Enteroscopic Cyanoacrylate Sclerotherapy of Jejunal and Gallbladder Varices in a Patient with Portal Hypertension

• Introduction
• Case Report
• Discussion
• Acknowledgment
• References

Bleeding from varices outside the gastroesophageal region is a rare, but regularly reported complication of portal hypertension. The treatment differs from the management of esophageal and gastric varices. We present here a report on the diagnosis and treatment of bleeding jejunal and gallbladder varices in a man with portal hypertension caused by chronic calcifying pancreatitis. The patient was suffering from recurrent, frequent, and massive gastrointestinal bleeding from varices at the anastomotic area of a cholecystojejunostomy. For diagnostic purposes, we carried out percutaneous Duplex ultrasonography and push enteroscopy with the Doppler technique.

The treatment of varices in this area is traditionally surgical. This is the first report of enteroscopic sclerotherapy being successfully carried out using cyanoacrylate to treat hemorrhage from jejunal and gallbladder varices. No clinical signs of gastrointestinal bleeding were observed during a follow-up period of seven months.

Introduction

Bleeding from esophageal and gastric varices is a common cause of severe gastrointestinal blood loss. In patients with portal hypertension, preexisting veins enlarge and form varices in the collateral circulation. The varices have a high risk of massive bleeding.

This type of varix is rarely observed in the small intestine, colon, rectum, wall of the common bile duct, or gallbladder, although hemorrhage from varices outside the gastroesophageal region has repeatedly been described [1] [2] [3] [4] . Varices in these ectopic locations are often diagnosed incidentally, either intraoperatively or at postmortem examinations. Accurate diagnosis in vivo is difficult. Endoscopic therapy cannot be carried out in the usual way, as the location of the bleeding source is out of range. This case report describes the diagnosis and successful treatment of bleeding jejunal and gallbladder varices.

Case Report

A 52-year-old man was admitted with clinical symptoms of massive upper gastrointestinal bleeding, with a reduction in hemoglobin to 3 mg/dl. He had been hospitalized many times in previous years due to severe, long-standing chronic calcifying pancreatitis. Compression of the distal common bile duct had previously been treated by carrying out a cholecystojejunostomy. Compression caused by calcifications and cysts had led to portal vein thrombosis, with subsequent portal hypertension, and finally to the development of esophageal and gastric varices.

Sclerotherapy of the esophageal and gastric varices was carried out during the gastroduodenoscopy procedure, and the patient was discharged. However, he was readmitted after a short time due to recurrent massive gastrointestinal hemorrhage. After gastroscopy, which showed a normal upper gastrointestinal tract as far as the duodenum, a push enteroscopy examination using an Olympus SIF-100 enteroscope immediately followed. The jejunal loop leading to the cholecystojejunostomy (the afferent loop) and the anastomotic region were inspected. Enlarged submucosal vessels leading to the gallbladder were visualized (Fig. [1]). Due to the cholecystojejunal anastomosis, it was possible to inspect the gallbladder itself, which was also found to have varices. An endoscopic Doppler ultrasound examination demonstrated typical portal venous flow in the vessels. The presence of this collateral circulation was confirmed on conventional sonography (Figure [2]) and duplex sonography (Figure [3]).

Because of the history of multiple abdominal surgical interventions, the patient was considered inoperable, and it was decided to carry out endoscopic sclerotherapy with cyanoacrylate injections. After intubation of the anastomotic area, it was possible to puncture and sclerose some of the large varicose vessels (Figure [4]) successfully and without complications. An endoscopic Doppler ultrasound examination immediately after the injections showed no further blood flow, and this was confirmed at the first follow-up enteroscopy two days later (Figure [5]). The patient’s hemoglobin level stabilized for the first time for an extended period (at the time of writing, the follow-up period was seven months), indicating that the cholecystojejunal varices had been the source of the recurrent bleeding previously.

Discussion

The development of esophageal and gastric varices is a well-known complication of portal hypertension. Varices located in the duodenum, jejunum, ileum, rectum, gallbladder, or common bile duct often remain undetected (gallbladder varices can be found in 25-30 % of patients with portal hypertension, for example) [5] [6] . Diagnosis can be very difficult, due to the characteristically hidden location and the intermittent nature of the bleeding. Push enteroscopy is a useful method of detecting varices in the small bowel, up to 1.5 m from the incisors. Intraoperative enteroscopy extends the range of the examination to the terminal ileum. Varices in the gallbladder and the common bile duct can be seen as mural filling defects on endoscopic retrograde cholangiopancreatography [7]. Using duplex ultrasonography, these varices typically show the presence of serpentine vessels, with pulsed Doppler imaging showing a low-velocity venous signal [6] [8] [9] . Diagnosis of varices using computed tomography and angiography to demonstrate tubular structures has also been reported [2] [3] [6] [7] [8] [9] [10] [11] .

