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]).
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.
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.
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.
Endoscopy_UCTN_Code_TTT_1AO_2AD
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