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Endoscopic N-butyl-2-cyanoacrylate (Histoacryl) obliteration of jejunal varices by using the double balloon enteroscope
Endoscopic N-butyl-2-cyanoacrylate (Histoacryl) obliteration of jejunal varices by using the double balloon enteroscope Hakim Hekmat, MD, Abdulbaqi Al-toma, MD, Maarten P. J. H. Mallant, MD, Chris J. J. Mulder, PhD, Maarten A. J. M. Jacobs, PhD Amsterdam, The Netherlands
Hemorrhage associated with small-bowel varices is an uncommon, difficult to treat, and often fatal manifestation of portal hypertension. There are no precise data on the incidence of this cause of bleeding. The main cause is portal hypertension or a local stenosis or thrombosis of the superior mesenteric vein. About 8.1% of patients with portal hypertension who underwent capsule endoscopy have small-bowel varices.1 Varices have been found both in the proximal and distal small bowel. At ileocoloscopy, 18% of patients with liver cirrhosis and portal hypertension have ileal varices.2 Double-balloon enteroscopy (DBE) has the potential to visualize the whole small bowel, take biopsy specimens, and perform all necessary endoscopic interventions.3
CASE REPORT A 49-year-old man with a medical history of perinuclearantineutrophil cytoplasmic antibodies (P-ANCA) negative microscopic polyangiitis with thrombosis of both superior and inferior vena cava was referred to our medical center for further investigation and treatment of recurrent overt GI bleeding (OGIB). A detailed laboratory investigation at the referring hospital excluded all known primary and secondary causes of a hypercoagulable state. Within the last 2.5 months, the patient was repeatedly admitted to his hospital with recurrent melena or OGIB. Upper-GI endoscopy revealed the presence of esophageal varices grade II, without stigmata of recent bleeding. No bleeding focus was found at coloscopy. He received 42 units of packed red blood cells in the 2 weeks preceding the referral. The venous phase of CT angiography revealed the presence of occlusion of the inferior vena cava and both common iliac veins, with extensive portocaval and cava-caval collaterals (Figs. 1 and 2), but no active bleeding was demonstrated. A DBE was performed by using a double-balloon enteroscope (Fujinon EN-450 T5; Fujinon Inc, Saitama, Japan). A solitary jejunal varix at about 240 cm from the ligament of Treitz, with stigmata of recent bleeding, was found (Fig. 3) and was treated with an injection of Histoacryl 0.5 mL (B. Braun, Melsungen, Germany), mixed with 0.5 mL Lipiodol (Guerbet, Aulnay-sous-Bois, France). The varix, after treatment, is shown in Figure 4. No other varices were found distally in the small bowel. Two months after the interven350 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 2 : 2007
Figure 1. CT angiography in portal venous phase, showing portosystemic collateral with varices (arrow). Note the absence of contrast in the inferior vena cava (arrowhead) and distended azygos and hemiazygos veins (open arrows).
tion, the patient had a stable Hb level, and no recurrence of the melena was recognized. His maintenance medications consisted of oral anticoagulants and azathioprine.
DISCUSSION GI hemorrhage caused by small-bowel varices is a rare entity. Small-bowel varices are usually secondary to portal hypertension or stenosis, and thrombosis of the portomesenteric vein system. These were not demonstrated in this patient; furthermore, detailed laboratory investigation excluded all known primary and secondary causes of hypercoagulable state. Therefore, the only plausible cause of the jejunal varices in this patient was an inferior vena cava occlusion. A causal association with P-ANCA negative microscopic polyangiitis cannot be confirmed or refuted. To the best of our knowledge, this causal association has not been reported earlier. There are only a few case reports that discuss other treatment modalities of bleeding jejunal varices. Transjugular intrahepatic portosystemic shunt has been used in cases of small-bowel varices complicating portal hypertension caused by liver cirrhosis.4,5 Percutaneous transhepatic balloon dilation and stent placement has been reported in www.giejournal.org
Brief Reports
Figure 3. Endoscopic figure taken with DBE, showing a jejunal varix with stigmata of recent bleeding.
Figure 2. Volume rendering technique of portal and systemic venous system. Absence of femoral venous flow on the right side and inferior vena cava (stars). Collateral venous pathways (arrowheads) and portosystemic shunts with varices (arrow).
