1
|
Liu J, Wang P, Wang LM, Guo J, Zhong N. Outcomes of endoscopic sclerotherapy for jejunal varices at the site of choledochojejunostomy (with video): Three case reports. World J Gastroenterol 2024; 30:2059-2067. [PMID: 38681128 PMCID: PMC11045488 DOI: 10.3748/wjg.v30.i14.2059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/09/2024] [Accepted: 03/26/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Hemorrhage associated with varices at the site of choledochojejunostomy is an unusual, difficult to treat, and often fatal manifestation of portal hypertension. So far, no treatment guidelines have been established. CASE SUMMARY We reported three patients with jejunal varices at the site of choledochojejunostomy managed by endoscopic sclerotherapy with lauromacrogol/α-butyl cyanoacrylate injection at our institution between June 2021 and August 2023. We reviewed all patient records, clinical presentation, endoscopic findings and treatment, outcomes and follow-up. Three patients who underwent pancreaticoduodenectomy with a Whipple anastomosis were examined using conventional upper gastrointestinal endoscopy for suspected hemorrhage from the afferent jejunal loop. Varices with stigmata of recent hemorrhage or active hemorrhage were observed around the choledochojejunostomy site in all three patients. Endoscopic injection of lauromacrogol/α-butyl cyanoacrylate was carried out at jejunal varices for all three patients. The bleeding ceased and patency was observed for 26 and 2 months in two patients. In one patient with multiorgan failure and internal environment disturbance, rebleeding occurred 1 month after endoscopic sclerotherapy, and despite a second endoscopic sclerotherapy, repeated episodes of bleeding and multiorgan failure resulted in eventual death. CONCLUSION We conclude that endoscopic sclerotherapy with lauromacrogol/α-butyl cyanoacrylate injection can be an easy, effective, safe and low-cost treatment option for jejunal varicose bleeding at the site of choledochojejunostomy.
Collapse
Affiliation(s)
- Jun Liu
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Peng Wang
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Li-Mei Wang
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Jing Guo
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Ning Zhong
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| |
Collapse
|
2
|
Nasr S, Dahmani W, Jaziri H, Becheikh Y, Ameur W, Elleuch N, Jmaa A. Massive hematochezia due to jejunal varices successfully treated with coil embolization. Clin Case Rep 2022; 10:e6339. [PMID: 36188043 PMCID: PMC9487444 DOI: 10.1002/ccr3.6339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 07/27/2022] [Accepted: 08/30/2022] [Indexed: 11/08/2022] Open
Abstract
We report a case of hematochezia with hemodynamic instability due to jejunal varices in a cirrhotic patient with no prior history of surgery. The patient was managed with coil embolization via the portal vein. After which, the patient did not present any hemorrhage recurrence and maintained a stable hemoglobin level.
Collapse
Affiliation(s)
- Sahar Nasr
- Department of GastroenterologyUniversity of SousseSousseTunisia
| | - Wafa Dahmani
- Department of GastroenterologyUniversity of SousseSousseTunisia
| | - Hanene Jaziri
- Department of GastroenterologyUniversity of SousseSousseTunisia
| | | | - Wafa Ben Ameur
- Department of GastroenterologyUniversity of SousseSousseTunisia
| | - Nour Elleuch
- Department of GastroenterologyUniversity of SousseSousseTunisia
| | - Ali Jmaa
- Department of GastroenterologyUniversity of SousseSousseTunisia
| |
Collapse
|
3
|
