Hemorrhage from varices in the jejunal loop after reconstruction of the biliary tract
is quite rare. Portal hypertension due to extrahepatic portal vein stenosis or obstruction
at the site of a previously performed choledocho-jejunostomy results in the formation
of hepatoportal collaterals through the anastomosis, thus creating varices in the
afferent loop that can rupture and hemorrhage [1]
[2]. We present endoscopic sclerotherapy under balloon-assisted enteroscopy for hemorrhagic
jejunal varices after choledocho-jejunostomy ([Video 1]).
Video 1 Endoscopic sclerotherapy under balloon-assisted enteroscopy for hemorrhagic jejunal
varices after choledocho-jejunostomy.
A 67-year-old man was admitted to our hospital with recurrent massive gastrointestinal
bleeding (GIB). He had undergone choledocho-jejunostomy (Roux-en-Y) for pancreaticobiliary
maljunction 14 years earlier, and 12 years later, he had the first episode of GIB.
At another hospital, it was revealed that the cause of hemorrhage was jejunal varices
at the site of the choledocho-jejunostomy anastomosis, which appeared to have developed
due to an extrahepatic portal vein obstruction.
A transileocolic vein obliteration utilizing a catheter and coils was carried out
and resulted in successful hemostasis. On the arrival at our hospital, recurrent jejunal
varices were revealed by enhanced computed tomography ([Fig. 1]).
Fig. 1 Enhanced computed tomography showing jejunal varices (arrow).
Balloon-assisted enteroscopy using a single-balloon endoscope (SIF-Q260; Olympus,
Tokyo, Japan) was carried out. It showed the coils, which were exposed ([Fig. 2 a]) near to the site of the choledocho-jejunostomy anastomosis ([Fig. 2 b]). Jejunal varices with a fibrin plug were also revealed ([Fig. 2 c]). We performed endoscopic injection sclerotherapy (EIS) using a mixture of 1.5 mL
N-butyl-2-cyanoacrylate and 0.5 mL lipiodol at the jejunal varices ([Fig. 2 d]). After EIS, the injectate could be seen occupying the jejunal varices ([Fig. 3]). There were no adverse events concerning the EIS treatment. From then on, no GIB
episodes were encountered.
Fig. 2 Endoscopic images. a The coils, which were exposed near to the site of the choledocho-jejunostomy anastomosis.
b Choledocho-jejunostomy anastomosis. c Jejunal varices with a fibrin plug (arrow). d Endoscopic injection sclerotherapy for jejunal varices.
Fig. 3 After endoscopic injection sclerotherapy, the injectate was seen occupying the jejunal
varices (arrow).
We conclude that EIS using balloon-assisted enteroscopy can be an effective, easy,
and safe treatment selection for hemorrhagic jejunal varices.
Endoscopy_UCTN_Code_TTT_1AP_2AD
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.
This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos
