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.     

Isolated ectopic jejunal varices in a patient with extrahepatic portal vein obstruction – A case report

Introduction and importanceAmong the various causes for lower gastrointestinal bleeding, ectopic varices constitute a small chunk. Though rare, these can pose a diagnostic challenge with recurrent bleed leading to multiple admission and blood transfusions.Case presentationA 41-year-old male presented to our department with multiple episodes of melena. On further evaluation with CT angiography, a diagnosis of extrahepatic portal vein obstruction with moderate splenomegaly and ectopic jejunal varix was made. He underwent splenectomy with resection of involved jejunal segment with side to side anastomosis.Clinical discussionThe diagnosis of ectopic varices remains elusive in a large number of cases in view of the varied etiology. Various newer endoscopic and imaging modalities can play a diagnostic as well as therapeutic role but this also further complicates the management as there is a lack of substantial guidelines directing the treatment protocol. As a result, we have to resort to a case by case approach for the optimal management in these cases.ConclusionThe main modality of management for bleeding ectopic varices is percutaneous or endoscopic. Surgery is reserved for refractory cases, with decompressive shunts combined with segmental resection of involved intestine being at the forefront of surgical options.     

Bleeding small-bowel varices

A case of bleeding jejunal varices in a 27-year-old man is reported. Portal hypertension resulted from portal vein thrombosis and the varices were not associated with portasystemic shunting. Because mesenteric varices are rare, they are seldom the cause of gastrointestinal hemorrhage. However, they should be suspected in patients with an obscure source of bleeding and portal hypertension. The pathogenesis, roentgenographic criteria and surgical management are discussed.     

Controlling the bleeding of jejunal varices formed at the site of choledochojejunostomy: report of 2 cases and a review of the literature

Introduction

Hemorrhage from jejunal varices formed at the site of Roux-en-Y choledochojejunostomy is rather rare, and no guidelines have so far been established for its treatment. This report presents the cases of 2 patients with jejunal varices formed at the site of choledochojejunostomy that were treated using different methods. An obstruction of the extrahepatic portal vein resulted in massive gastrointestinal bleeding in both cases

Case 1

A 59-year-old male developed jejunal varices at the site of choledochojejunostomy. Multidetector computed tomography showed that the source of bleeding was located in the small intestine near portojejunal varices. The jejunal vein supplying the afferent loop was embolized using interventional radiology. There was no evidence of liver dysfunction or rebleeding after the embolization

Case 2

A 79-year-old female developed jejunal varices at the site of choledochojejunostomy. Abdominal angiography could not detect the source of bleeding, and hence, a mesocaval shunt operation was performed.     

Unusual Bleeding From Hepaticojejunostomy Controlled by Adult Variable Stiffness Colonoscopy: Report of a Case and Literature Review

We herein present a case of a 59-year-old man who had undergone pylorus preserving pancreaticoduodenectomy with regional lymph node dissection prior to episodes of melena. Series of conventional endoscopic investigations failed to identify the bleeding source. Enhanced computed tomography scan revealed complete obstruction of the main portal vein with numerous collateral veins running towards the hepatic hilus. Comprehensively, hemorrhage from the jejunal varices caused by postoperative portal hypertension was highly suspected. As the jejunal loop was out of reach, adult variable-stiffness colonoscope (AVSC) was utilized to solve the Roux-en-Y anatomy. Numerous telangiectasis and small varices at hepaticojejunostomy were observed and in the mean time, bleeding was noticed and endoclips were placed without any delay. Ectopic variceal bleeding in jejunal loop after pancreaticoduodenectomy is difficult to manage. We believe that AVSC is an alternative device when specialized jejunal endoscopy is not available.Key words: Hepaticojejunostomy, Adult variable stiffness colonoscopy, Endoclip, Jejunal varicose vein, Portal hypertensionBleeding ectopic varices in the jejunal loop after biliary reconstruction is a rare entity.¹ Management of such bleeding is difficult and is not well defined. Here, we report a case of a pancreatic cancer patient who had pylorus-preserving pancreaticoduodenectomy (PD) 2.5 years prior to variceal bleeding at hepaticojejunostomy (HJ) anastomosis (Roux-en-Y fashion). We successfully treated this out-of-reach afferent jejunal loop bleeding by using adult variable stiffness colonoscopy (AVSC).     