Rassow S, Büttner S, Thalhammer A, Huber NM, Heise M, Peiffer KH, Avaniadi D, Seifert J, Geiger H, Bechstein WO, Pession U, Hauser IA. A 55-Year-Old Man with Recurrent Gastrointestinal Bleeding Due to Stricture of the Portal Vein Anastomotic Site 12 Years After Combined Pancreas and Kidney Transplantation. Am J Case Rep 2022; 23:e936148. [PMID: 35437299 PMCID: PMC9036831 DOI: 10.12659/ajcr.936148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Varices of the upper gastrointestinal tract are due to portal hypertension and can result from occlusion of the portal venous system. This report is of a 55-year-old man with recurrent gastrointestinal bleeding due to stricture of the portal vein anastomotic site to inferior vena cava (IVC) 12 years after combined pancreas and kidney transplantation. CASE REPORT A 55-year-old man presented bleeding episodes requiring transfusion of more than 70 units of red blood cells (RBCs), complicated by bacterial and viral infection episodes including cytomegalovirus (CMV) reactivation and hepatitis E and transient impairment of function of the renal allograft. Endoscopy, computed tomography (CT) scan, and angiography revealed jejunal varices due to anastomotic stricture at the portal vein to IVC as the cause of the hemorrhage. Neither conservative therapy nor an anastomosis between the splenic vein of the graft and the internal iliac vein as a bypass could stop the life-threatening bleeding. During the recurrent bleeding, CD4 T lymphocytes were low, indicating immunodeficiency despite paused immunosuppressive therapy. After the hemorrhage resolved and immunosuppression was restarted, CD4 T lymphocyte levels normalized. Finally, to stop the hemorrhage and save the transplanted kidney and the patient's life, graft pancreatectomy was performed. Long-term damage to the renal transplant was not found. CONCLUSIONS This report is of a rare case of portal hypertension as a long-term complication of transplant surgery. Although acute venous thrombosis at the anastomotic site is a recognized postoperative complication of pancreatic transplant surgery, this case highlights the importance of post-transplant follow-up and diagnostic imaging.
Collapse
Affiliation(s)
- Steffen Rassow
- Medical Clinic III, Department of Nephrology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany,Medical Clinic, Krankenhaus Nordwest, Frankfurt am Main, Germany
| | - Stefan Büttner
- Medical Clinic III, Department of Nephrology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Axel Thalhammer
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Nora Marie Huber
- Medical Clinic III, Department of Nephrology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Michael Heise
- Department of General and Visceral Surgery, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Kai-Henrik Peiffer
- Medical Clinic I, Department of Gastroenterology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Despina Avaniadi
- Medical Clinic III, Department of Nephrology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Julia Seifert
- Medical Clinic III, Department of Nephrology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Helmut Geiger
- Medical Clinic III, Department of Nephrology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Wolf Otto Bechstein
- Department of General and Visceral Surgery, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Ursula Pession
- Department of General and Visceral Surgery, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Ingeborg Anni Hauser
- Medical Clinic III, Department of Nephrology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany,Corresponding Author: Ingeborg Anni Hauser, e-mail:
| |
Collapse
|
4
|
Solanki S, Jena SS, Das SAP, Yadav A, Mehta NN, Nundy S. Isolated ectopic jejunal varices in a patient with extrahepatic portal vein obstruction - A case report. Int J Surg Case Rep 2021; 86:106299. [PMID: 34419724 PMCID: PMC8379621 DOI: 10.1016/j.ijscr.2021.106299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/06/2021] [Accepted: 08/07/2021] [Indexed: 01/17/2023] Open
Abstract
Introduction and importance Among 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 presentation A 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 discussion The 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. Conclusion The 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. Ectopic varices are an unusual cause of lower GI bleeding caused by porto-systemic collaterals. Ectopic varices most commonly occur at jejuno-ileum, but duodenal varices are more prone to bleed. The optimal management varies with each case due to paucity of treatment guidelines. Decompressive shunt with splenectomy and segmental resection of intestine effectively prevents rebleeding.