Figure 4. Endoscopic figure taken with DBE picture, showing the varix after treatment.
cases where the varices are caused by extra hepatic stenosis of the portal vein or the superior mesenteric vein.6,7 Furthermore, enteroscopic sclerotherapy of proximal jejunal varices by using push enteroscope has been described.8 We demonstrated here a successful obliteration of a jejunal varix by using Histoacryl in a lesion found approximately 240 cm from the ligament of Treitz. Histoacryl is known to be effective in obliterating esophageal and fundic varices; furthermore, earlier studies on the hemodynamic effect of endoscopic embolization for esophageal varices showed that neither the portal blood flow nor the liver function is affected by sclerotherapy and that no thrombosis of the portal veins was detected.9,10 By taking into consideration the small theoretical risk of portal vein thrombosis after sclerotherapy (because of hepatopetal blood flow) and the poor clinical condition of the patient, which made it impossible to choose other interventions, we opted for sclerotherapy, without further evaluation of blood flow. Because of the prompt improvement of the condition of the patient, we did not consider further radiologic follow-up. The use of Histoacryl for jejunal lesions by using the DBE has not been reported earlier. The use of the DBE technique has made it relatively easy to diagnose and to treat such lesions deep in the small bowel.
DISCLOSURE
www.giejournal.org
Volume 65, No. 2 : 2007 GASTROINTESTINAL ENDOSCOPY 351
All authors have nothing to declare.
REFERENCES 1. De Palma GD, Rega M, Masone S, et al. Mucosal abnormalities of the small bowel in patients with cirrhosis and portal hypertension: a capsule endoscopy study. Gastrointest Endosc 2005;62:529-34. 2. Misra SP, Dwivedi M, Misra V, et al. Ileal varices and portal hypertensive ileopathy in patients with cirrhosis and portal hypertension. Gastrointest Endosc 2004;60:778-83. 3. Heine GD, Hadithi M, Groenen MJ, et al. Double-balloon enteroscopy: indications, diagnostic yield, and complications in a series of 275 patients with suspected small-bowel disease. Endoscopy 2006;38:42-8. 4. Lopez-Benitez R, Seidensticker P, Richter GM, et al. Case report: massive lower intestinal bleeding from ileal varices treatment with transjugular intrahepatic portosystemic shunt (TIPSS). Radiologe 2005 Oct 24 [Epub ahead of print]. 5. Shibata D, Brophy DP, Gordon FD, et al. Transjugular intrahepatic portosystemic shunt for treatment of bleeding ectopic varices with portal hypertension. Dis Colon Rectum 1999;42:1581-5. 6. Hiraoka K, Kondo S, Ambo Y, et al. Portal venous dilatation and stenting for bleeding jejunal varices: report of two cases. Surg Today 2001; 31:1008-11.
Brief Reports 7. Sakai M, Nakao A, Kaneko T, et al. Transhepatic portal venous angioplasty with stenting for bleeding jejunal varices. Hepatogastroenterology 2005;52:749-52. 8. Getzlaff S, Benz CA, Schilling D, et al. Enteroscopic cyanoacrylate sclerotherapy of jejunal and gallbladder varices in a patient with portal hypertension. Endoscopy 2001;33:462-4. 9. Chikamori F, Kuniyoshi N, Shibuya S, et al. Short-term portal hemodynamic effects of endoscopic embolization for esophageal varices. Dig Surg 2000;17:454-8. 10. Szczepanik AB, Proniewski J, Huszcza S. Portal venous system after endoscopic sclerotherapy of esophageal varices in patients with liver cirrhosis: prospective study with Doppler sonography. Hepatogastroenterology 2005;52:1448-51.
Department of Gastroenterology and Hepatology (H.H., A.A-toma.); Department of Radiology (M.P.M.); Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands (C.J.M., M.A.J.). Reprint requests: M.A.J.M. Jacobs, PhD, Gastroenterology en Hepatology, VU University Medical Center, PO Box 7057, 1007MB, Amsterdam, The Netherlands. Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2006.07.001
Small-bowel perforation after colonoscopy Allison Lambert, BS, Scott Q. Nguyen, MD, John C. Byrn, MD, Eric W. Fishman, MD, Han-Yu Shen, MD New York, New York, USA
Colonic perforation is a known risk of colonoscopy and occurs in 0.2% to 1% of cases.1,2 Perforation of the small bowel after colonoscopy is extremely rare, and only case reports exist in the literature. We present the case of smallbowel thermal injury after a colonoscopy with polypectomy.
