Endoscopy 2018; 50(07): E159-E162
DOI: 10.1055/a-0595-7507
© Georg Thieme Verlag KG Stuttgart · New York

Massive upper gastrointestinal bleeding post-Whipple’s surgery from anastomotic varices due to mesenteric hypertension

Yu Jun Wong
Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
Farah Gillian Irani
Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
Malcolm Tan
Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
Melissa Teo
Division of Surgical Oncology, Singapore General Hospital, Singapore
National Cancer Center, Singapore
› Author Affiliations
Further Information

Publication History

Publication Date:
09 May 2018 (eFirst)

A 45-year-old man was admitted with hematemesis. He had undergone Whipple’s surgery 7 years previously for a 5-cm serous cystadenoma of the pancreatic head. Upon presentation, he was hypotensive (blood pressure 82/59 mmHg) and tachycardic (110 beats/min), with a hemoglobin of 6.8 g/dL. Gastroscopy revealed bleeding anastomotic varices alongside the gastrojejunal anastomosis ([Fig. 1]). Hemostasis was secured with a Boston Resolution clip ([Video 1]). Computed tomography (CT) scanning, followed by mesenteric angiography in the portal venous phase and CT arterioportography showed proximal superior mesenteric vein (SMV) occlusion, with a large collateral vein draining the small bowel into the anastomotic varices, which decompressed via the enlarged left coronary vein (LCV) into a patent portal vein ([Fig. 2]). The occluded SMV was recanalized, dilated to 8 mm, and stented with a 7 × 29-mm Omnilink stent via a transhepatic approach, thereby re-establishing antegrade flow with subsequent collapse of the collateral vein and anastomotic varices ([Fig. 3]).

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Fig. 1 Endoscopic images showing bleeding anastomotic varices alongside the anastomosis of the gastroduodenostomy. Endoscopic hemostasis of the bleeding varices was achieved using a Boston Resolution clip.

Video 1 A bleeding anastomotic varix is seen alongside the gastrojejunal anastomosis and is secured with a Boston resolution clip.

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Fig. 2 Computed tomography scan images of the abdomen showing: a the anastomotic varices; b a collateral vein with occluded superior mesenteric vein (SMV); c occluded SMV; d occluded portal vein and left coronary vein.
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Fig. 3 Computed tomography of arterioportography showing: a the collateral vein draining into anastomotic varices; b the vaices draining into the left coronary vein; c the occluded superior mesenteric vein recanalized, dilated, and stented with a 7 × 29-mm Omnilink stent.

Gastrointestinal bleeding is a complication reported in 2 % – 8 % of patients following a Whipple procedure [1]. Sources of upper gastrointestinal bleeding include pseudoaneurysms, pancreatic fistulas, anastomotic ulcers, and ectopic varices [2] [3] [4] [5]. We report a case of bleeding anastomotic varices that developed from mesenteric hypertension as a result of SMV occlusion following surgery. As the small bowel was solely draining back to the portal vein via a collateral vein and anastomotic varices, endoscopic glue injection into the anastomotic varices could have led to bowel ischemia. Successful stenting of the occluded SMV resulted in the re-establishment of normal hemodynamics, decompressing the anastomotic varices, and therefore preventing future bleeding episodes.


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