Jejunal varices after choledochojejunostomy treated with laparotomic transcatheter variceal embolization

• Published in: Nippon Shōkakibyō Gakkai zasshi Vol. 113; no. 11; p. 1923
• Main Authors: Waguri, Nobuo, Azumi, Rie, Sugimura, Kazuhito, Arao, Yoshihisa, Ikarashi, Shunzo, Sakai, Norihiro, Ogawa, Masahiro, Osaki, Akihiko, Sato, Munehiro, Aiba, Tsuneo, Yoneyama, Osamu, Furukawa, Koichi, Igarashi, Kentarou
• Format: Journal Article
• Language: Japanese
• Published: Japan 2016
• Subjects: Choledochostomy - adverse effects; Embolization, Therapeutic - adverse effects; Gastrointestinal Hemorrhage - etiology; Humans; Jejunal Diseases - therapy; Laparotomy - adverse effects; Male; Middle Aged; Tomography, X-Ray Computed; Treatment Outcome; Varicose Veins - diagnostic imaging; Varicose Veins - therapy
• ISSN: 0446-6586
• DOI: 10.11405/nisshoshi.113.1923

Portal hypertension induces collateral shunt formation between the portal and systemic circulation, decompressing the elevated portal pressure. Ectopic varices outside of the gastroesophageal region, such as jejunal varices, are rare conditions. This report describes the successful embolization of ruptured jejunal varices resulting from an extrahepatic portal obstruction. A 62-year-old man was admitted to our hospital with recurrent massive gastrointestinal bleeding. Fourteen months earlier, he had undergone a choledochojejunostomy and pancreatic cystojejunostomy for bile duct stenosis with an enlarged pancreatic pseudocyst due to severe chronic pancreatitis. Contrast-enhanced computed tomography showed jejunal intramural dilated vessels close to the choledochojejunal anastomosis, but extravasation was not observed. Due to the lack of a rapid definitive diagnosis, the patient required massive blood transfusions. Hemorrhagic scintigraphy using Tc-HSAD finally identified the site of the hemorrhage. Angiography and double-balloon endoscopy revealed the anastomotic jejunal varices to be the result of an extrahepatic portal obstruction. Laparotomic transcatheter variceal embolization with microcoils was successful in halting the refractory gastrointestinal bleeding. This surgery preserved hepatopetal portal venous flow by another route, and no complications were observed. At present, 4 years post-surgery, there has been no recurrence of gastrointestinal hemorrhage. The development of jejunal varices is often associated with postoperative adhesions. Some patients with a history of hepatico- or choledochojejunostomy may experience portal hypertension resulting from extrahepatic portal obstruction, leading to the formation of jejunal varices as hepatopetal portal collaterals. The choice of therapy in each patient should be based on the individual hemodynamics of the ectopic varices.