Recurrent bleeding from Jejunal varix in a patient with Cirrhosis and previous hepaticojejunostomy treated with Histoacryl
Geff Watson1, Ahmed Abu-Shanab1, Rory O’Donohoe2, Masood Iqbal1
1Liver Unit,St. Vincent's University Hospital,Dublin 2Radiology Department,St. Vincent's University Hospital,Dublin
Variceal bleeding is a common complication seen in patients diagnosed with liver cirrhosis . The origin of bleeding can often be detected by direct visualisation using endoscopic procedures or radiologically. However in rare instances the source of bleeding may not be immediately apparent, and it is important to consider the possibility of ectopic varices.
We present a case of gastrointestinal bleeding in a patient with cirrhosis where the source of bleeding was initially unclear, however push enteroscopy detected an ectopic varix at the site of a previous hepaticojejunostomy.
Case Report: A 44 year old gentleman was transferred to Liver Unit from a peripheral hospital with ongoing melena on a background of alcoholic cirrhosis .Furthermore three years ago he developed a biliary stricture post laparoscopic cholecystectomy that required multiple biliary stents and ultimately a hepaticojejunostomy. An oesophagogastroduodenscopy (OGD) was performed on admission to the peripheral hospital and showed mild oesophagitis and grade 1 varices. CT Angiogram the following day reported no active bleeding. A repeat OGD after transfer to our unit confirmed grade 1 oesophageal varices and portal hypertensive gastropathy, with no source of bleeding identified. A CT four phase Liver was performed and showed a nodular liver and occlusion of the main portal vein with cavernous transformation. He received multiple blood transfusions throughout his admission (eight in the peripheral hospital and requiring a further twenty six units in our unit). Enteroscopy was attempted using a pediatric colonoscope and was successfully passed to the jejunal loop as far as the hepticojejunostomy. An area of mucosal erythema with prominent vessels along with a fresh clot was seen adjacent to the hepaticojejunostomy.The site was injected with histoacryl. A repeat enteroscopy was performed the following week and clearly displayed a healed ectopic varix at the site of hepaticojejunostomy.He was discharged few days later with no recurrence of bleeding .
Ectopic varices should be considered in a patient with cirrhosis and portal hypertension when presented with obscure haemorrhage with a prior history of hepaticojejunostomy.