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

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.

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• References

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• 2 Ali S, Asad UR, Udayakumar N. An Unusual Cause of recurrent gastrointestinal bleeding after Whipple’s surgery. Gastroenterology 2017; 153: e1-e2
• 3 Damle A, Clemenzi AA, Jabbour N. et al. Rare cause of delayed upper gastrointestinal bleeding after pancreaticoduodenectomy. J Pancreas 2012; 13: 222-225
• 4 Schäfer M, Heinrich S, Pfammatter T. et al. Management of delayed major visceral arterial bleeding after pancreatic surgery. HPB (Oxford) 2011; 13: 132-138
• 5 Gomes AP, Guede PE, Rosa L. et al. Splancnic hypertension following a Whipple procedure: interdisciplinary approach. EURORAD: Radiological Case Database. Available from: http://www.eurorad.org/eurorad/case.php?id=10218 Accessed: 9 February 2018