Collapse
Affiliation(s)
- Sanket Solanki
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, Delhi 110060, India.
| | - Suvendu Sekhar Jena
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, Delhi 110060, India
| | - Sri Aurobindo Prasad Das
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, Delhi 110060, India
| | - Amitabh Yadav
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, Delhi 110060, India
| | - Naimish N Mehta
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, Delhi 110060, India
| | - Samiran Nundy
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, Delhi 110060, India
| |
Collapse
|
5
|
Tai Y, Tong H, Wei B, Wu H. Ectopic variceal bleeding after hepatobiliary surgery: A case report. Medicine (Baltimore) 2021; 100:e24975. [PMID: 33655966 PMCID: PMC7939183 DOI: 10.1097/md.0000000000024975] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 02/11/2021] [Indexed: 02/05/2023] Open
Abstract
RATIONALE Jejunal varices are rare in portal hypertension and are often difficult to diagnose and treat. Herein, we present a case of gastrointestinal bleeding due to jejunal varices after hepatobiliary surgery. PATIENT CONCERNS A 69-year-old man presented with recurrent massive gastrointestinal bleeding. He underwent partial right hepatectomy and cholangiojejunostomy 2 years prior to the first onset of bleeding. Two sessions of endoscopic vessel ligation for esophageal varices were performed afterwards, and hematemesis resolved completely, but massive melena still recurred during the following 5 years. DIAGNOSIS The patient was diagnosed with jejunal varices caused by portal venous stenosis after hepatobiliary surgery. INTERVENTION Portal venous angioplasty using balloon dilation and stent implantation was performed. OUTCOMES After the intervention procedure, the patient did not experience any onset of gastrointestinal bleeding during follow-up. LESSONS Hepatopancreatobiliary could lead to the formation of jejunal varices. The combined use of capsule endoscopy, contrast-enhanced computed tomography, and sometimes portal venography is a promising strategy to search for jejunal varices. Transcatheter angioplasty appears to be a safe and effective method for treatment of jejunal varices in certain appropriate cases.
Collapse
Affiliation(s)
- Yang Tai
- Department of Gastroenterology
- Laboratory of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
| | | | - Bo Wei
- Department of Gastroenterology
| | - Hao Wu
- Department of Gastroenterology
| |
Collapse
|
6
|
Evola G, Mazzone G, Corsaro A, Brancato G, Evola FR, Basile G. Hemorrhagic shock from post-traumatic rupture of microcystic splenic lymphangioma: A case report and review of the literature. Int J Surg Case Rep 2020; 75:376-379. [PMID: 32987290 PMCID: PMC7522038 DOI: 10.1016/j.ijscr.2020.09.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/06/2020] [Accepted: 09/06/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Lymphangioma is an abnormal proliferation of lymphatic vessels. Isolated splenic lymphangioma (SL) is rare; in the last 30 years only 22 cases were reported in the literature. Diagnosis is difficult by the absence of typical symptoms and signs. SL is often asymptomatic and occasionally detected through radiological exams or, after the onset of a life-threatening complication, at surgery or pathological examination. Surgery represents the treatment of choice. PRESENTATION OF CASE A 22-year-old Caucasian male was admitted to the Emergency Department after a car accident, complaining of sudden onset, severe, left upper quadrant abdominal pain. Abdominal examination revealed mild abdominal distention and a severe abdominal pain on superficial and deep palpation of left upper abdominal quadrant with obvious muscle guarding and rebound tenderness. Abdominal computed tomography scan showed splenic rupture with hemoperitoneum. Laboratory tests reported severe anemia. The patient received blood transfusions and was taken emergently to the operating room for exploratory laparotomy, evacuation of hemoperitoneum and splenectomy. The postoperative course was uneventful, the patient was discharged on the 7th post-operative day. Diagnosis of microcystic SL was made at pathological examination. DISCUSSION Post-traumatic splenic rupture may be favored by the presence of a unknown and asymptomatic isolated SL. Although different types of treatment of SL are reported in the literature, splenectomy represents the treatment of choice to avoid complications. CONCLUSION Isolated SL is difficult to diagnose and suspect because of lack of pathognomonic symptoms and specific diagnostic signs. It can be diagnosed after the onset of a life-threatening complication. Splenectomy is the preferable definitive treatment.
