This case describes a 64-year-old man with a history of total pancreatectomy, duodenectomy,
and total gastrectomy for pancreatic cancer. He previously underwent reconstruction
with esophagojejunal anastomosis and hepaticojejunal anastomosis, without Roux-en-Y.
Arterial bridges of the superior mesenteric artery and the celiac trunk were performed,
for which he received permanent antiplatelet therapy; he also uses oral anticoagulants
to treat a deep vein thrombosis of the right upper extremity related to a central
venous catheter. The patient presented with melena and acute anemia. Computed tomography
angiography showed dense content in the small bowel with no evidence of active bleeding.
It was decided to do an upper endoscopy ([Video 1]).
Video 1 Endoscopic management of jejunal hemorrhage.
In the mucosa surrounding the hepaticojejunal anastomosis, three vascular lesions
were observed ([Fig. 1 a]), with enhanced visualization achieved with linked color imaging ([Fig. 1 b]) and blue laser imaging ([Fig. 1 c]). Two of the lesions were compatible with angioectasias, and the third was compatible
with a cirsoid aneurysm, which presented a visible vessel with red stigmata.
Fig. 1 Endoscopic views of the hepaticojejunal anastomosis showing perianastomotic neoformation
of blood vessels. a White-light mode. b Linked color imaging mode. c Blue laser imaging mode. d Hemoclip placement to the perianastomotic newly formed blood vessels and their tributaries.
It was decided to treat the lesion with argon plasma coagulation (APC), which caused
active bleeding. Two clips were placed to achieve hemostasis. More clips were placed
on the surrounding mucosa to treat the arteriolar vessels causing the lesion ([Fig. 1 d]).
The patient recovered with no new episodes of gastrointestinal bleeding, and was discharged
on the third day.
Dieulafoy’s lesions in the jejunum are rare (1 %) [1]. In this case, there was doubt about the origin of the lesion; it could have been
related to neoformation of blood vessels or varicose veins [2].
Diagnosis and treatment can be performed endoscopically in most cases [3], and a lower rate of rebleeding has been reported using combined endoscopic therapies
[4]. Use of APC to treat angiodysplasia around the hepaticojejunal anastomosis has been
reported previously [5].
Endoscopy_UCTN_Code_CCL_1AZ_2AO
Endoscopy E-Videos is an open 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. Processing charges apply (currently EUR
375), discounts and wavers acc. to HINARI are available.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
