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An Unusual Cause of Recurrent Gastrointestinal Bleeding After Whipple’s Surgery
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58
Bilal Hameed, Uma Mahadevan, and Kay Washington, Section Editors
An Unusual Cause of Recurrent Gastrointestinal Bleeding After Whipple’s Surgery Q2
Saeed Ali,1 Asad ur Rahman,1 and Udayakumar Navaneethan2 1
Department of Internal Medicine, 2Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
Question: A 55-year-old Caucasian woman was admitted to the hospital with recurrent melena and hematochezia. Her past medical history was significant for a well-differentiated neuroendocrine tumor of the head of the pancreas for which she had undergone Whipple’s procedure 10 years ago. Her postoperative course was complicated by portal vein thrombosis. She also had a history of compensated liver cirrhosis secondary to nonalcoholic fatty liver disease. She was extensively evaluated in the past 2 years for recurrent gastrointestinal (GI) bleeding with upper and lower endoscopy, double balloon enteroscopy, video capsule endoscopy, and angiography. However, the underlying diagnosis was uncertain despite this extensive workup. She had received a total of 12 units of packed red blood cell transfusion over 2 years. There was no evidence of esophageal or gastric varices. She denied nonsteroidal anti-inflammatory drugs or anticoagulants and antiplatelet use. Physical examination revealed splenomegaly without jaundice. Rectal examination showed bright red blood in the rectal vault. Laboratory data showed normocytic normochromic anemia (hemoglobin 7.4 g/dL), platelet count of 114,000/mm3, and an International Normalized Ratio of 1. Magnetic resonance imaging of abdomen showed hepatic cirrhosis with portal hypertension and cavernous transformation of the portal vein. Push enteroscopy was performed and ruled out peptic ulcer disease, and esophageal and gastric varices. She had worsening hematochezia and melena with a persistent decrease in hemoglobin requiring 5 units of packed red cell transfusions. A Tc-99–labeled red cell scan failed to identify active bleeding. Colonoscopy showed fresh blood in the colon and terminal ileum. However, no area of active bleeding was visualized. Antegrade double balloon enteroscopy was performed next day to evaluate the persistent bleeding that revealed 2 lesions at the choledochojejunostomy site with stigmata of recent bleeding (Figure A, B). What is the diagnosis? How is this condition diagnosed and managed? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Q1
Conflicts of interest The authors have made the following disclosures: Udayakumar Navaneethan is a consultant for AbbVie and Janssen, and on the speaker bureau for Takeda and Janssen. © 2017 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2016.12.046
Gastroenterology 2017;-:e1–e2 DIS 5.4.0 DTD YGAST60918 proof 29 June 2017 5:14 pm ce
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ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174
Answer to: Image 1: Ectopic Variceal Hemorrhage Ectopic varices are large, portosystemic collaterals that are seen at sites other than the gastroesophageal region. Our patient had large varices at the site of choledochojejunostomy. These varices were successfully injected with 3 mL of n-butyl-2-cyanoacrylate (Figure C). The GI bleeding resolved and she was discharged home. The patient was last followed up at 2 months with no evidence of recurrent bleeding. An ectopic varix is a rare cause of GI bleeding and is seen in <5% of all variceal bleeding.1 Ectopic varices are typically associated with cirrhosis. Less commonly, they may result from portal vein thrombosis, mesenteric venous thrombosis, chronic pancreatitis, or adhesions from prior surgery. Ectopic varices at choledochojejunostomy site in patients who have undergone surgery is rarely reported owing to limited lifespan.2 It is often challenging to diagnose ectopic varices in the small intestine, owing to its length; tortuosity and the intermittent nature of bleeding which could explain the negative red blood cell scan. Push enteroscopy, nuclear scans, and angiography have all been used to diagnose small intestinal varices.3 The jejunal varices formed at choledochojejunostomy site can be treated by (a) obliteration of the varices that cause bleeding (by endoscopic sclerotherapy injecting N-butyl-2-cyanoacrylate,2 balloon-occluded retrograde transvenous obliteration, reanastomosis, surgical ligation or embolization) or (b) portal decompression (by portal venous dilatation and stenting, shunt operation [surgical shunt or transjugular intrahepatic portosystemic shunt], and splenectomy).1,3 Because the varices collapse after an episode of bleeding, the previous antegrade double balloon enteroscopy could not visualize them. Capsule endoscopy cannot visualize the anastomosis because this is in the afferent limb and the capsule cannot traverse upstream. This case report illustrates the importance of evaluating the anastomotic sites for ectopic varices in patients with previous surgery.
References 1. 2. 3.
Saeki Y, Ide K, Kakizawa H, et al. Controlling the bleeding of jejunal varices formed at the site of choledochojejunostomy: report of 2 cases and a review of the literature. Surg Today 2013:1–6. Hsu Y-C, Yen H-H, Chen Y-Y, et al. Successful endoscopic sclerotherapy for cholecystojejunostomy variceal bleeding in a patient with pancreatic head cancer. World J Gastroenterol 2010;16:123–125. Mansoor E, Singh A, Nizialek G, et al. Massive gastrointestinal bleeding due to isolated jejunal varices in a patient with extrahepatic portal hypertension: a case report. Am J Gastroenterol 2016;111:1209–1211.