Collapse
Affiliation(s)
- Giuseppe Evola
- General and Emergency Surgery Department, Garibaldi Hospital, Piazza Santa Maria di Gesù 5, 95100, Catania, Italy.
| | - Giovanni Mazzone
- First Department of Surgery, Azienda Ospedaliero-Universitaria "Policlinico-V. Emanuele-San Marco", P.O. San Marco, Viale C.A. Ciampi, 95121, Catania, Italy
| | - Antonino Corsaro
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Via S. Sofia 78, 95123, Catania, Italy
| | - Giovanna Brancato
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Via S. Sofia 78, 95123, Catania, Italy
| | - Francesco Roberto Evola
- Department of Orthopedic and Traumatology, Cannizzaro Hospital, Via Messina 829, 95126, Catania, Italy
| | - Guido Basile
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Via S. Sofia 78, 95123, Catania, Italy
| |
Collapse
|
7
|
Jejunal Varices Bleeding in a Patient with Extensive Portomesenteric Thrombosis Secondary to Factor V Leiden Mutation: A Management Dilemma. Case Rep Gastrointest Med 2019; 2019:4526472. [PMID: 30881706 PMCID: PMC6381577 DOI: 10.1155/2019/4526472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 12/06/2018] [Accepted: 01/22/2019] [Indexed: 02/05/2023] Open
Abstract
Ectopic varices are portosystemic collaterals that occur away from the gastroesophageal junction and account for 1-5% of all variceal bleeding. Its occurrence in the jejunum is rare. Most common cause of ectopic jejunal varices is portal hypertension especially in those patients who have undergone prior abdominal surgery. Portomesenteric thrombosis is a rare cause of ectopic jejunal varices. Ectopic varices are rare cause of obscure GI bleeding and hence should be always suspected in patients with history of portal hypertension who present with GI bleeding and have negative upper and lower GI endoscopies. Management of patients with ectopic varices is often very challenging and requires multidisciplinary approach. Therapeutic options include endoscopic therapy, interventional radiologic procedures, surgically creating shunting, or surgical resection. We present the case of a 52-year-old patient who was on anticoagulation for extensive portomesenteric thrombosis secondary to factor V Leiden heterozygous mutation and presented with melena and symptomatic anemia. Investigations showed bleeding jejunal varices as the cause of anemia. We discuss the therapeutic options and dilemma in the management of such cases.
Collapse
|
8
|
Kunihara S, Oka S, Tanaka S, Otani I, Igawa A, Nagaoki Y, Aikata H, Chayama K. Predictive Factors of Portal Hypertensive Enteropathy Exacerbation in Patients with Liver Cirrhosis: A Capsule Endoscopy Study. Digestion 2018; 98:33-40. [PMID: 29672296 DOI: 10.1159/000486666] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 01/08/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS The clinical course and exacerbation of portal hypertensive enteropathy (PHE) are yet to be fully clarified. This study aimed to identify factors related to PHE exacerbation in patients with liver cirrhosis (LC). METHODS Fifty patients with LC (33 male; mean age, 67 years), who underwent capsule endoscopy (CE) at the Hiroshima University Hospital between February 2009 and September 2015, were followed up for >6 months. Exacerbation is defined as the appearance of new lesions or worsening of existing lesions. The association between PHE exacerbation and the clinical factors was evaluated. RESULTS PHE exacerbation was identified in 24 out of 50 (48%) of cases: erythema (14 cases); angioectasia (11 cases); erosions (9 cases); villous edema (8 cases); and esophageal varices (EVs; 6 cases). The following factors were significantly associated with PHE exacerbation: portosystemic shunts, EVs and portal hypertensive gastropathy (PHG) exacerbation. After therapy, CE findings among the 24 cases were as follows: villous edema (19 cases); erythema (17 cases); angioectasia (16 cases); erosions (12 cases); and EVs (9 cases), and no observable abnormalities in 2 cases. On multivariate analysis, exacerbation of EVs and PHG were independent predictors of PHE exacerbation. CONCLUSION EVs and PHG exacerbation may predict PHE exacerbation in patients with LC.
