Percutaneous transsplenic embolization of jejunal varices in a patient with liver cirrhosis: a case report
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- Lee, J.Y., Song, S., Kim, J. et al. Abdom Imaging (2013) 38: 52. doi:10.1007/s00261-012-9894-2
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Bleeding jejunal varices are rare and could be life threatening. They are usually found in the presence of portal hypertension and prior history of gastrointestinal surgery. They can be effectively managed by radiological interventions such as transjugular intrahepatic portosystemic shunt or transhepatic embolization of varices. However, in patients with portal vein obstruction, an alternative access is necessary. We report a case of bleeding jejunal varices associated with postoperative adhesion in a patient with portal vein thrombosis which was successfully managed by percutaneous transsplenic embolization.
Esophagogastric varices have been reported to be the most common complication in patients with portal hypertension, while ectopic varices are very rare. Ectopic varices are defined as varices which develop anywhere in the abdomen except in the cardioesophageal junction, and include those developing in the small intestine, colon, rectum, peritoneum, or umbilicus. They represent an unusual cause of hemorrhage [1, 2]. The jejunum is a very rare location for ectopic varices, and the diagnosis of jejunal varices is based on the clinical triad of portal hypertension, hematochezia without hematemesis, and previous abdominal surgery .
There are various methods to treat bleeding jejunal varices such as endoscopic management, surgery, and radiological intervention. Among these options, technical difficulties may arise when performing endoscopic management due to the limitation in device length and anatomic changes related with previous surgery. Meanwhile, surgery is at times not feasible due to the high risk that lies therein. Interventional managements such as transjugular intrahepatic portosystemic shunt (TIPS) or transhepatic embolization can be effective . However, in patients with portal vein obstruction, such interventional procedures may be difficult or even impossible. As an alternative method, transsplenic approach could be advocated in such circumstances .
To our knowledge, percutaneous transsplenic embolization of jejunal varices has been described only once in literature, where the varices were found at the site of prior choledochojejunostomy . We report a case of bleeding jejunal varices associated with postoperative adhesion in a patient with portal vein thrombosis which was successfully managed by percutaneous transsplenic embolization.
After embolization, hematochezia ceased, suggesting successful hemostasis. There was no development of splenic hematoma or hemoperitoneum on CT obtained 4 days later. The patient was discharged 6 days after the procedure without complication.
Ectopic varices account for between 1% and 5% of all variceal bleedings . It has been known that the ectopic varices can occur in anywhere of the gastrointestinal tract and the peritoneum. The incidence of ectopic varices involving the jejunum and ileum has been reported to be around 18% [1, 2, 4].
According to its etiology, jejunal varix can be categorized as postoperative or inherited [3–8]. The former always develops in patients with portal hypertension, while the latter has been reported to develop in the absence of portal hypertension. Postoperative lesions occur at the site of anastomosis or postoperative adhesion.
In English literature, four cases of perianastomotic jejunal varices have been reported [3–5, 8]. They were associated with bilio-enteric anastomoses in three patients and esophagojejunostomy in one, all of whom had portal hypertension. Biliary-to-enteric anastomosis was thought to induce jejunal varices through inflammatory changes occurring secondary to leakage at the anastomosis site or adhesion [4, 8]. The jejunal varices within the anastomoses provided hepatopetal collateral pathways in these patients with underlying portal hypertension. Regarding the etiology of jejunal varices in the patient with portal hypertension who had undergone esophagojejunostomy, the varices were thought to have developed after inevitable resection of the hepatofugal collaterals during total gastrectomy. As a result, jejunal veins would have acquired hepatofugal blood flow, to constitute the esophagojejunal varices .
In our case, development of jejunal varices owed to postoperative adhesion. Until now, only two cases have been reported, where adhesion occurred between the jejunum and the abdominal wall [7, 8]. Portosystemic collateral formation within adhesions from previous surgery may be the mechanism for the development of jejunal varices. The adhesions tend to bring the parietal surface of viscera in contact with the abdominal wall, and portal hypertension results in the formation of varices below the intestinal mucosa . Our patient also had similar risk factors including portal hypertension and past history of surgery. The varices occurred at the site of adhesion between the jejunum and the abdominal wall.
Conventional methods for endovascular treatment of variceal bleeding include TIPS, percutaneous transhepatic embolization, and balloon-occluded retrograde transvenous obliteration [3, 9]. The first two methods require the presence of a patent portal vein, while the third, adequate anatomy such as a gastrorenal shunt.
In the presence of portal vein obstruction, another route is required to access the varices. Lim et al. used transumbilical route for the management of the jejunal varices which developed at the site of postoperative adhesion . In our case, we chose the transsplenic route. Even though the percutaneous transsplenic approach is not widely advocated, such technique can be effective in the presence of a thrombosed intrahepatic portal vein or large amount of ascites around the liver . Several previous studies described the safety and feasibility of the transsplenic approach for portal venous intervention [3, 10, 11]. The possible drawbacks of this approach may be difficulty during advancement of the catheter within a tortuous vein and bleeding complications [3, 10]. The latter includes hemorrhage from the splenic puncture site and intrasplenic hematomas, both of which should be considered as major complications. Bleeding complications can be prevented by tract embolization using coils, glue, or gelatin sponge particles [3, 10, 11]. In our case, we also performed tract embolization with the use of coils. Although percutaneous transhepatic approach is safer than the transsplenic counterpart, the transsplenic approach is nevertheless a feasible and useful technique when transhepatic approach is not possible.
Bleeding from jejunal varices is a rare entity and, in the presence of portal vein obstruction, percutaneous transsplenic embolization could be considered as an effective and alternative method to treat bleeding jejunal varices.
All authors have no financial relationships with commercial entities.