First Author: Ankita Satpute, Medical Student, Case Western Reserve University School of Medicine, Cleveland, OH
Introduction: Esophageal (50%), gastric (5-33%), and rectal varices have been identified as the most common sites of gastrointestinal varices in patients with portal hypertension. While varices may develop anywhere along the GI tract, suspicion for jejunal varices is often low and they can be difficult to diagnose. This case is one of few documented reports of enlarged jejunal varices as an isolated source of GI bleed.
Case Presentation: A 64-year-old Caucasian male with a history of Factor V Leiden Mutation and recurrent DVTs/PEs presented to an outside ED with a one week history of shortness of breath and lightheadedness along with a one day history of tarry black stools.
In concordance with his symptoms, the patient was found to have severe anemia with a hemoglobin level of 5.9 and was subsequently transfused multiple units of packed RBCs. Chest CTA confirmed bilateral pulmonary embolisms. Following diagnosis, the patient was stabilized and transferred to main campus for anticoagulation in the setting of a GI bleed.
The patient was admitted to main campus in stable condition and received further blood transfusions after additional episodes of melena and endorsement of orthostatic hypotension. The Gastroenterology team investigated the source of bleeding through multiple diagnostic procedures including EGDs, colonoscopies, and push enteroscopy, which were all negative for a likely source. Ultimately, a double balloon enteroscopy was successful in identifying isolated and enlarged jejunal varices (>5mm) in two areas of the jejunum as the source of bleeding. These varices were not amenable to endoscopic intervention, but were repeatedly monitored throughout the hospital course. Of note, no esophageal varices were documented, and otherwise, only isolated type II gastric varices were visualized, but were not considered significant in the setting.
Portal hypertension in this patient was manifested secondary to chronic portal vein and superior mesenteric vein thromboses, with no evidence of liver cirrhosis. The patient underwent successful surgical intervention to construct a side-to-side variceal caval anastomosis with a portosystemic shunt and placement of an IVC filter. After a challenging recovery, the patient was discharged home in stable condition with an emphasized need for life-long anticoagulation.
Discussion: This case highlights the importance of visualizing the small bowel and investigating jejunal varices as a potential source of gastrointestinal bleeding in patients with portal hypertension. In this unique report, large jejunal varices were identified as the etiology of GI bleed without evidence of esophageal varices and only visualization of nonbleeding type II gastric varices. Double balloon enteroscopy is a challenging procedure, but may be effective in investigating the small bowel when other sources of GI bleeding have been negated.