CASE REPORT A 67-year-old woman presented to the emergency department with complaints of abdominal pain 1 day after a screening colonoscopy. A 2-cm sessile polyp in the cecum had been removed by using snare polypectomy with cautery. The procedure was uncomplicated, and she was discharged home shortly after the case. In the emergency department, she reported sharp, left lower quadrant pain that began after she had dinner after her colonoscopy. On examination, she was afebrile, with normal vital signs. She had diffuse peritonitis. Her white blood cell count was elevated, to 15,000 mL (normal range, 5000-10,000 mL). A plain radiograph was negative for free air. An abdominal CT revealed fluid in the pelvis and extraluminal air (Fig. 1). The patient was taken urgently to surgery. Upon exploration, liquid enteric contents were found in the peritoneal cavity. A full-thickness cautery injury was found at the cecum at the aforementioned polypectomy site, without evidence of perforation. In the mid ileum, there was a full-thickness burn, with perforation at the antimesenteric side (Fig. 2). This was the source of the spillage. This ileal injury was repaired primarily after debridement of the site of perforation. The cecal injury was reinforced by imbrication of the serosal surfaces. The patient did well after surgery.
Reports of small-bowel perforations after colonoscopy are extremely rare. One report described a double ileal perforation after colonoscopy secondary to dense, fixed pelvic adhesions.3 The investigators hypothesized that dense adhesions between the 2 involved loops of the ileum and the rectosigmoid created a fixed point that tore as torque and pressure were used to advance the colonoscope through the colon. Another report revealed a case of ileal perforation during a colonoscopy in which excessive amounts of pneumatic pressure were used to insufflate the colon.4 In this case, large amounts of air were required to distend a narrowed segment of large bowel affected by chronic diverticular disease. The air escaped into the ileum and led to perforation.
352 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 2 : 2007
www.giejournal.org
Figure 1. CT of the abdomen upon admission to the emergency department. Free air was present adjacent to bowel loops.
DISCUSSION
Hemorrhage associated with small-bowel varices is an uncommon, difficult to treat, and often fatal manifestation of portal hypertension. There are no precise data on the incidence of this cause of bleeding. The main cause is portal hypertension or a local stenosis or thrombosis of the superior mesenteric vein. About 8.1% of patients with portal hypertension who underwent capsule endoscopy have small-bowel varices.1 Varices have been found both in the proximal and distal small bowel. At ileocoloscopy, 18% of patients with liver cirrhosis and portal hypertension have ileal varices.2 Double-balloon enteroscopy (DBE) has the potential to visualize the whole small bowel, take biopsy specimens, and perform all necessary endoscopic interventions.3
CASE REPORT A 49-year-old man with a medical history of perinuclearantineutrophil cytoplasmic antibodies (P-ANCA) negative microscopic polyangiitis with thrombosis of both superior and inferior vena cava was referred to our medical center for further investigation and treatment of recurrent overt GI bleeding (OGIB). A detailed laboratory investigation at the referring hospital excluded all known primary and secondary causes of a hypercoagulable state. Within the last 2.5 months, the patient was repeatedly admitted to his hospital with recurrent melena or OGIB. Upper-GI endoscopy revealed the presence of esophageal varices grade II, without stigmata of recent bleeding. No bleeding focus was found at coloscopy. He received 42 units of packed red blood cells in the 2 weeks preceding the referral. The venous phase of CT angiography revealed the presence of occlusion of the inferior vena cava and both common iliac veins, with extensive portocaval and cava-caval collaterals (Figs. 1 and 2), but no active bleeding was demonstrated. A DBE was performed by using a double-balloon enteroscope (Fujinon EN-450 T5; Fujinon Inc, Saitama, Japan). A solitary jejunal varix at about 240 cm from the ligament of Treitz, with stigmata of recent bleeding, was found (Fig. 3) and was treated with an injection of Histoacryl 0.5 mL (B. Braun, Melsungen, Germany), mixed with 0.5 mL Lipiodol (Guerbet, Aulnay-sous-Bois, France). The varix, after treatment, is shown in Figure 4. No other varices were found distally in the small bowel. Two months after the interven350 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 2 : 2007
Figure 1. CT angiography in portal venous phase, showing portosystemic collateral with varices (arrow). Note the absence of contrast in the inferior vena cava (arrowhead) and distended azygos and hemiazygos veins (open arrows).
