Journal Article

Small Bowel Varices: Beyond Our Reach?

Senatore, Frank, Rubin, Moshe, Pakala, Tina

2018

Overview

Introduction: Gastroesophageal (GE) varices are common manifestations of portal hypertension (PHT). Ectopic varices are less common but serious complications of PHT that can be located throughout the small and large bowel, biliary tree, peritoneum and pelvic organs. Regardless of their location, they confer a very high mortality if bleeding occurs.Case Presentation: A 35-year-old male presented with a 3-day history of melena. He had a past medical history of alcohol related cirrhosis. On examination, vitals remarkable for HR of 110, BP of 95/42. Abdominal exam remarkable for tense ascites. Digital rectal exam revealed black tarry stool. Hemoglobin was 8.1, platelets 28, total bilirubin 7, INR 1.89; MELD score was 21 and discriminant function 55.8. He underwent EGD showing grade 1 esophageal varices with no stigmata of recent bleeding and portal hypertensive gastropathy. However on duodenal examination, there were large clusters of varices in the second portion, not amenable to banding given their size. Patient then underwent colonoscopy showing melena in the terminal ileum, but no source of bleeding in the colon. Post-endoscopy, he continued to have melena, with further decreases in his hemoglobin despite transfusion and octreotide therapy. A nuclear bleeding scan located the bleeding to the duodenum. The patient underwent TIPS resulting in stabilization of his hemoglobin and no further episodes of bleeding. Discussion: Duodenal varices are uncommon, occurring in approximately 0.4% of patients with PHT. Literature suggests that duodenal varices are more common when evaluated via angiography. As duodenal varices rarely penetrate the submucosa, their incidence is likely severely underestimated by endoscopic detection. Nonetheless, when present within the small bowel, they can be a potential life-threatening cause of GI bleeding, with mortality rates reported as high as 40%. While clear guidelines exist for managing GE varices including prophylactic therapy with band ligation or nonselective beta blocker therapy, treatment of small bowel varices is not well defined. Current literature suggests that while endoscopic sclerotherapy, band ligation or surgical resection are potential treatment modalities, their success is unclear. Portocaval shunts, as our patient had, appear to be definitive therapy, but additional case series and studies are needed to better delineate a treatment algorithm.

• Publisher: Wolters Kluwer Health Medical Research, Lippincott Williams & Wilkins
• Subject: Endoscopy / Gastroenterology / Hemoglobin / Liver cirrhosis / Mortality / Small intestine