P4227 - Bleeding in the Shadows: Isolated Jejunal Varices Treated with Push Enteroscopy Sclerotherapy

Award: Presidential Poster Award

Jagadish Koyi, MD¹, Mir Zulqarnain, DO², Mohamed Ahmed, MD³, Anand Venugopal, MD, PhD⁴, Wendell Clarkston, MD^5
1University of Missouri - Kansas City School of Medicine, Kansas City, MO; ²University of Missouri Kansas City School of Medicine, Saint Luke's Hospital, Kansas City, MO; ³University of Missouri-Kansas City, Saint Luke's Hospital, Kansas City, MO; ⁴University of Missouri Kansas City School of Medicine, Saint Lukes Hospital, Kansas City, MO; ⁵University of Missouri - Kansas City School of Medicine, Saint Luke's Hospital, Kansas City, MO

Introduction: Small Intestinal varices account for < 5% gastrointestinal bleeding (GIB) and most often are secondary to prior abdominal surgeries or portal hypertension. Here we present a rare case of massive GIB due to isolated jejunal varices in the absence of overt signs of portal hypertension or prior abdominal surgeries.

Case Description/Methods: A 62-year-old male with atrial fibrillation, chronic alcohol use presented with melena. Initial vitals were 80/40mm Hg with labs noting hemoglobin 4.6g/dl. Patient was resuscitated with blood products. Imaging with computed tomography with angiography revealed dilated varicose veins in walls of the proximal jejunum and infiltration of mesenteric fat with mesenteric adenopathy along with bilateral pulmonary emboli (PE). Push enteroscopy revealed multiple proximal jejunal varices with stigmata of recent bleeding from about 105cm to 115 cm of scope insertion. Endoclips were placed for localization. MRI abdomen revealed isolated superior mesenteric vein thrombosis (SMV) as a likely cause of jejunal varices. IR was unsuccessful at SMV recanalization. There was concern for infiltrative or malignant process in the mesentery causing occlusion of SMV. Oncology work up revealed mildly reduced protein C level (61%) with hypercellular bone marrow. Liver biopsy revealed steatohepatitis and fibrosis (stage 2-3), and mesenteric lymph node biopsy was negative for malignancy. Patient was discharged with anticoagulation for PE but was readmitted with recurrent melena. Repeat push enteroscopy revealed three columns of jejunal varices seen adjacent to a previously placed Endo Clip with one column appearing to have multiple areas of red nipple sign and red wale sign with active oozing. Due to active bleeding, this column was injected with 4 ml of sclerosing agent with adequate hemostasis.

Discussion: The management of ectopic varices associated with cirrhosis, portal hypertension is well defined and includes treatment modalities such as octreotide, beta-blockers, Transjugular Intrahepatic Portosystemic Shunts, etc. However the optimal management of isolated ectopic varices without cirrhosis is less clear. There are only a few case reports applying sclerotherapy for the treatment of isolated jejunal varices. Three recent cases reported sclerotherapy for jejunal varices at the site of choledochojejunostomy and one case utilized double balloon enteroscopy with sclerotherapy. This case adds to this limited literature regarding the safety and efficacy of small volume sclerotherapy.



Disclosures:


Jagadish Koyi, MD¹, Mir Zulqarnain, DO², Mohamed Ahmed, MD³, Anand Venugopal, MD, PhD⁴, Wendell Clarkston, MD⁵. P4227 - Bleeding in the Shadows: Isolated Jejunal Varices Treated with Push Enteroscopy Sclerotherapy, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.