Collapse
Affiliation(s)
- Sayoko Kunihara
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Shiro Oka
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Shinji Tanaka
- Department of Endoscopy and Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Ichiro Otani
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Atsushi Igawa
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuko Nagaoki
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroshi Aikata
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| |
Collapse
|
9
|
Endoscopic Sclerotherapy with a Large Volume of High Concentration of Cyanoacrylate for Jejunal Variceal Bleeding bys Single-Balloon Enteroscopy. ACTA ACUST UNITED AC 2018; 54:medicina54050068. [PMID: 30344299 PMCID: PMC6262278 DOI: 10.3390/medicina54050068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 09/04/2018] [Accepted: 09/06/2018] [Indexed: 12/14/2022]
Abstract
Jejunal varices are a rare manifestation of portal hypertension, and they are associated with a high mortality and poor prognosis when bleeding occurs. A bleeding jejunal varix is much more challenging to diagnose and manage because of its anatomic location. Herein, we describe the case of a 62-year-old man with active jejunal variceal bleeding who presented with massive hematochezia and hypovolemic shock. He was treated successfully with a high volume and concentration of a glue mixture as endoscopic sclerotherapy using single-balloon enteroscopy in the intensive care unit. Enteroscopic sclerotherapy is an effective option for jejunal variceal bleeding.
Collapse
|
10
|
Balogh J, Gordon-Burroughs S, Schwarz P, Galati J, McFadden R, Cusick M, Snyder M, Bailey H, Weiner M, Wong A, Ochoa R, Saharia A, Gaber A, Ghobrial R. Treatment of Refractory Gastrointestinal Bleeding in Patients With Portal Hypertension: A Case Series and Treatment Algorithm. Transplant Proc 2017; 49:1864-1869. [DOI: 10.1016/j.transproceed.2017.06.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 06/16/2017] [Indexed: 12/29/2022]
|
11
|
Laparotomy-Assisted Endoscopic Injection of Jejunal Varices for Overt Small Bowel Bleeding. ACG Case Rep J 2017; 4:e79. [PMID: 28670593 PMCID: PMC5482908 DOI: 10.14309/crj.2017.79] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 05/05/2017] [Indexed: 12/22/2022] Open
Abstract
A 54-year old male liver transplant recipient with Roux-en-Y choledochojejunostomy was admitted for symptomatic anemia. Despite endoscopies and a bleeding scan, active bleeding was not visualized. Angiography and abdominal computed tomography demonstrated possible jejunal varices at the choledochojejunal anastomosis. Double-balloon enteroscopy demonstrated varices with overlying clots in the Roux limb at the anastomosis. Due to the extensive loop formation and unstable position of the endoscope, therapeutic intervention could not be performed. Operative enterotomy and intraoperative endoscopy were subsequently required. A varix in the jejunum with venous flow on Doppler was injected twice with cyanoacrylate and successfully obturated.
Collapse
|
12
|
Mansoor E, Singh A, Nizialek G, Veloso HM, Katz J, Cooper GS, Isenberg G. Massive Gastrointestinal Bleeding Due to Isolated Jejunal Varices in a Patient With Extrahepatic Portal Hypertension: A Case Report. Am J Gastroenterol 2016; 111:1209-11. [PMID: 27481431 DOI: 10.1038/ajg.2016.191] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Emad Mansoor
- Department of Internal Medicine, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Ajaypal Singh
- Division of Gastroenterology and Liver Disease, Department of Medicine-Gastroenterology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Gregory Nizialek
- Department of Internal Medicine, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Hazel Marie Veloso
- Division of Gastroenterology and Liver Disease, Department of Medicine-Gastroenterology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Jeffry Katz
- Division of Gastroenterology and Liver Disease, Department of Medicine-Gastroenterology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Gregory S Cooper
- Division of Gastroenterology and Liver Disease, Department of Medicine-Gastroenterology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Gerard Isenberg
- Division of Gastroenterology and Liver Disease, Department of Medicine-Gastroenterology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| |
Collapse
|
13
|
