiopathic varices in the small bowel and colon. Ectopic varices, especially in the colon are rare and are usually associated with portal hypertension. Idiopathic colonic varices in association with small bowel varices are even more infrequently described in existing literature. Clinical presentation has been reported with massive hemorrhage, recurrent bleeds and even as incidental findings in endoscopies and imaging performed for other reasons. Management options include conservative frequent follow up or surgery if there is evidence of recurrent bleeds or massive hemorrhage.

Double-balloon enteroscopy–facilitated cyanoacrylate-injection endotherapy of small-bowel varices: an international experience from 2 European tertiary centers (with videos)

Small-bowel varices (SBVs) are an uncommon consequence of portal hypertension. Radiologic intervention is usually considered for first-line management. When radiologic intervention is not possible, management options become very limited. The aim of this study was to evaluate the usefulness of double-balloon enteroscopy (DBE)-facilitated cyanoacrylate-injection endotherapy of SBVs. This was a retrospective review of DBE-facilitated cyanoacrylate-injection endotherapy of SBVs (December 2015 to October 2016). Ten DBEs were performed in 6 patients (4 women; median age, 68.5 years). No radiologic or surgical options were deemed feasible. Thirteen nests of SBVs were identified and injected with cyanoacrylate glue without hemorrhagic or embolic adverse events. At the 30-day follow-up after therapy, only 1 patient had experienced a mild recurrence of mid-gut bleeding; this was managed conservatively. One patient presented with acute GI bleeding 7 months later, and a repeat DBE with cyanoacrylate-injection endotherapy was successfully performed. One patient succumbed to his underlying advanced cholangiocarcinoma after 2 months. The remaining patients had a median follow-up of 12 months without any recurrent GI bleeding. DBE-facilitated cyanoacrylate-injection endotherapy of SBVs appears to be a safe and effective option when other first-line options are not feasible.

J-Pouch Ectopic Varices: A Rare Cause of Lower GI Bleed

Variceal bleeding is a life-threatening complication of portal hypertension in patients with cirrhosis. Varices are portosystemic venous shunts that arise as a result of portal hypertension, most commonly located in the gastroesophageal (GE) area. Ectopic varices (ECV) are enlarged portosystemic venous collaterals located anywhere outside of the GE region. ECV bleeds are uncommon but can lead to significant morbidity and mortality. We present a rare case of lower GI bleeding from a small bowel varix in a J-pouch. A 34-year-old female with a history of ulcerative colitis status post total proctocolectomy with ileal pouch-anal anastomosis (IPAA or J-pouch) and primary sclerosing cholangitis with compensated cirrhosis was transferred to our hospital for an overt, obscure GI bleed. She initially presented to an outside hospital (OSH) with hematochezia and syncope. EGD, push enteroscopy, pouchoscopy, and capsule endoscopy at the OSH all failed to find the source of bleeding. Due to continued overt bleeding requiring 14 U of packed RBCs over 10 days, she was transferred to our medical center. Repeat EGD found no blood and no gastroesophageal varices. Pouchoscopy revealed red blood and clots in the J-pouch, but normal underlying mucosa and no obvious source of bleeding. A tagged RBC scan was positive for bleeding localized to a loop of small bowel in the right lower quadrant. CT-angiogram demonstrated a large ectopic venous collateral adjacent to the IPAA (Fig. 1) which was supplied by the superior mesenteric vein and drained by the right gonadal vein (Fig. 2), consistent with a small bowel varix. This ECV was the most likely cause of her recurrent bleeding. She underwent TIPS with reduction of portosystemic gradient from 25 to 11 mmHg and significant decompression of the ECV, rendering selective embolization unnecessary. She was discharged 5 days later and had no further bleeding at a 2 month follow-up visit. ECV account for 1-5% of all variceal bleeding episodes. Small bowel varices are most commonly seen in patients with portal hypertension and prior abdominal surgery. A triad of portal hypertension, hematochezia without hematemesis, and previous abdominal surgery should prompt evaluation for small bowel varices via CT scan with both arterial and venous phases. This case illustrates that, although rare, small bowel varices can present as massive lower GI bleeding and require a multidisciplinary approach with therapy tailored based on institutional expertise.Figure: CTA venous phase showing large venous collateral adjacent to J-pouch consistent with small bowel varix.Figure: Venogram illustrating enlarged superior mesenteric vein (SMV) filling varix with outflow tract through the right gonadal vein (R Gonadal V.).

