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

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

Jejunal varices as a rare cause of recurrent gastrointestinal bleeding in a 74-year-old man with extrahepatic portal hypertension after pancreato-biliary surgery

A 74-year-old man presented to our hospital with recurrent lower gastrointestinal bleeding. His past medical history was remarkable for a duodenal papilla carcinoma and he underwent a pylorus-preserving pancreaticoduodenectomy 4 years before. During diagnostic work-up a severe portal vein stenosis after surgery and multiple dilated intramural jejunal varices, which formed as collateral pathways could be detected. Based on these findings, the recurrent haemorrhages were considered to be due to repeated rupturing and bleeding of jejunal varices. Therapeutically, the portal vein stenosis was treated with endovascular stent placement leading to a reduction in prestenotic portal pressure. During follow-up no further episodes of gastrointestinal bleeding were observed. Bleeding from jejunal varices is a very rare cause of gastrointestinal haemorrhages and represents a diagnostic and therapeutic challenge. However, it should be considered in differential diagnosis of obscure recurrent gastrointestinal haemorrhages in patients with a history of hepato-pancreato-biliary surgery.