Read AJ, Appelman HD, DiMagno MJ. Massive Jejunal Bleeding From an Unlikely Source. Clin Gastroenterol Hepatol 2016; 14:A25-6. [PMID: 26325398 DOI: 10.1016/j.cgh.2015.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Accepted: 08/23/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Andrew J Read
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, Michigan
| | - Henry D Appelman
- Department of Pathology, University of Michigan, Ann Arbor, Michigan
| | - Matthew J DiMagno
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, Michigan
| |
Collapse
|
14
|
Capsule Endoscopy for Portal Hypertensive Enteropathy. Gastroenterol Res Pract 2015; 2016:8501394. [PMID: 26819613 PMCID: PMC4706926 DOI: 10.1155/2016/8501394] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 07/15/2015] [Indexed: 02/08/2023] Open
Abstract
Portal hypertensive enteropathy (PHE) is a mucosal abnormality of the small bowel that is observed in patients with portal hypertension (PH) and can lead to gastrointestinal bleeding and anemia. The pathogenesis is still not completely understood. The introduction of new endoscopic methods, including capsule endoscopy (CE) or balloon-assisted enteroscopy, has increased the detection of these abnormalities. CE can also serve as a road map for deciding subsequent interventions and evaluating the treatment effect. The prevalence of PHE is reportedly 40-70% in patients with PH. Endoscopic findings can be roughly divided into vascular and nonvascular lesions such as inflammatory-like lesions. Traditionally, PHE-associated factors include large esophageal varices, portal hypertensive gastropathy or colopathy, Child-Turcotte-Pugh class B or C, a history of variceal treatment, and acute gastrointestinal bleeding. More recently, on using scoring systems, a high computed tomography or transient elastography score was reportedly PHE-related factors. However, the prevalence of PHE and its related associated factors remain controversial. The management of PHE has not yet been standardized. It should be individualized according to each patient's situation, the availability of therapy, and each institutional expertise.
Collapse
|
15
|
Mekaroonkamol P, Cohen R, Chawla S. Portal hypertensive enteropathy. World J Hepatol 2015; 7:127-138. [PMID: 25729469 PMCID: PMC4342596 DOI: 10.4254/wjh.v7.i2.127] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 10/28/2014] [Accepted: 11/19/2014] [Indexed: 02/06/2023] Open
Abstract
Portal hypertensive enteropathy (PHE) is a condition that describes the pathologic changes and mucosal abnormalities observed in the small intestine of patients with portal hypertension. This entity is being increasingly recognized and better understood over the past decade due to increased accessibility of the small intestine made possible by the introduction of video capsule endoscopy and deep enteroscopy. Though challenged by its diverse endoscopic appearance, multiple scoring systems have been proposed to classify the endoscopic presentation and grade its severity. Endoscopic findings can be broadly categorized into vascular and non-vascular lesions with many subtypes of both categories. Clinical manifestations of PHE can range from asymptomatic incidental findings to fatal gastrointestinal hemorrhage. Classic endoscopic findings in the setting of portal hypertension may lead to a prompt diagnosis. Occasionally histopathology and cross sectional imaging like computed tomography or magnetic resonance imaging may be helpful in establishing a diagnosis. Management of overt bleeding requires multidisciplinary approach involving hepatologists, endoscopists, surgeons, and interventional radiologists. Adequate resuscitation, reduction of portal pressure, and endoscopic therapeutic intervention remain the main principles of the initial treatment. This article reviews the existing evidence on PHE with emphasis on its classification, diagnosis, clinical manifestations, endoscopic appearance, pathological findings, and clinical management. A new schematic management of ectopic variceal bleed is also proposed.
Collapse
|
16
|
Tabbaa A, Hanouneh IA, Tsai CJ. An unusual cause of gastrointestinal bleeding and encephalopathy in an elderly woman. Gastroenterology 2014; 147:e9-e11. [PMID: 24877863 DOI: 10.1053/j.gastro.2014.02.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 02/18/2014] [Accepted: 02/21/2014] [Indexed: 12/02/2022]
Affiliation(s)
- Adam Tabbaa
- Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
| | - Ibrahim A Hanouneh
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, United States
| | - Chung-Jyi Tsai
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, United States
| |
Collapse
|