Massive bleeding from jejunal varices in a patient with thalassemia major detected by TC-99m red blood cell scintigraphy

Incidental Detection of Ectopic Ovary Varices by 99mTc-Red Blood Cell Bleeding Scintigraphy in a Patient With Cirrhosis

ABSTRACT

A 72-year-old woman with cirrhosis underwent a 99mTc-labeled red blood cell (RBC) bleeding scan because of recurrent gastrointestinal bleeding. The images showed abnormal 99mTc-RBC accumulation in a mass in the region of the left ovary. Contrast-enhanced CT showed expansion of left ovary vein from the left renal vein, which twisted into an enhanced round mass in the left ovary area. Finally, a diagnosis of ectopic ovary varices was made, which is secondary to cirrhosis with portal hypertension. Ovary varices should be included as differential diagnoses of 99mTc-RBC bleeding scintigraphy.

Successful Treatment of a Case of Ectopic Jejunal Varices with Portal Venous Stenting

Patient: Female, 77

Final Diagnosis: Ectopic variceal bleeding of the jejunum

Symptoms: Abdominal pain • hematemesis • melena

Medication: —

Clinical Procedure: Portal vein stenting

Specialty: Gastroenterology and Hepatology

Solitary Variceal Rupture in the Small Intestine

A 70-year-old man was referred to our hospital to undergo treatment for hepatocellular carcinoma. In hospital, he complained of hematochezia and a laboratory analysis revealed a decreased level of hemoglobin. Abdominal computed tomography revealed a tumor in the small intestine, with slow enhancement of the dorsal region. Double-balloon enteroscopy revealed a submucosal tumor with a depression in the jejunum. Partial enterectomy was performed and a pathological examination demonstrated the presence of a solitary varix. Solitary varix in the small intestine has not been reported previously. We herein report an extremely rare case of solitary varix in the jejunum.

Enteroscopic Management of Ectopic Varices in a Patient with Liver Cirrhosis and Portal Hypertension

Portal hypertension and liver cirrhosis may predispose patients to varices, which have a propensity to bleed and cause significant morbidity and mortality. These varices are most commonly located in the gastroesophageal area; however, rarely ectopic varices may develop in unusual locations outside of this region. Haemorrhage from these sites can be massive and difficult to control; thus early detection and management may be lifesaving. We present a case of occult gastrointestinal bleeding in a patient with underlying alcoholic liver disease where an ectopic varix was ultimately detected with push enteroscopy.

A case of variceal bleeding from the jejunum in liver cirrhosis

While esophagogastric varices are common manifestations of portal hypertension, variceal bleeding from the jejunum is a rare complication of liver cirrhosis. In addition, ectopic variceal bleeding occurs in the duodenum and at sites of previous bowel surgery in most cases, including of stomas. We report a case of obscure overt gastrointestinal bleeding from jejunal varices in a 55-year-old woman who had not previously undergone abdominal surgery, who had liver cirrhosis induced by the hepatitis C virus. Emergency endoscopy revealed the presence of esophageal varices without stigmata of recent bleeding, and no bleeding focus was found at colonoscopy. She continued to produce recurrent melena with hematochezia and received up to 21 units of packed red blood cells. CT angiography revealed the presence of jejunal varices, but no active bleeding was found. Capsule endoscopy revealed fresh blood in the jejunum. The patient submitted to embolization of the jejunal varices via the portal vein, after which she had a stable hemoglobin level and no recurrence of the melena. This is a case of variceal bleeding from the jejunum in a liver cirrhosis patient without a prior history of abdominal surgery.

False positive GI bleed on Tc-99m RBC scintigraphy due to ileal varices

Tc-99m labeled RBC scintigraphy is commonly employed in the evaluation of acute gastrointestinal bleeding. On Tc-99m RBC studies gastrointestinal bleeding is seen as an initial focus of increased radiotracer activity that on subsequent images increases in intensity and changes position in a pattern that conforms to segments of bowel. We report a case of a patient with multiple episodes of hematochezia that presented with lower gastrointestinal hemorrhage. A Tc-99m labeled RBC scan was performed and the findings suggested a GI bleed. However, subsequent angiography revealed prominent ileal varices simulating an acute bleed. Although most varices fill promptly and should not be misinterpreted as a focus of hemorrhage, slow filling varices can simulate an acute bleed and lead to a false positive interpretation.

Updates in the pathogenesis, diagnosis and management of ectopic varices

Ectopic varices (EcV) comprise large portosystemic venous collaterals located anywhere other than the gastro-oesophageal region. No large series or randomized-controlled trials address this subject, and therefore its management is based on available expertise and facilities, and may require a multidisciplinary team approach. EcV are common findings during endoscopy in portal hypertensive patients and their bleeding accounts for only 1–5% of all variceal bleeding. EcV develop secondary to portal hypertension (PHT), surgical procedures, anomalies in venous outflow, or abdominal vascular thrombosis and may be familial in origin. Bleeding EcV may present with anaemia, shock, haematemesis, melaena or haematochezia and should be considered in patients with PHT and gastrointestinal bleeding or anaemia of obscure origin. EcV may be discovered during panendoscopy, enteroscopy, endoscopic ultrasound, wireless capsule endoscopy, diagnostic angiography, multislice helical computed tomography, magnetic resonance angiography, colour Doppler-flow imaging, laparotomy, laparoscopy and occasionally during autopsy. Patients with suspected EcV bleeding need immediate assessment, resuscitation, haemodynamic stabilization and referral to specialist centres. Management of EcV involves medical, endoscopic, interventional radiological and surgical modalities depending on patients’ condition, site of varices, available expertise and patients’ subsequent management plan.