Spectrum of small-bowel mucosal abnormalities identified by capsule endoscopy in patients with portal hypertension of varied etiology

Bleeding from small intestinal ectopic varices and persistent anemia caused by portal hypertensive enteropathy (PHE) can be very challenging. Capsule endoscopy (CE) is one of the best noninvasive modalities in identifying such lesions. The aims of this study are to study the prevalence of small-bowel changes related to portal hypertension (PHT) and to correlate them with the observations related to the effects of portal hypertension in the esophagus, stomach, and colon. Thirty-two patients with various etiologies of PHT with either anemia or gastrointestinal bleed were included along with age- and sex-matched controls without PHT. All patients underwent blood tests, gastroscopy, colonoscopy, and CE. The small-bowel findings by CE were categorized as inflammatory-like and vascular lesions. The small-bowel changes were analyzed to find out any association with various demographic, clinical, and endoscopic variables. Thirty-one out of 32 patients with PHT (96.8%) had PHE identified by CE. Of them, 31 (96.8%) had inflammatory-like appearance, 11 (34.4%) had vascular lesions, and 2 (6.2%) had small-bowel varices. Inflammatory-like appearance was noted in eight (25%) and angiodysplastic lesions in two (6.2%) controls. Findings compatible with PHE were detected in 96.8% of the patients and 25% of the controls (X 2 =34.72, p=0.000).The presence of PHE was not associated with any of the above-mentioned variables. Small-bowel mucosal changes were seen in significantly higher number of patients with PHT with anemia.

The Utility of Capsule Endoscopy in Patients under 50 Years of Age with Recurrent Iron Deficiency Anaemia: Is the Juice Worth the Squeeze?

Background and Aims. The role of capsule endoscopy (CE) in the <50 years of age patients with iron deficiency anaemia (IDA) remains unclear. We aim to assess its utility in this cohort. Methods. All patients referred for CE for recurrent IDA were included retrospectively. Patients were divided into Group 1 (<50 years) and Group 2 (≥50 years). Results. There were 971 patients with recurrent IDA and 28% belonged to Group 1. The mean age was 40 years in this group with a DY of 28% (n = 76). Significant diagnoses included erosions and ulcers (26%; n = 71), small bowel (SB) angioectasia (AE) (10%; n = 27), SB tumours (3%; n = 7), Crohn's disease (3%; n = 7), SB bowel strictures (1%; n = 3), and SB varices (1%; n = 2). On logistic regression, the presence of diabetes (P = 0.02) and the use of warfarin (P = 0.049) was associated with increased DY. The DY in Group 2 was 38% which was significantly higher than in Group 1 (P = 0.02). While SB tumours were equally common in both groups, AE was commoner in Group 2 (P < 0.001). Conclusion. A significant proportion of patients <50 years are referred for CE. Although the DY is lower compared to those ≥50 years, significant pathology is found in this age group. CE is advisable in patients <50 years old with recurrent IDA and negative bidirectional endoscopies.

Small Bowel Variceal Bleeding Secondary to Gyno-Enteric Shunt

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.

PTU-038 Prolonged Overt Obscure Gastrointestinal Bleeding – A “real World” Experience

IntroductionProlonged overt obscure gastrointestinal bleeding (OGIB) after an initial normal oesophagogastroduodenoscopy and colonoscopy can be difficult to manage. “Real-world” studies with all of the endoscopic (capsule endoscopy, device-assisted enteroscopy), radiological...

PTU-017 The Use Of Small Bowel Capsule Endoscopy In The Octogenarians Group; The Edinburgh Experience

IntroductionOver the last 13 years, the clinical use of capsule endoscopy (CE) has revolutionised the investigation pathways for the small-bowel. Although non-invasive (as procedure), there are reports of capsule aspiration...

PTH-185 Capsule Endoscopy and Obscure Gastrointestinal Bleeding: Experience from a Tertiary Centre

IntroductionCapsule endoscopy (CE) is the first line modality to investigate the small bowel (SB) in patients with obscure gastrointestinal bleeding (OGB). We investigated the largest cohort of patients to date...

Vascular Lesions in the Small Bowel

Angiectasias are the most frequent vascular lesions in the small bowel. Unusual findings include severe segmental lymphangiectasia or idiopathic lymphangiectasia with whitish, swollen villi. Multiple small red spots or petechiae can be seen in portal hypertensive enteropathy, in rare cases even small bowel varices. Ischemic enteritis and vasculitis cause ulcerations of the small bowel. This article is part of an expert video encyclopedia.

PTH-186 The Utility of Capsule Endoscopy in Patients with Iron Deficiency Anaemia Under 50 Years- is the Juice Worth the Squeeze?

IntroductionThe role of capsule endoscopy (CE) in patients with iron deficiency anaemia (IDA) under the age of 50 years remains unclear. There is paucity of data on its use in...