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Bilal Hameed, Uma Mahadevan, and Kay Washington, Section Editors
An Unusual Cause of Recurrent Gastrointestinal Bleeding After Whipple’s Surgery Q2
Saeed Ali,1 Asad ur Rahman,1 and Udayakumar Navaneethan2 1
Department of Internal Medicine, 2Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
Question: A 55-year-old Caucasian woman was admitted to the hospital with recurrent melena and hematochezia. Her past medical history was significant for a well-differentiated neuroendocrine tumor of the head of the pancreas for which she had undergone Whipple’s procedure 10 years ago. Her postoperative course was complicated by portal vein thrombosis. She also had a history of compensated liver cirrhosis secondary to nonalcoholic fatty liver disease. She was extensively evaluated in the past 2 years for recurrent gastrointestinal (GI) bleeding with upper and lower endoscopy, double balloon enteroscopy, video capsule endoscopy, and angiography. However, the underlying diagnosis was uncertain despite this extensive workup. She had received a total of 12 units of packed red blood cell transfusion over 2 years. There was no evidence of esophageal or gastric varices. She denied nonsteroidal anti-inflammatory drugs or anticoagulants and antiplatelet use. Physical examination revealed splenomegaly without jaundice. Rectal examination showed bright red blood in the rectal vault. Laboratory data showed normocytic normochromic anemia (hemoglobin 7.4 g/dL), platelet count of 114,000/mm3, and an International Normalized Ratio of 1. Magnetic resonance imaging of abdomen showed hepatic cirrhosis with portal hypertension and cavernous transformation of the portal vein. Push enteroscopy was performed and ruled out peptic ulcer disease, and esophageal and gastric varices. She had worsening hematochezia and melena with a persistent decrease in hemoglobin requiring 5 units of packed red cell transfusions. A Tc-99–labeled red cell scan failed to identify active bleeding. Colonoscopy showed fresh blood in the colon and terminal ileum. However, no area of active bleeding was visualized. Antegrade double balloon enteroscopy was performed next day to evaluate the persistent bleeding that revealed 2 lesions at the choledochojejunostomy site with stigmata of recent bleeding (Figure A, B). What is the diagnosis? How is this condition diagnosed and managed? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Q1
Conflicts of interest The authors have made the following disclosures: Udayakumar Navaneethan is a consultant for AbbVie and Janssen, and on the speaker bureau for Takeda and Janssen. © 2017 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2016.12.046
Gastroenterology 2017;-:e1–e2 DIS 5.4.0 DTD YGAST60918 proof 29 June 2017 5:14 pm ce
59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174
Answer to: Image 1: Ectopic Variceal Hemorrhage Ectopic varices are large, portosystemic collaterals that are seen at sites other than the gastroesophageal region. Our patient had large varices at the site of choledochojejunostomy. These varices were successfully injected with 3 mL of n-butyl-2-cyanoacrylate (Figure C). The GI bleeding resolved and she was discharged home. The patient was last followed up at 2 months with no evidence of recurrent bleeding. An ectopic varix is a rare cause of GI bleeding and is seen in <5% of all variceal bleeding.1 Ectopic varices are typically associated with cirrhosis. Less commonly, they may result from portal vein thrombosis, mesenteric venous thrombosis, chronic pancreatitis, or adhesions from prior surgery. Ectopic varices at choledochojejunostomy site in patients who have undergone surgery is rarely reported owing to limited lifespan.2 It is often challenging to diagnose ectopic varices in the small intestine, owing to its length; tortuosity and the intermittent nature of bleeding which could explain the negative red blood cell scan. Push enteroscopy, nuclear scans, and angiography have all been used to diagnose small intestinal varices.3 The jejunal varices formed at choledochojejunostomy site can be treated by (a) obliteration of the varices that cause bleeding (by endoscopic sclerotherapy injecting N-butyl-2-cyanoacrylate,2 balloon-occluded retrograde transvenous obliteration, reanastomosis, surgical ligation or embolization) or (b) portal decompression (by portal venous dilatation and stenting, shunt operation [surgical shunt or transjugular intrahepatic portosystemic shunt], and splenectomy).1,3 Because the varices collapse after an episode of bleeding, the previous antegrade double balloon enteroscopy could not visualize them. Capsule endoscopy cannot visualize the anastomosis because this is in the afferent limb and the capsule cannot traverse upstream. This case report illustrates the importance of evaluating the anastomotic sites for ectopic varices in patients with previous surgery.
References 1. 2. 3.
Saeki Y, Ide K, Kakizawa H, et al. Controlling the bleeding of jejunal varices formed at the site of choledochojejunostomy: report of 2 cases and a review of the literature. Surg Today 2013:1–6. Hsu Y-C, Yen H-H, Chen Y-Y, et al. Successful endoscopic sclerotherapy for cholecystojejunostomy variceal bleeding in a patient with pancreatic head cancer. World J Gastroenterol 2010;16:123–125. Mansoor E, Singh A, Nizialek G, et al. Massive gastrointestinal bleeding due to isolated jejunal varices in a patient with extrahepatic portal hypertension: a case report. Am J Gastroenterol 2016;111:1209–1211.
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