Surgical treatment for bleeding ileal varices: A case report

Introduction and importanceBleeding from ileal varices is a rare and a life-threatening situation. Its management is difficult and includes endoscopic, surgical and interventional radiology treatment.Here we report a successful emergency surgery for bleeding ileal varices in a patient with cirrhosis due to autoimmune hepatitis.Presentation of a caseA 60-year-old woman was admitted for rectal bleeding. She had a history of autoimmune hepatitis. She was treated by endoscopic ligation for oesophageal varices.Eso-gastro-duodenal fibroscopy and colonoscopy failed to reveal the bleeding site.CT scan was then performed showing ileal varices due to a portocaval shunt, there was a communication between the superior mesenteric vein and the right internal iliac vein.As the embolization was not feasible and the bleeding did not stop, an exploratory laparotomy was performed showing two dilated veins on the surface of the ileal wall, communicating with the right internal iliac vein. We performed a ligation of the vessels. Postoperative course was uneventful.DiscussionEctopic varices are a rare case of gastrointestinal bleeding. Most of those patients have portal hypertension and liver cirrhosis.Diagnosing bleeding ileal varices is difficult because endoscopic examination can't always reveal the bleeding site.Interventional radiology is a good option for patients having bleeding ileal varices knowing that they often have advanced liver cirrhosis making them poor candidates for surgery.Haemostasis by endoscopy is often temporary and bleeding frequently recurs.Surgery should be considered if non-invasive treatments failed to ensure the haemostasis.ConclusionBleeding ileal varices is a rare situation. Interventional radiology and endoscopy can be good options. If not feasible, surgical treatment should not be delayed.     

Treatment of Refractory Gastrointestinal Bleeding in Patients With Portal Hypertension: A Case Series and Treatment Algorithm

In patients with portal hypertension, ectopic varices can develop at any site along the gastrointestinal tract outside the classically described gastroesophageal location. Like esophageal variceal hemorrhage, bleeding from ectopic varices can be life-threatening. Diagnosis and treatment of ectopic varices can be challenging; to date, no effective treatment algorithm has been described. A systematic teamwork approach to diagnosing and treatment of ectopic varices is required to successfully manage hemorrhage from ectopic varices.     

Liver metastases, a rare cause of portal hypertension and stoma bleeding. Brief review of literature

INTRODUCTIONPortal hypertension is an unusual complication of liver metastases, which is frequently occurring in malignant disease. Portal hypertension may cause oesophageal varices and also stoma varices (colostomy and ileostomy). Oesophageal varices and bleeding from these varices have been frequently reported in literature. Stomal varices have also been reported in literature mostly associated with liver cirrhosis. These stomal varices lead to the massive bleeding causing morbidity and mortality.Portal hypertension is a pathological increase in portal pressure gradient (the difference between pressure in the portal and inferior vena cava veins). It is either due to an increase in portal blood flow or an increase in vascular resistance or combination of both. In liver cirrhosis, the primary factor leading to portal hypertension is increase in portal blood flow resistance and later on development of increased portal blood flow. It has been postulated that in liver metastasis the increase in portal flow resistance occurs at any site within portal venous system as a consequence of mechanical architectural disturbance.PRESENTATION OF CASEWe report a case of a 64 year old gentleman who developed portal hypertension due to secondary metastases from colorectal cancer. He subsequently developed bleeding varices in his end colostomy.DISCUSSIONWe believe that the combination of extensive metastases and chemotherapy induced portal hypertension in our patient.CONCLUSIONOur case and other literature review highlight that the recurrent bleeding stoma associated with colorectal cancer should be investigated for portal hypertension.     