Bleeding from ectopic varices is reported frequently, with a high mortality rate [1] [2] [3] [4] [11] [12] [13] [14] [15] . Endoscopic treatment is not possible in most cases, and patients with varices in the distal small intestine or biliary system have to undergo surgery. Recurrent bleeding and postoperative complications have been reported [11].

In the case reported here, successful detection of jejunal and gallbladder varices was possible endoscopically. Cyanoacrylate sclerotherapy was carried out without complications, using the same technique used for the treatment of gastric varices. The cyanoacrylate deposit in the anastomotic area region was visualized radiographically after the procedure (Figure [6]). The intervention avoided the need for surgery and the associated risk of intraoperative complications and side effects of intubation narcosis.

This case report demonstrates that it is possible to detect jejunal and gallbladder varices using imaging procedures, as well as endoscopically. Endoscopic treatment was performed for the first time, as an alternative to surgical intervention. The follow-up, with no further signs of gastrointestinal bleeding being detected, proves that this type of treatment can be successful.

Acknowledgment

We are grateful to M. Eric Weidman for his help in preparing the manuscript.

References

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D. Schilling, M.D.

Medizinische Klinik C
Klinikum der Stadt Ludwigshafen

Bremserstrasse 79
67063 Ludwigshafen
Germany


Fax: Fax:+ 49-621-503-4114

Email: E-mail:MedCLu@t-online.de

References

• 1 Wilson S E, Stone R T, Christie J P, Passaro E. Massive lower gastrointestinal bleeding from intestinal varices.  Arch Surg. 1979;  114 1158-1161
  PubMedSearch in Google Scholar
• 2 Paquet K J, Lazar A, Bickart J. Massive and recurrent gastrointestinal hemorrhage due to jejunal varices in an afferent loop: diagnosis and management.  Hepatogastroenterology. 1994;  41 276-277
  PubMedSearch in Google Scholar
• 3 Scheppach W, Wittenberg G, Kasper H, et al. Massive Blutungen aus jejunalem Varixknoten.  Z Gastroenterol. 1997;  35 195-198
  PubMedSearch in Google Scholar
• 4 Bashin D K, Sharma B C, Singh K, et al. Endoscopic management of bleeding ectopic varices with Histoacryl.  HPB Surg. 1999;  11 171-173
  PubMedSearch in Google Scholar
• 5 Chawla A, Dewan R, Sarin S K. The frequency and influence of gallbladder varices on gallbladder functions in patients with portal hypertension.  Am J Gastroenterol. 1995;  90 2010-2014
  PubMedSearch in Google Scholar
• 6 Rathi P M, Soni A, Upadhyay A P, et al. Gallbladder varices: diagnosis in children with portal hypertension on duplex sonography.  J Clin Gastroenterol. 1996;  23 228-231
  CrossrefPubMedSearch in Google Scholar
• 7 Won H K, Si Young S, Chung B K, et al. Common bile duct and gallbladder varices.  Gastrointest Endosc. 1992;  38 65-69
  PubMedSearch in Google Scholar
• 8 Paulson B A, Pozniak M A. Ultrasound case of the day: gallbladder varices.  RadioGraphics. 1993;  13 215-217
  PubMedSearch in Google Scholar
• 9 Chawla Y, Dilawari J B, Katariya S. Gallbladder varices in portal vein thrombosis.  AJR Am J Roentgenol. 1994;  162 643-645
  PubMedSearch in Google Scholar
• 10 Ralls P W, Mayekawa D S, Lee K P, et al. Gallbladder varices: diagnosis with color flow Doppler sonography.  J Clin Ultrasound. 1988;  16 595-598
  PubMedSearch in Google Scholar
• 11 Nobukazu Y, Mitsuhiko K, Takenobu K, et al. Jejunal varices as a cause of massive gastrointestinal bleeding.  Am J Gastroenterol. 1992;  87 514-517
  PubMedSearch in Google Scholar
• 12 Martin W R, Kohler B, Riemann J F. Diagnostik seltener Blutungsursachen am oberen Gastrointestinaltrakt.  Dtsch Med Wochenschr. 1991;  116 522-527
  PubMedSearch in Google Scholar
• 13 Heaton N D, Khawaya H, Howard E R. Bleeding duodenal varices.  Br J Surg. 1991;  78 1450-1451
  PubMedSearch in Google Scholar
• 14 Safadi R, Sviri S, Eid A, Levensart P. Gallbladder varices: a case report and a review of the literature.  Eur J Med Res. 1996;  20 506-508
  PubMedSearch in Google Scholar
• 15 Eriguchi N, Aoyagi S, Hara M, et al. Jejunal varices as a cause of massive gastrointestinal bleeding: a case report.  Kurume Med J. 1998;  45 227-230
  PubMedSearch in Google Scholar

D. Schilling, M.D.

Medizinische Klinik C
Klinikum der Stadt Ludwigshafen

Bremserstrasse 79
67063 Ludwigshafen
Germany


Fax: Fax:+ 49-621-503-4114

Email: E-mail:MedCLu@t-online.de