Rowan SOM/Jefferson Health NJ Franklinville, NJ, United States
Matthew Everwine, DO1, David Truscello, DO2, Zainab Shahid, DO3, Sangam Shivaprasad, 4, Maulik Shah, DO5, Theresa Disandro, DO6, Christina Tofani, MD7 1Rowan SOM/Jefferson Health NJ, Franklinville, NJ; 2Rowan University School of Osteopathic Medicine, Sewell, NJ; 3Rowan University School of Osteopathic Medicine, Stratford, NJ; 4Rowan University, Stratford, NJ; 5Rowan University School of Osteopathic Medicine, Cherry Hill, NJ; 6Virtua Health, Cherry Hill, NJ; 7Thomas Jefferson University Hospital, Philadelphia, PA
Introduction: The small bowel, encompassing the region between the ligament of Treitz and the ileocecal valve, is the least common site of gastrointestinal (GI) bleeding and accounts for 5% of all diagnosed GI bleeds. Diagnosis is challenging due to the location, mobility and difficulty visualizing the small bowel. Small bowel varices are an uncommon cause of GI bleeding. We present a rare case of hematochezia occurring secondary to ectopic small bowel varices.
Case Description/Methods: A 55 year old male with alcoholic cirrhosis presented to the hospital for two days of hematochezia and hematemesis. Labs showed a hemoglobin of 5.2, platelet 67, WBC 15.6, total bilirubin 7.9, direct bilirubin 4.0, AST 27, ALT 8, ALKP 76, and albumin 2.1. CTA revealed contrast near the pylorus. Octreotide and pantoprazole were subsequently initiated. EGD demonstrated large esophageal varices with two bands placed and a non-bleeding gastric ulcer. A mesenteric angiogram was negative. Repeat EGD 5 days later showed normal duodenum and no evidence of bleeding at the previously identified varix and ulcer. The patient had persistent hematochezia. Bleeding and Meckel scans were negative. Follow up enteroscopy and colonoscopy revealed a clean based ulcer at prior banding site, portal hypertensive gastropathy, clean based antral ulcer, and blood within the distal ileum. The patient was transferred to a tertiary center for small bowel evaluation. A capsule endoscopy (CE) was performed revealing small bowel varices. The patient received a total of 31units of PRBC, 25units of FFP, and 8units of platelets.
Discussion: Small bowel vascular anomalies include angiodysplasia, arterio-venous malformation, Dieulafoy’s lesion, and varices. Small bowel varices are a rare cause of GI bleeding occurring in less than 5% of all small bowel bleeds. Due to the rare incidence rates, patients often undergo extensive diagnostic testing. This includes CT, EGD, colonoscopy, nuclear bleeding scan, mesenteric angiogram, Meckel scan, push enteroscopy, and CE. Small bowel varices in our patient were seen using CE. Compared to CTA, angiography, and push enteroscopy, CE has a higher diagnostic yield. Furthermore, the diagnostic yield of deep enteroscopy is increased in those with a positive CE. Early detection of uncommon causes of GI bleeds using CE may reduce hospital stay, transfusions, and additional tests. Currently, there is no clear consensus on the best modality for diagnosing small bowel varices and this topic requires further investigation.
Figure: Capsule endoscopy demonstrating small bowel varices.
Disclosures: Matthew Everwine indicated no relevant financial relationships. David Truscello indicated no relevant financial relationships. Zainab Shahid indicated no relevant financial relationships. Sangam Shivaprasad indicated no relevant financial relationships. Maulik Shah indicated no relevant financial relationships. Theresa Disandro indicated no relevant financial relationships. Christina Tofani indicated no relevant financial relationships.
Matthew Everwine, DO1, David Truscello, DO2, Zainab Shahid, DO3, Sangam Shivaprasad, 4, Maulik Shah, DO5, Theresa Disandro, DO6, Christina Tofani, MD7. P2566 - A Varix Uncommon Cause of Hematochezia, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.