B0330 - Where's That Bleed?! A Case of Intermittent Ectopic Jejunal Variceal Bleeding

Aaron Fein, DO¹, Naba Saeed, MD², Hammad Qureshi, MD¹, Steven I. Shedlofsky, MD^3
1University of Kentucky, Lexington, KY; ²The University of Kentucky, Lexington, KY; ³University of Kentucky College of Medicine, Lexington, KY

Introduction: Variceal bleeding is a potentially life-threatening complication of cirrhosis. Although most often found in the esophagus and stomach, collateral pathways can develop throughout the abdomen in the setting of portal hypertension leading to “ectopic” varices eg retro/intra-peritoneal, small bowel, rectal, urinary bladder and biliary tract varices. They demonstrate hepatofugal flow on imaging, but are difficult to find, which may delay therapeutic interventions. Here, we present a patient with recurrent hematochezia secondary to ectopic jejunal variceal bleeding.

Case Description/Methods: A 51-year-old female with hepatitis C/alcohol related cirrhosis, decompensated by variceal bleeding s/p TIPS, ascites and HE, presented with melena. EGD: superficial esophageal tears, as well as a clot overlying a varix, for which three bands were placed. Her hemoglobin declined from 11.6 to 6.1 g/dL with worsening encephalopathy, vital instability, intermittent hematochezia, and fever. Repeat EGD: healing post-banding ulcers without active bleeding. Colonoscopy: numerous superficial ulcers with adherent clots, but no active bleeding; biopsies consistent with ischemic colitis. CTA was done without active extravasation identified. US abdomen showed distal TIPS stenosis, so IR was consulted for TIPS revision. The volume of hematochezia then became profuse. STAT CTA found an area of jejunal blush and angiography revealed an ectopic SMV branch varix to the jejunum with aberrant connection to the left ovarian vein, which was embolized. Her TIPS was also revised, with a decrease in porto-systemic pressure gradient from 16 to 7 mmHg. Subsequently, her bleeding resolved, hemodynamics and encephalopathy improved, and she was ultimately extubated and transferred to the floor.

Discussion: Ectopic varices account for up to 5% of variceal bleeds with a bleeding rate thought to be 4 times higher than esophageal varices and a reported mortality up to 40%. About 17% are jejunal/ileal varices. Rapid detection and treatment by embolization and reduction in portal pressures via TIPS, BRTO or portal vein stenting are key. In our patient, despite delay in diagnosis due to intermittent bleeding, hemostasis was finally achieved with direct embolization and reduction in portal pressure. It is imperative that a high suspicion be maintained for ectopic varices in any patient with portal hypertension and intra/extraluminal signs of bleeding, and other modalities such as MRA or CT enterography be utilized if endoscopy/CTA are non-revealing.



Disclosures:


Aaron Fein, DO¹, Naba Saeed, MD², Hammad Qureshi, MD¹, Steven I. Shedlofsky, MD³. B0330 - Where's That Bleed?! A Case of Intermittent Ectopic Jejunal Variceal Bleeding, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.