Abdominal Imaging

, Volume 38, Issue 1, pp 52–55

Percutaneous transsplenic embolization of jejunal varices in a patient with liver cirrhosis: a case report

Authors

  • Ji Young Lee
    • Department of RadiologyHanyang University Hospital
    • Department of RadiologyHanyang University Hospital
  • Jinoo Kim
    • Department of RadiologyHanyang University Guri Hospital
  • Byung-Hee Koh
    • Department of RadiologyHanyang University Hospital
  • Yongsoo Kim
    • Department of RadiologyHanyang University Guri Hospital
  • Woo Kyoung Jeong
    • Department of RadiologyHanyang University Guri Hospital
  • Min Yeong Kim
    • Department of RadiologyHanyang University Guri Hospital
Article

DOI: 10.1007/s00261-012-9894-2

Cite this article as:
Lee, J.Y., Song, S., Kim, J. et al. Abdom Imaging (2013) 38: 52. doi:10.1007/s00261-012-9894-2

Abstract

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.

Keywords

Jejunal varicesTranssplenicEmbolizationEsophagojejunostomy

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 [1].

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 [3]. 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 [3].

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 [3]. 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.

Case report

A 67-year-old man presented with hematochezia for 3 days. He had undergone total gastrectomy with esophagojejunostomy for esophageal cancer and had been diagnosed with alcoholic liver cirrhosis, Child–Pugh grade B, 1 year ago. The laboratory values revealed decreased hemoglobin levels (10 g/dL), decreased platelet count (69 × 103/mm3), and decreased albumin level (2.8 g/dL). Despite ongoing hematochezia, esophagogastroduodenoscopy and colonoscopy failed to demonstrate the source of bleeding. Abdominal CT demonstrated features of liver cirrhosis and, in addition, thrombosed portal vein involving extra- and intrahepatic segments. There were varices in proximity to a jejunal loop which had adhered to the abdominal wall (Fig. 1), and the varices showed communication with subcutaneous veins within the abdominal wall. 99m Tc-labeled RBC scintigraphy showed active bleeding from the left upper abdomen, which corresponded to the site of jejunal varices detected on CT.
https://static-content.springer.com/image/art%3A10.1007%2Fs00261-012-9894-2/MediaObjects/261_2012_9894_Fig1_HTML.jpg
Fig. 1

Axial CT scan of a 69-year-old man demonstrates varices (white arrow) in the jejunal loop which is adhered to the abdominal wall. There is communication between the varices and subcutaneous veins within the abdominal wall (black arrows).

The patient was referred to the Department of Radiology, where the interventional radiologist decided that TIPS or transhepatic embolization of varices would be difficult owing to an obstructed portal vein secondary to thrombosis. The transsplenic approach was chosen to access and embolize the varices. The perihilar splenic vein was punctured with a 21-gauge Chiba needle (Cook, Bloomington, IN) under ultrasound guidance and a 5-F sheath (Terumo, Tokyo, Japan) was introduced. Portogram obtained by contrast injection through the sheath confirmed portal vein occlusion and demonstrated the varices which were supplied by two jejunal branches (Fig. 2). On delay phase of the portogram, the varices drained into the subcutaneous veins of the abdominal wall. The afferent veins were selected with using a 5 Fr Davis catheter (Cook, Bloomington, IN), after which mixtures of Histoacryl (B. Braun, Tuttlingen, Germany) and Lipiodol (Lipiodol Ultrafluide, Laboratoire Guerbet, Aulnay-Sous-Bois, France) mixed at ratios 1:1 and 1:2 (total dose of Histoacryl mixture: 5 mL) were infused for variceal embolization. After removing the sheath, the tract within the spleen was embolized using conventional coils (Cook, Bloomington, IN).
https://static-content.springer.com/image/art%3A10.1007%2Fs00261-012-9894-2/MediaObjects/261_2012_9894_Fig2_HTML.jpg
Fig. 2

A, B Portogram obtained after successful transsplenic approach shows complete occlusion (arrow) of the portal vein and cavernous transformation. There are varices in the left abdomen which supplied by two jejunal branches. There is contrast filling within small subcutaneous veins (arrow heads) around the jejunal varices. C Completion portogram, obtained after embolization of both afferent veins with infusion of glue, shows no contrast filling within the varices.

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.

Discussion

Ectopic varices account for between 1% and 5% of all variceal bleedings [1]. 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 [38]. 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 [35, 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 [5].

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 [1]. 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 [7]. 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 [3]. 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.

Conclusion

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.

Disclosure

All authors have no financial relationships with commercial entities.

Copyright information

© Springer Science+Business Media, LLC 2012