Surgical management of gastric varices and morbid obesity: a novel approach

BackgroundMorbid obesity is a growing pandemic. The greater prevalence of chronic conditions such as diabetes, hypertension, and heart and liver disease has made management of obesity challenging. Many surgical techniques are in practice, each with some elements of restrictive or malabsorptive components. Nonalcoholic steatohepatitis can lead to portal hypertension, which can further manifest as upper gastrointestinal bleeding.MethodsWe performed sleeve gastrectomy at a nonuniversity tertiary care center, as a novel approach for the management of isolated gastric varices, in a morbidly obese cirrhotic patient.ResultsThe operating time was 142 minutes. The estimated blood loss was 150 mL. The patient did not receive intraoperative or postoperative transfusions. The length of stay was prolonged to 10 days because of an ischemic cardiac event that was managed by coronary angioplasty on postoperative day 7. The patient did not develop any other complications. During the next couple of months, the patient lost significant weight and had no complaints.ConclusionSleeve gastrectomy with devascularization is a durable approach that will address the problems of both portal hypertension and morbid obesity, with the desired effect of weight reduction and treatment of gastric varices using a single surgical approach.     

Ectopic gastrointestinal variceal bleeding with portal hypertension

Massive gastrointestinal bleeding from gastrointestinal varices is one of the most serious complications in patients with portal hypertension. However, if no bleeding point can be detected by endoscopy in the predilection sites of gastrointestinal varices, such as the esophagus and stomach, ectopic gastrointestinal variceal bleeding should be considered as a differential diagnosis. Herein, we report a case of ectopic ileal variceal bleeding in a 57-year-old woman, which was successfully diagnosed by multi-detector row CT(MDCT) and angiography and treated by segmental ileum resection. To date, there have been no consensus for the treatment of ectopic ileal variceal bleeding. This review was designed to clarify the clinical characteristics of patients with ectopic ileal variceal and discuss possible treatment strategies. From the PubMed database and our own database, we reviewed 21 consecutive cases of ileal variceal bleeding diagnosed from 1982 to 2017. MDCT and angiography is useful for the rapid examination and surgical resection of an affected lesion and is a safe and effective treatment strategy to avoid further bleeding.     

Portal Vein Stenting to Treat Portal Vein Stenosis in a Patient With Malignant Tumor and Gastrointestinal Bleeding

This report describes the successful use of portal venous stent placement for a patient with recurrent melena secondary to jejunal varices that developed after subtotal stomach preserved pancreatoduodenectomy (SSPPD). A 67-year-old man was admitted to our hospital with tarry stool and severe anemia at 2 years after SSPPD for carcinoma of the head of the pancreas. Abdominal computed tomography examination showed severe stenosis of the extrahepatic portal vein caused by local recurrence and showed an intensely enhanced jejunal wall at the choledochojejunostomy. Gastrointestinal bleeding scintigraphy also revealed active bleeding near the choledochojejunostomy. Based on these findings, jejunal varices resulting from portal vein stenosis were suspected as the cause of the melena. Portal vein stenting and balloon dilation was performed via the ileocecal vein after laparotomy. Coiling of the jejunal varices and sclerotherapy of the dilate postgastric vein with 5% ethanolamine oleate with iopamidol was performed. After portal stent placement, the patient was able to lead a normal life without gastrointestinal hemorrhage. However, he died 7 months later due to liver metastasis.Key words: Portal vein stenosis, Portal vein stent, PancreatoduodenectomyObstruction of the extrahepatic portal vein can lead to portal hypertension, splenomegaly, and gastrointestinal bleeding due to esophageal or gastric varices. Malignant portal vein stenosis accounts for 15 to 24% of all cases of portal venous stenosis or occlusion and usually results from portal vein tumor thrombus or external compression of the portal vein by neoplasms.^1–4 When a patient with malignant tumors undergoes subtotal stomach preserved pancreatoduodenectomy (SSPPD), formation of hepatopetal collaterals is precluded by lymph node dissection and resection of the peribiliary vascular plexus around the hepatoduodenal ligament. Instead, jejunal varices form at the choledochojejunostomy site. The treatment of portal vein stenosis remains controversial, and the indications for portal vein stent placement have not yet been clarified.This report describes a case of successful portal vein stenting for a patient with portal vein stenosis and repetitive bleeding from jejunal varices that developed after SSPPD.     