tion, the patient had a stable Hb level, and no recurrence of the melena was recognized. His maintenance medications consisted of oral anticoagulants and azathioprine.
DISCUSSION GI hemorrhage caused by small-bowel varices is a rare entity. Small-bowel varices are usually secondary to portal hypertension or stenosis, and thrombosis of the portomesenteric vein system. These were not demonstrated in this patient; furthermore, detailed laboratory investigation excluded all known primary and secondary causes of hypercoagulable state. Therefore, the only plausible cause of the jejunal varices in this patient was an inferior vena cava occlusion. A causal association with P-ANCA negative microscopic polyangiitis cannot be confirmed or refuted. To the best of our knowledge, this causal association has not been reported earlier. There are only a few case reports that discuss other treatment modalities of bleeding jejunal varices. Transjugular intrahepatic portosystemic shunt has been used in cases of small-bowel varices complicating portal hypertension caused by liver cirrhosis.4,5 Percutaneous transhepatic balloon dilation and stent placement has been reported in www.giejournal.org
Brief Reports
Figure 3. Endoscopic figure taken with DBE, showing a jejunal varix with stigmata of recent bleeding.
Figure 2. Volume rendering technique of portal and systemic venous system. Absence of femoral venous flow on the right side and inferior vena cava (stars). Collateral venous pathways (arrowheads) and portosystemic shunts with varices (arrow).
Figure 4. Endoscopic figure taken with DBE picture, showing the varix after treatment.
cases where the varices are caused by extra hepatic stenosis of the portal vein or the superior mesenteric vein.6,7 Furthermore, enteroscopic sclerotherapy of proximal jejunal varices by using push enteroscope has been described.8 We demonstrated here a successful obliteration of a jejunal varix by using Histoacryl in a lesion found approximately 240 cm from the ligament of Treitz. Histoacryl is known to be effective in obliterating esophageal and fundic varices; furthermore, earlier studies on the hemodynamic effect of endoscopic embolization for esophageal varices showed that neither the portal blood flow nor the liver function is affected by sclerotherapy and that no thrombosis of the portal veins was detected.9,10 By taking into consideration the small theoretical risk of portal vein thrombosis after sclerotherapy (because of hepatopetal blood flow) and the poor clinical condition of the patient, which made it impossible to choose other interventions, we opted for sclerotherapy, without further evaluation of blood flow. Because of the prompt improvement of the condition of the patient, we did not consider further radiologic follow-up. The use of Histoacryl for jejunal lesions by using the DBE has not been reported earlier. The use of the DBE technique has made it relatively easy to diagnose and to treat such lesions deep in the small bowel.
DISCLOSURE
www.giejournal.org
Volume 65, No. 2 : 2007 GASTROINTESTINAL ENDOSCOPY 351
All authors have nothing to declare.
REFERENCES 1. De Palma GD, Rega M, Masone S, et al. Mucosal abnormalities of the small bowel in patients with cirrhosis and portal hypertension: a capsule endoscopy study. Gastrointest Endosc 2005;62:529-34. 2. Misra SP, Dwivedi M, Misra V, et al. Ileal varices and portal hypertensive ileopathy in patients with cirrhosis and portal hypertension. Gastrointest Endosc 2004;60:778-83. 3. Heine GD, Hadithi M, Groenen MJ, et al. Double-balloon enteroscopy: indications, diagnostic yield, and complications in a series of 275 patients with suspected small-bowel disease. Endoscopy 2006;38:42-8. 4. Lopez-Benitez R, Seidensticker P, Richter GM, et al. Case report: massive lower intestinal bleeding from ileal varices treatment with transjugular intrahepatic portosystemic shunt (TIPSS). Radiologe 2005 Oct 24 [Epub ahead of print]. 5. Shibata D, Brophy DP, Gordon FD, et al. Transjugular intrahepatic portosystemic shunt for treatment of bleeding ectopic varices with portal hypertension. Dis Colon Rectum 1999;42:1581-5. 6. Hiraoka K, Kondo S, Ambo Y, et al. Portal venous dilatation and stenting for bleeding jejunal varices: report of two cases. Surg Today 2001; 31:1008-11.
