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• W4313366919 abstract "Question: A 66-year-old man presented to the hospital with symptoms of dyspnea on exertion and melena. Two years before, he underwent pancreaticoduodenectomy to resect an intraductal papillary mucinous neoplasm with high-grade dysplasia at the pancreatic head with uneventful post-operative course. On presentation, his vital signs were stable, and no stigmata of liver disease or splenomegaly were found on physical examination. His laboratory tests were notable for a hemoglobin 8.0 g/dL (from baseline of 11 g/dL), platelets 174 × 109/L, blood urea nitrogen 29 mg/dL, and International Normalized Ratio 1.0. Initial upper endoscopy was performed 1 day after presentation and was without evidence of anastomotic ulceration, esophagogastric varices, or other potential etiology for bleeding. He continued to have melena and was transfused with a total of 2 units of packed red blood cells. Bidirectional endoscopy was performed on day 3 of admission. Endoscopic evaluation of his colon and terminal ileum was unremarkable. However, repeated upper endoscopy with deep intubation of the afferent jejunal limb using a pediatric colonoscope revealed Figure A at the level of the hepaticojejunostomy. The hepaticojejunostomy itself was normal without evidence of bleeding or ulceration (Figure B). What is the most likely explanation for his gastrointestinal bleeding? Look on page 35 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. Gastrointestinal bleeding is uncommon (<8%) after pancreaticoduodenectomy but is associated with high mortality rates.1Limongelli P. Khorsandi S.E. Pai M. et al.Management of delayed postoperative hemorrhage after pancreaticoduodenectomy: a meta-analysis.Arch Surg. 2008; 143: 1001-1007Crossref PubMed Scopus (91) Google Scholar Specific causes include anastomotic ulceration, pancreatic fistula, pseudoaneurysm, or sequelae of portal hypertension due to portomesenteric venous stenosis or thrombosis.2Biondetti P. Fumarola E.M. Ierardi A.M. et al.Bleeding complications after pancreatic surgery: interventional radiology management.Gland Surg. 2019; 8: 150-163Crossref PubMed Scopus (32) Google Scholar In our case, the diagnosis was made after deep intubation of the afferent limb revealed a network of varices with stigmata of recent bleeding at the hepaticojejunostomy. Computed tomography of the abdomen with intravenous contrast was obtained after endoscopy (Figure C), revealing chronic thrombosis of the portal and proximal superior mesenteric veins with cavernous transformation (red arrow), upper abdominal varices adjacent to the afferent jejunal limb, and no evidence of cirrhosis. Review of cross-sectional imaging before his pancreaticoduodenectomy (Figure D) revealed no evidence of portomesenteric vascular abnormalities. As such, variceal formation was thought to be secondary to extrahepatic portal venous obstruction and thrombosis from post-surgical inflammation or scarring. Ectopic varices are portosystemic collaterals that form outside the esophagogastric region and frequently pose a diagnostic and therapeutic challenge.3Sarin S.K. Kumar C.K.N. Ectopic varices.Clin Liver Dis (Hoboken). 2012; 1: 167-172PubMed Google Scholar Their formation is driven by locoregional factors and can occur in the presence of absence of cirrhosis. Ectopic variceal hemorrhage at a bilioenteric anastomosis after pancreaticoduodenectomy has rarely been described.4Ali S. Asad Ur R. Navaneethan U. An unusual cause of recurrent gastrointestinal bleeding after Whipple’s surgery.Gastroenterology. 2017; 153: e1-e2Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar,5Wakasugi M. Tsujie M. Goda S. et al.Laparotomy-assisted transcatheter variceal embolization for bleeding jejunal varices formed at the site of choledochojejunostomy: report of a case and review of the literature.Int J Surg Case Rep. 2020; 77: 554-559Crossref PubMed Scopus (1) Google Scholar The present case illustrates the importance of fully exploring the afferent limb in patients with surgically altered anatomy presenting with obscure GI bleeding. Conventional esophagogastroduodenoscopy is frequently unable to fully evaluate the entire afferent limb owing to its length and anatomic distortion. As such, the use of a colonoscope or balloon enteroscopy where available is critical for complete assessment of the upper GI tract in cases with negative index esophagogastroduodenoscopy and colonoscopy. The use of balloon enteroscopy has been shown to safely increase the diagnostic and therapeutic yields of endoscopic evaluation to 81% and 64%, respectively, in the evaluation of obscure GI bleeding in such patients.6Aryan M. Colvin T. Ahmed A.M. et al.Role of balloon enteroscopy for obscure gastrointestinal bleeding in those with surgically altered anatomy: a systematic review.World J Gastrointest Endosc. 2022; 14: 434-442Crossref PubMed Google Scholar,7Baba H. Wakabayashi M. Oba A. et al.Unusual bleeding from hepaticojejunostomy controlled by adult variable stiffness colonoscopy: report of a case and literature review.Int Surg. 2014; 99: 584-589Crossref PubMed Scopus (2) Google Scholar Management of ectopic variceal hemorrhage requires multidisciplinary consultation with gastroenterologists, interventional radiologists, and surgeons to determine an optimal therapeutic approach owing to the substantial clinical and anatomic variation in each case. Multiple therapeutic strategies have been reported for the management of bleeding ectopic varices at the site of a bilioenteric anastomosis. These include techniques directed at 1) direct variceal obliteration, via direct endoscopic therapies (eg, sclerotherapy, ligation, cyanoacrylate) or coil embolization, or 2) portal decompression via portal vein dilation or stenting, surgical decompression, or splenectomy.8Hyun D. Park K.B. Cho S.K. et al.Portal vein stenting for delayed jejunal varix bleeding associated with portal venous occlusion after hepatobiliary and pancreatic surgery.Korean J Radiol. 2017; 18: 828-834Crossref PubMed Scopus (14) Google Scholar,9Taniguchi H. Moriguchi M. Amaike H. et al.Hemorrhage from varices in hepaticojejunostomy in the fifth and tenth year after surgery for hepatic hilar bile duct cancer: a case report.Cases J. 2008; 1: 59Crossref PubMed Google Scholar Given the portal cavernous transformation, portal venous stenting or variceal embolization was thought not to be technically feasible. Surgical decompression was thought to be prohibitively high risk. As such, endoscopic therapy was recommended as a first-line approach to treatment after multidisciplinary discussion. On day 6 of his hospitalization, the patient underwent successful injection of 2 mL 2-octyl cyanoacrylate (in a single injection) via a 23-gauge needle to the ectopic varices (Figures E and F) and was also started on low-dose carvedilol. His melena resolved and he was discharged from the hospital uneventfully. He remained without recurrent bleeding during 1 year of close follow-up. This case illustrates the importance of including ectopic varices in the differential diagnosis of gastrointestinal hemorrhage in patients after pancreatic surgery, particularly at surgical anastomosis sites. If identified, defining their vascular supply and implementing a multidisciplinary approach is paramount to their management." @default.
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• W4313366919 date "2023-07-01" @default.
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• W4313366919 title "A Rare Cause of Gastrointestinal Bleeding After Pancreaticoduodenectomy" @default.
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