Ectopic ileal varices associated with recurrent bleeding: report of a case

Bleeding from ectopic varices of the ileum associated with portal hypertension is occasionally life-threatening. However, it is not easy to make an accurate preoperative diagnosis. A 62-year-old woman presented with hematochezia and anemia. Conventional examinations could not locate the bleeding point, but subsequent capsule endoscopy indicated gastrointestinal bleeding from hemorrhaging ileal varices. Contrast-enhanced abdominal computed tomography, three-dimensioned abdominal computed tomography, and mesenteric angiography demonstrated the presence of ileal and right ovarian varices. The patient then underwent an exploratory laparotomy which confirmed these findings, and resection of the affected ileum and right ovary was performed safely. Capsule endoscopy should be a diagnostic option for patients with obscure gastrointestinal bleeding, and ileal varices should be considered as one of the differential diagnoses.     

Mesocaval shunt for portal hypertensive small bowel bleeding documented with intraoperative enteroscopy

INTRODUCTIONBesides upper gastrointestinal tract, small bowel has also been implicated as a potential source of hemorrhage in patients with portal hypertension.PRESENTATION OF CASEWe report an interesting case of recurrent massive small intestinal bleeding in a patient with portal hypertension secondary to liver cirrhosis treated with a mesocaval shunt. Endoscopic assessment with gastroscopy and colonoscopy failed to identify the source of hemorrhage. An intraoperative enteroscopy was conducted which revealed a diffuse bleeding pattern from the small bowel mucosa.DISCUSSIONAn interposition mesocaval shunt procedure was successfully carried out on an emergency basis that eventually managed to control bleeding.CONCLUSIONIn cases, where a diffuse pattern of hemorrhage exist or non-operative measures fail emergency mesocaval shunting seems to be an efficacious alternative treatment approach for portal hypertension related intestinal bleeding.     

Small bowel gastrointestinal stromal tumor presenting with gastrointestinal bleeding in patient with type 1 Neurofibromatosis: Management and laparoscopic treatment. Case report and review of the literature

Introduction and importanceGastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm of the gastrointestinal tract. It may be asymptomatic; nevertheless, gastrointestinal bleeding is the most frequent symptom, due to mucosal erosion. Its poor lymph node metastatic spread makes GIST often suitable of minimally invasive surgical approach. The importance of this study is to increase the awareness among physicians about this condition in particular scenarios as in our case and to stress the role of laparoscopic surgery.Case presentationA 74-year-old female patient presented to the emergency department with hematemesis, followed by haematochezia and melena. The patient had a medical history of type 1 Neurofibromatosis (NF1). She underwent, after CT scan, esophagogastroduodenoscopy, and endoscopic haemostasis. Finally, we performed a laparoscopic resection of a mass of the first jejunal loop. The postoperative period was predominantly uneventful. Pathological examination confirmed a low-risk GIST.Clinical discussionProximal jejunal GIST may cause an upper and lower gastrointestinal bleeding. A multidisciplinary team approach is mandatory for the correct management of this disease and its complications (bleeding). GISTs are indicated as the most commonly gastrointestinal NF1 associated tumours. In case of localised and resectable GIST surgical treatment is the mainstay and laparoscopic surgery is a valid alternative.ConclusionIn case of abdominal bleeding mass in a NF1 patient, it is important to keep in mind the well-known association between NF1 and GIST to facilitate the diagnosis and to quickly perform the appropriate treatment. Laparoscopic approach is safe and effective if the oncological radicality is respected.     

Upper G.I. hemorrhage from glass fragments’ ingestion in a patient with jejunal diverticula – Case report

IntroductionAcute upper gastrointestinal bleeding is a common emergency. The ingestion of foreign bodies represents a less frequent cause of bleeding, but it is equally life-threatening, especially if the patient does not report the incident.Presentation of caseWe are reporting the case of a 77-year-old patient with a bleeding caused by ingestion of glass fragments with co-existing jejunal diverticula.DiscussionThe ingestion of foreign bodies is a rare, mostly accidental event. Another possible source of upper G.I. bleeding is jejunal diverticula; in this case, the examination of the specimens showed evidence of glass ingestion fragments as the likely cause of bleeding.ConclusionSurgeons should be aware that patients may fail to report correctly on the possible causes of bleeding, misleading the diagnosis, and delaying the diagnostic routes.     