Brief Reports 7. Sakai M, Nakao A, Kaneko T, et al. Transhepatic portal venous angioplasty with stenting for bleeding jejunal varices. Hepatogastroenterology 2005;52:749-52. 8. Getzlaff S, Benz CA, Schilling D, et al. Enteroscopic cyanoacrylate sclerotherapy of jejunal and gallbladder varices in a patient with portal hypertension. Endoscopy 2001;33:462-4. 9. Chikamori F, Kuniyoshi N, Shibuya S, et al. Short-term portal hemodynamic effects of endoscopic embolization for esophageal varices. Dig Surg 2000;17:454-8. 10. Szczepanik AB, Proniewski J, Huszcza S. Portal venous system after endoscopic sclerotherapy of esophageal varices in patients with liver cirrhosis: prospective study with Doppler sonography. Hepatogastroenterology 2005;52:1448-51.
Department of Gastroenterology and Hepatology (H.H., A.A-toma.); Department of Radiology (M.P.M.); Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands (C.J.M., M.A.J.). Reprint requests: M.A.J.M. Jacobs, PhD, Gastroenterology en Hepatology, VU University Medical Center, PO Box 7057, 1007MB, Amsterdam, The Netherlands. Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2006.07.001
Small-bowel perforation after colonoscopy Allison Lambert, BS, Scott Q. Nguyen, MD, John C. Byrn, MD, Eric W. Fishman, MD, Han-Yu Shen, MD New York, New York, USA
Colonic perforation is a known risk of colonoscopy and occurs in 0.2% to 1% of cases.1,2 Perforation of the small bowel after colonoscopy is extremely rare, and only case reports exist in the literature. We present the case of smallbowel thermal injury after a colonoscopy with polypectomy.
CASE REPORT A 67-year-old woman presented to the emergency department with complaints of abdominal pain 1 day after a screening colonoscopy. A 2-cm sessile polyp in the cecum had been removed by using snare polypectomy with cautery. The procedure was uncomplicated, and she was discharged home shortly after the case. In the emergency department, she reported sharp, left lower quadrant pain that began after she had dinner after her colonoscopy. On examination, she was afebrile, with normal vital signs. She had diffuse peritonitis. Her white blood cell count was elevated, to 15,000 mL (normal range, 5000-10,000 mL). A plain radiograph was negative for free air. An abdominal CT revealed fluid in the pelvis and extraluminal air (Fig. 1). The patient was taken urgently to surgery. Upon exploration, liquid enteric contents were found in the peritoneal cavity. A full-thickness cautery injury was found at the cecum at the aforementioned polypectomy site, without evidence of perforation. In the mid ileum, there was a full-thickness burn, with perforation at the antimesenteric side (Fig. 2). This was the source of the spillage. This ileal injury was repaired primarily after debridement of the site of perforation. The cecal injury was reinforced by imbrication of the serosal surfaces. The patient did well after surgery.
Reports of small-bowel perforations after colonoscopy are extremely rare. One report described a double ileal perforation after colonoscopy secondary to dense, fixed pelvic adhesions.3 The investigators hypothesized that dense adhesions between the 2 involved loops of the ileum and the rectosigmoid created a fixed point that tore as torque and pressure were used to advance the colonoscope through the colon. Another report revealed a case of ileal perforation during a colonoscopy in which excessive amounts of pneumatic pressure were used to insufflate the colon.4 In this case, large amounts of air were required to distend a narrowed segment of large bowel affected by chronic diverticular disease. The air escaped into the ileum and led to perforation.
352 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 2 : 2007
www.giejournal.org
Figure 1. CT of the abdomen upon admission to the emergency department. Free air was present adjacent to bowel loops.
DISCUSSION