Ectopic Small Bowel Varices - A Rare Cause of Obscure Gastrointestinal Bleed

Introduction: Ectopic varices (ECV) are a rare cause of gastrointestinal bleed (GIB) and account for about 1-5% of variceal bleeding. Their location in the small bowel (SB) is even rare and represents a clinical, diagnostic and therapeutic challenge. Here we present an interesting case of SB varices (SBV) presenting a lower GIB. Case Report: A 55 year old man with known hepatitis C, human immunodeficiency virus (HIV) and hepatocellular carcinoma (HCC) presented with recurrent melena. He had multiple prior admissions for GIB and had multiple esophagogastroduodenoscopies (EGD) and colonoscopies in the past. His hemoglobin was 5.6 gm/dl, platelet count 244,000/μl and internationalized normalized ratio (INR) was 1.7. EGD showed grade III esophageal varices with no stigmata of recent bleeding. Colonoscopy revealed active bleeding from ileocecal valve. Bleeding scan was positive for active bleed likely within small bowel. Mesenteric angiography showed no evidence of bleeding or arterio-venous malformation (attempts to show a venous phase were unsuccessful). Computerized tomography angiography identified a large ectopic varix in the small bowel as the source of bleeding. This varix was connecting the superior mesenteric vein to the right inferior epigastric vein. The patient was referred for surgical evaluation. Discussion: Portal hypertension (PHT) usually causes gastro-esophageal varices (GEV). ECV, although rare, can occur in any other part of gastrointestinal (GI) tract including small bowel and missing these lesions can have grave consequences. Bleeding associated with SBV can be life-threatening. A triad of portal hypertension, hematochezia, and prior abdominal surgery is characteristic of SBV. Diagnosis is fairly challenging and a high index of suspicion is needed. SBV should be considered as a possibility in any patient with GIB and portal hypertension, especially if no stigmata of recent bleeding from GEV is noted. Differential diagnostic modalities including radiological imaging, nuclear scans, angiography and endoscopy; and a multidisciplinary approach which includes a hepatologist, endoscopist, interventional radiologist and surgeon is usually needed for appropriate diagnosis and optimal therapy. Conclusion: ECV represents a particular challenge to clinicians as they are difficult to identify, diagnose and treat. Bleeding from ECV has significant morbidity and mortality and hence clinicians should consider ECV as a possibility in patients with PHT presenting as lower GIB especially if they have non-bleeding GEV.

Effects of transjugular intrahepatic portosystemic shunt on changes in the small bowel mucosa of cirrhotic patients with portal hypertension

The introduction of capsule endoscopy (CE) has facilitated the detection of mucosal changes in the small bowel, and such mucosal changes have been noted in cirrhotic patients with portal hypertension; these changes are described as portal hypertensive enteropathy. The aim of this study was to assess the effects of transjugular intrahepatic portosystemic shunt (TIPS) on the small bowel mucosal changes detected by CE in cirrhotic patients with portal hypertension. TIPS was performed in fifteen cirrhotic patients with portal hypertension. All patients underwent CE before and 2 weeks after TIPS. The small bowel mucosal changes were defined as edema, angiodysplasia-like lesions, red spots, and small bowel varices. Changes in the portosystemic pressure gradient (PSG) and CE findings were evaluated. Before TIPS, small bowel edema was detected in all 15 patients, angiodysplasia-like lesions in 7, and red spots in 14 patients. The PSG decreased significantly, from 21.2 ± 2.6 before TIPS to 8.9 ± 3.3 mmHg (p < 0.001) after the procedure. After TIPS, the small bowel edema was attenuated in 8 of the 15 patients. In two patients with angiodysplasia-like lesions and 4 with red spots, these lesions were attenuated after TIPS. The average score for small bowel edema and the grade of red spots were reduced significantly after TIPS (2.3 ± 0.7-1.8 ± 0.6, p < 0.005 and 1.6 ± 0.9-1.3 ± 0.7, p < 0.05, respectively). Small bowel varices were seen in 4 patients before TIPS and all these varices disappeared after TIPS. In cirrhotic patients with portal hypertension, small bowel edema, red spots, and small bowel varices were attenuated after TIPS. Portal hypertension may be an important factor in the development of small bowel mucosal changes.

VH25 Small Bowel Varices Diagnosed by Endoscopic Ultrasound during Deep Enteroscopy

VH25 Small Bowel Varices Diagnosed by Endoscopic Ultrasound during Deep Enteroscopy

Yield and impact of emergency capsule enteroscopy in severe obscure-overt gastrointestinal bleeding

Patients with obscure-overt gastrointestinal bleeding (OOGIB) are defined by overt hemorrhage and negative upper and lower endoscopy findings. At present, the place of emergency capsule enteroscopy in patients with severe OOGIB is unknown. The aim of this study was to assess the diagnostic yield and the impact of emergency capsule enteroscopy on further management in patients with severe OOGIB. Between 2003 and 2010, we retrospectively included all patients with severe OOGIB who underwent emergency capsule enteroscopy in the 24-48 h following negative urgent upper and lower endoscopy. Severe OOGIB was defined by ongoing bleeding with hemodynamic instability and/or the need for significant red blood cell transfusion. Out of 5744 patients hospitalized in our Gastrointestinal Bleeding Unit, 55 (1%) presented with severe OOGIB and underwent emergency capsule enteroscopy. Capsule enteroscopy showed blood in 41 patients (75%) and lesions in 37 patients (67%). Findings included small bowel angiodysplasia in 19 patients (35%), ulcers in 7 (13%), tumors in 5 (9%), small-bowel varices in 2 (3%), cecum angiodysplasia in 4 (7%), fresh blood in small bowel without identified lesion in 12 (22%). Specific diagnostic and therapeutic procedures were undertaken in 78 % of patients. Further management included endoscopy (54%), surgery (22%), and radiology (2%). Emergency capsule enteroscopy identified bleeding lesions in 67 % of patients with severe OOGIB. Emergency capsule enteroscopy seems to be a promising diagnostic tool with a subsequent impact on clinical management in patients with severe OOGIB.