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A rare cause of obscure gastrointestinal bleeding: an anastomotic enteric varix not associated with portal hypertension
Digestive and Liver Disease 39 (2007) 196–197
Correspondence
A rare cause of obscure gastrointestinal bleeding: an anastomotic enteric varix not associated with portal hypertension Sir, Mid gastrointestinal (GI) bleeding represents about 5% of all bleeds [1]. Push enteroscopy (PE), capsule endoscopy (CE) and recently double balloon enteroscopy (DBE) are used to diagnose these lesions. Vascular malformations, Crohn disease and small bowel tumours represent the most frequent finding [2], while enteric varices are rare cause of bleeding. We observed a 65-year-old woman with melena. Her past medical history included a choledoco-jejuno anastomosis with a Y-en-Roux loop for a cholodocal cyst 3 years previously, re-confectioned 4 months later for the development of a stenosis. One year previously she presented with melena requiring transfusion of 4 units of packed red blood cells; upper and lower endoscopy that not reveal the site of bleeding. Six months later, the bleeding recurred. Upper endoscopy revealed duodenal erosions and lower endoscopy was normal. The patient was discharged under omeprazole therapy. Her only medication was aspirin. Vital signs and physical examination were normal. Haemoglobin level was 8.5 g/dl. Upper and lower endoscopies were normal again. Since bleeding recurred during the hospitalisation PE was performed. At the level of the jejunal anastomosis with the Y-en-Roux loop, a bulge of the mucosa with a small reddish break at the top and red blood all around the lesion (Fig. 1) was seen which arose the suspicion of a bowel varix. Since patient did not show any clinical and instrumental signs of liver disease and portal hypertension, and the exact nature of the lesion was not clear, we decided not to treat endoscopically the lesion and to refer the patient to the surgeon. At laparotomy, large venous trunks were found at the level of the anastomosis, but no signs of portal hypertension were present. A segment of jejunum, including the anastomosis, was resected and a new anastomosis between the jejunum and the Y-en-Roux loop was confectioned.
Fig. 1. A small bowel varix at the level of the anastomosis with a Y-en-Roux loop. A small reddish mucosal break at the top of the bulge is evident.
The post-operative course was uneventful and the patient was discharged 10 days later. The patient has had no further episodes of bleeding for 2 years follow-up. Conventional procedures allow diagnosis of mid GI bleeding in only 10–20% of cases [1,2]. Currently, CE is suggested to be performed before DBE in patients with suspected mid GI bleeding [1]. PE is easier and cheaper than DBE, and may still have a diagnostic role if the bleeding source is suspected to be, as in our case, in the proximal jejunum [3]. Most of the lesions in mid intestinal bleeders are well within the reach of PE [3,4]. Moreover, PE is immediately available and gives an immediate response. This is important considering that ‘urgent’ CE and DBE are not always feasible, and the likelihood to find a lesion is inversely related to the time since the prior bleed [4].
1590-8658/$30 © 2006 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dld.2006.10.011
Correspondence / Digestive and Liver Disease 39 (2007) 196–197
Lesions at the anastomotic level, mainly ulcers of ischemic origin, are not rare in patients operated of gastric resection. Duodenal and enteric varices are rare in patients with portal hypertension. Varices have been described also at anastomotic level but only in patients with portal hypertension [5]. Sclerotherapy, cyanoacrylate injection and band ligation represent the therapeutical options for duodenal varices [6], but carry risk of complications and failure, probably because the blood flow is higher than in esophageal varices and they drain into the inferior vena cava. In the present case, the surgical option was considered because the patient did not show any signs of portal hypertension and the origin of the varix was unknown. A ligation or compression of a venous trunk at the site of anastomosis during operation was supposed to be the cause of the venous ectasia. In conclusion, the present report adds a new element to the list of small bowel lesions and further supports the impression that PE may still play a role in the diagnostic definition and treatment of most of these lesions.
Conflict of interest statement None declared.
197
References [1] Ell C, May A. Mid-gastrointestinal bleeding: capsule endoscopy and push-and-pull enteroscopy give rise to a new medical term. Endoscopy 2006;38:73–5. [2] Zuckerman GR, Prakash C, Askin MP, Lewis BS. AGA technical review on the evaluation and management of occult and obscure gastrointestinal bleeding. Gastroenterology 2000;118:201–21. [3] Zaman A, Katon RM. Push enteroscopy for obscure gastrointestinal bleeding yields a high incidence of proximal lesions within reach of a standard endoscope. Gastrointest Endosc 1998;47:372–6. [4] Pennazio M, Santucci R, Rondonotti E, Abbiati C, Beccari G, Rossini FP, et al. Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases. Gastroenterology 2004;126:643–53. [5] Bosch A, Marsano L, Varilek GW. Successful obliteration of duodenal varices after endoscopic ligation. Dig Dis Sci 2003;48:1809–12. [6] Norton ID, Andrews JC, Kamath PS. Management of ectopic varices. Hepatology 1998;28:1154–8.
G. Manes ∗ E.C. Ferrara A. Massari Department of Gastroenterology, L. Sacco University Hospital, Milan, Italy Available online 27 December 2006
∗ Corresponding author at: Divisione e Cattedra di Gastroenterologia, Polo Universitario L. Sacco, Via G. B. Grassi 74, 20157 Milan, Italy. Tel.: +39 02 39043316; fax: +39 02 39042337. E-mail address: [email protected] (G. Manes).
