P0814 - Parallel TIPS and Band Ligation Used for the Treatment of Portal Hypertension and Jejunal Variceal Bleeding

Yazan Sallam, MD¹, Mir Zulqarnain, DO², Zain Almomani, MD³, Anand Venugopal, MD, PhD⁴, John H. Helzberg, MD⁵, Laura Alba, MD⁶, Majdi Hamarshi, MD⁷, Anatoly Loskutov, MD⁸, Jagadish Koyi, MD^3
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 School of Medicine, Kansas City, MO; ⁴University of Missouri Kansas City School of Medicine, Saint Lukes Hospital, Kansas City, MO; ⁵Saint Lukes Liver Disease and Management Unit, Kansas City, MO; ⁶Saint Lukes Liver Disease and Mangement Unit, Kansas City, MO; ⁷Saint Lukes Critical Care Department, Kansas City, MO; ⁸Saint Lukes Interventional Radiology, Kansas City, MO

Introduction: Chronic portomesenteric vein thrombosis (PMVT) can rarely lead to the formation of jejunal varices. Although trans-jugular intrahepatic portosystemic shunt (TIPS) placement is generally effective for the management of ectopic variceal bleeding, its role in ectopic varices due to chronic PMVT is not defined. Here we present a case of jejunal variceal bleeding in the setting of decompensated cirrhosis and factor V Leiden complicated by chronic PMVT that recurred despite parallel TIPS placement but subsequently resolved with band ligation.

Case Description/Methods: A 50-year-old female patient, with a history of Roux en Y gastric bypass, Factor V Leiden, and decompensated cirrhosis was admitted to the intensive care unit (ICU) with hematemesis.

Computed tomography (CT) scan of the abdomen on admission showed chronic PMVT. Esophagogastroduodenoscopy (EGD) was performed and revealed large esophageal varices with stigmata of recent bleeding. Esophageal variceal band ligation was performed. However, the patient developed recurrent hematemesis for which she underwent middle hepatic vein to right portal vein TIPS placement along with recanalization of her chronic portal vein thrombosis. She had recurrent bleeding and, to attempt to further reduce portal pressures, the patient underwent a left hepatic vein to left portal vein parallel TIPS with cessation of bleeding and successful discharge home. The day after discharge the patient developed recurrent hematemesis requiring repeat ICU admission. Repeat EGD with intubation of the efferent jejunal limb demonstrated a jejunal varix with stigmata of recent bleeding (Figure A,B) which was previously not noted. Variceal band ligation was performed with successful hemostasis. Anticoagulation was resumed and the patient was discharged with no further bleeding noted at follow up.

Discussion: Chronic PMVT can rarely result in bleeding jejunal varices which carry a high mortality rate. Although the utility of TIPS placement for the management of bleeding ectopic varices has been described, its role in managing ectopic varices secondary to PMVT is unclear. We speculate that portal vein recanalization may have increased flow through jejunal varices from persistent mesenteric venous thrombosis in this case. There are only 2 other cases documented regarding ectopic varices with mesenteric vein thrombosis attributed to heterozygous factor V Leiden mutation. To our knowledge this is the first case to demonstrate band ligation as a successful treatment modality.



Disclosures:


Yazan Sallam, MD¹, Mir Zulqarnain, DO², Zain Almomani, MD³, Anand Venugopal, MD, PhD⁴, John H. Helzberg, MD⁵, Laura Alba, MD⁶, Majdi Hamarshi, MD⁷, Anatoly Loskutov, MD⁸, Jagadish Koyi, MD³. P0814 - Parallel TIPS and Band Ligation Used for the Treatment of Portal Hypertension and Jejunal Variceal Bleeding, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.