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Bleeding Isolated Jejunal Varix Without Portal Hypertension

Okwara, Chinemerem J. MD1; Rustagi, Tarun MD1

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doi: 10.14309/crj.0000000000000354
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CASE REPORT

A 47-year-old woman with chronic neck pain and recent heavy ibuprofen use presented with syncope and melena requiring transfusion of 6 units of packed red cells. Esophagogastroduodenoscopy showed nonbleeding shallow gastric antral ulcers. No old or fresh blood was noted in the gastric or duodenal lumen. She continued to have maroon-colored stools prompting further evaluation with video capsule endoscopy, which found active bleeding in the proximal-mid jejunum. Subsequently, single-balloon (device-assisted) enteroscopy was performed, which revealed an actively bleeding varix in the proximal-mid jejunum (Figure 1). Two endoscopic clips were placed for temporary hemostasis and to aid fluoroscopic localization. Interventional radiology was consulted, and visceral arteriography with delayed portal venography and subselective proximal jejunal arteriography was performed. An early draining portal vein branch compatible with a jejunal varix was noted, but embolization could not be performed. Multiphasic computed tomography confirmed jejunal varix without evidence of cirrhosis, portal hypertension, or additional abdominal varices. Given the ongoing bleeding, a surgical intervention was planned. Exploratory laparotomy with intraoperative single-balloon enteroscopy was performed with localization and tattooing of the involved jejunal segment, followed by surgical resection and end-end jejuno-jejunal anastomosis (Figure 2). The patient had an uneventful postoperative course with no recurrence of bleeding at a 1-year follow-up.

Figure 1.
Figure 1.:
Enteroscopy showing (A) an active bleeding from a jejunal varix and (B) a large varix in the proximal-mid jejunum.
Figure 2.
Figure 2.:
Intraoperative single-balloon enteroscopy for localization of jejunal varix.

DISCLOSURES

Author contributions: Both authors contributed equally to this manuscript. T. Rustagi is the article guarantor.

Financial disclosure: None to report.

Previous presentation: This case was presented at the American College of Gastroenterology Annual Scientific Meeting, October 5–10, 2018; Philadelphia, Pennsylvania.

Informed consent was obtained for this case report.

© 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.