Correspondence
A rare cause of obscure gastrointestinal bleeding: an anastomotic enteric varix not associated with portal hypertension Sir, Mid gastrointestinal (GI) bleeding represents about 5% of all bleeds [1]. Push enteroscopy (PE), capsule endoscopy (CE) and recently double balloon enteroscopy (DBE) are used to diagnose these lesions. Vascular malformations, Crohn disease and small bowel tumours represent the most frequent finding [2], while enteric varices are rare cause of bleeding. We observed a 65-year-old woman with melena. Her past medical history included a choledoco-jejuno anastomosis with a Y-en-Roux loop for a cholodocal cyst 3 years previously, re-confectioned 4 months later for the development of a stenosis. One year previously she presented with melena requiring transfusion of 4 units of packed red blood cells; upper and lower endoscopy that not reveal the site of bleeding. Six months later, the bleeding recurred. Upper endoscopy revealed duodenal erosions and lower endoscopy was normal. The patient was discharged under omeprazole therapy. Her only medication was aspirin. Vital signs and physical examination were normal. Haemoglobin level was 8.5 g/dl. Upper and lower endoscopies were normal again. Since bleeding recurred during the hospitalisation PE was performed. At the level of the jejunal anastomosis with the Y-en-Roux loop, a bulge of the mucosa with a small reddish break at the top and red blood all around the lesion (Fig. 1) was seen which arose the suspicion of a bowel varix. Since patient did not show any clinical and instrumental signs of liver disease and portal hypertension, and the exact nature of the lesion was not clear, we decided not to treat endoscopically the lesion and to refer the patient to the surgeon. At laparotomy, large venous trunks were found at the level of the anastomosis, but no signs of portal hypertension were present. A segment of jejunum, including the anastomosis, was resected and a new anastomosis between the jejunum and the Y-en-Roux loop was confectioned.
Fig. 1. A small bowel varix at the level of the anastomosis with a Y-en-Roux loop. A small reddish mucosal break at the top of the bulge is evident.
The post-operative course was uneventful and the patient was discharged 10 days later. The patient has had no further episodes of bleeding for 2 years follow-up. Conventional procedures allow diagnosis of mid GI bleeding in only 10–20% of cases [1,2]. Currently, CE is suggested to be performed before DBE in patients with suspected mid GI bleeding [1]. PE is easier and cheaper than DBE, and may still have a diagnostic role if the bleeding source is suspected to be, as in our case, in the proximal jejunum [3]. Most of the lesions in mid intestinal bleeders are well within the reach of PE [3,4]. Moreover, PE is immediately available and gives an immediate response. This is important considering that ‘urgent’ CE and DBE are not always feasible, and the likelihood to find a lesion is inversely related to the time since the prior bleed [4].
1590-8658/$30 © 2006 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dld.2006.10.011
Correspondence / Digestive and Liver Disease 39 (2007) 196–197
Lesions at the anastomotic level, mainly ulcers of ischemic origin, are not rare in patients operated of gastric resection. Duodenal and enteric varices are rare in patients with portal hypertension. Varices have been described also at anastomotic level but only in patients with portal hypertension [5]. Sclerotherapy, cyanoacrylate injection and band ligation represent the therapeutical options for duodenal varices [6], but carry risk of complications and failure, probably because the blood flow is higher than in esophageal varices and they drain into the inferior vena cava. In the present case, the surgical option was considered because the patient did not show any signs of portal hypertension and the origin of the varix was unknown. A ligation or compression of a venous trunk at the site of anastomosis during operation was supposed to be the cause of the venous ectasia. In conclusion, the present report adds a new element to the list of small bowel lesions and further supports the impression that PE may still play a role in the diagnostic definition and treatment of most of these lesions.
Conflict of interest statement None declared.
197
References [1] Ell C, May A. Mid-gastrointestinal bleeding: capsule endoscopy and push-and-pull enteroscopy give rise to a new medical term. Endoscopy 2006;38:73–5. [2] Zuckerman GR, Prakash C, Askin MP, Lewis BS. AGA technical review on the evaluation and management of occult and obscure gastrointestinal bleeding. Gastroenterology 2000;118:201–21. [3] Zaman A, Katon RM. Push enteroscopy for obscure gastrointestinal bleeding yields a high incidence of proximal lesions within reach of a standard endoscope. Gastrointest Endosc 1998;47:372–6. [4] Pennazio M, Santucci R, Rondonotti E, Abbiati C, Beccari G, Rossini FP, et al. Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases. Gastroenterology 2004;126:643–53. [5] Bosch A, Marsano L, Varilek GW. Successful obliteration of duodenal varices after endoscopic ligation. Dig Dis Sci 2003;48:1809–12. [6] Norton ID, Andrews JC, Kamath PS. Management of ectopic varices. Hepatology 1998;28:1154–8.
G. Manes ∗ E.C. Ferrara A. Massari Department of Gastroenterology, L. Sacco University Hospital, Milan, Italy Available online 27 December 2006
∗ Corresponding author at: Divisione e Cattedra di Gastroenterologia, Polo Universitario L. Sacco, Via G. B. Grassi 74, 20157 Milan, Italy. Tel.: +39 02 39043316; fax: +39 02 39042337. E-mail address: [email protected] (G. Manes).