Effect of a portal venous stent for gastrointestinal hemorrhage from jejunal varices caused by portal hypertension after pancreatoduodenectomy

We report herein the case of a 64-year-old man successfully treated by portal venous stent placement for repeated gastrointestinal bleeding associated with jejunal varices. He was admitted to our hospital with melena 8 years after having a pancreatoduodenectomy for carcinoma of the papilla of Vater. From portogram findings showing severe portal vein (PV) stenosis and dilated collaterals through the jejunal vein of the Roux-en-Y loop, jejunal varices resulting from PV stenosis were suspected as the cause of the melena. A metallic stent was placed in the PV following percutaneous transhepatic PV angioplasty. Although the cure of hemorrhagic jejunal varices caused by PV stenosis is difficult in patients who have undergone major abdominal surgery, patency of the stent in this patient has been maintained for 32 months without gastrointestinal hemorrhage. Metallic stent placement is recommended as a useful treatment for PV stenosis that is less invasive than open surgery.     

Successful embolization therapy for bleeding from jejunal varices after choledochojejunostomy: Report of a case

We report a case of successful embolization of jejunal varices that were the cause of massive gastrointestinal bleeding from a choledochojejunostomy site, resulting from obstruction of the extrahepatic portal vein. A 42-year-old man who had undergone choledochojejunostomy for intrahepatic and choledochal stones was readmitted after he started passing massive dark bloody stools. Gastrointestinal endoscopic examination and angiography could not identify the source of bleeding. Percutaneous transhepatic portography showed obstruction of the right branches of the portal vein. The formation of jejunal varices at the site of choledochojejunostomy was revealed by portography and by cholangioscopy, suggesting the varices as the cause of massive bleeding. Bleeding could not be controlled long-term by cholangioscopic sclerosing therapy. We finally stopped the bleeding by embolizing a jejunal vein to the afferent loop.     

A case of portal hypertension with massive gastrointestinal bleeding from ileal varices

A rare case of massive gastrointestinal bleeding from ileal varices was reported. On December 28, 1982, a 49-year-old male was admitted to Kurashiki Central Hospital because of massive gastrointestinal bleeding. Eleven years ago, the patient underwent an emergency operation for rupture of esophageal varices. The venous phase of selective superior mesenteric and celiac angiography showed mesenteric varices, but no definite bleeding point was noted. Endoscopy revealed esophageal varices, but no area of bleeding was encountered. Because of frequently repeated hemorrhages, laparotomy was performed. A large vein was found on the surface of the ileal wall, through an adhesion to the lateral pelvic wall. Partial resection of ileum was performed. Histological examination of the resected small bowel demonstrated ruptured submucosal varices. The postoperative course was uneventful and he was discharged on the 40th postoperative day. It is stressed that this disease should be considered as a differential diagnosis for a patient with lower gastrointestinal bleeding and portal hypertension.     

Adhesion-related variceal hemorrhage following sclerosis of esophageal varices

A 78-year-old woman with portal hypertension had recurrent episodes of lower gastrointestinal hemorrhage two months after bleeding esophageal varices had been successfully treated with endoscopic injection sclerosis. Labeled red blood cell scans and mesenteric angiographic examination allowed a preoperative diagnosis of adhesion-related varices as the cause of bleeding. The problem was successfully treated by dividing the adhesion and resecting the involved small intestine.     

An unusual presentation of EATL type 1: Emergency surgery due to life-threatening gastrointestinal bleeding

INTRODUCTIONEnteropathy-associated T-cell lymphoma (EATL) is a very rare malignancy. Reasons for hospital admission are variable.PRESENTATION OF CASE76 years old man admitted to emergency service with sudden and massive obscure gastrointestinal bleeding. There was no complaints in his history. After initial evaluation, emergency laparatomy had to be done. Bleeding lesion in proximal jejunum was resected. Histopathologically, the muscularis propria had abundant atypical lymphoid infiltrate in diffuse pattern. Atypical lymphoid cells expressed CD3 and CD30. The jejunal mucosa adjacent to the tumor showed effacement of normal villous architecture.DISCUSSIONEATL is known to cause anemia as a result of chronic bleeding. However in this case, the bleeding was abundant, irreplaceable and requiring emergency surgery. To our knowledge it is not reported previously.CONCLUSIONA sudden and massive gastrointestinal bleeding can be the first and unique sign of EATL.