Successful jejunal variceal obliteration with n-butyl-2-cyanoacrylate injection

Aims A 65-year-old woman was brought to the emergency department due to a transient loss of consciousness with head trauma and melena since the previous day. She denied other episodes of syncope, as well as hematemesis or hematochezia. Past medical conditions included alcoholic liver cirrhosis (Child-Pugh B classification). On physical examination the patient was initially hemodinamically stable and the neurologic examination was normal. Blood studies revealed mild normocytic normochromic anemia (hemoglobin 11.1 g/dL).

Methods On upper endoscopy, no blood or bleeding lesions were identified. Later however, the patient became lethargic and hemodinamically unstable despite fluid resuscitation. A contrasted computed tomography was performed, revealing several ectopic intestinal varices located in the Treitz angle, however no unequivocal signs of active bleeding were described.

Results Due to the possibility of small-bowel portal hypertensive bleeding, an antegrade balloon assisted enteroscopy was performed, revealing active bleeding from a jejunal varix. Successful jejunal variceal obliteration was performed with injection of 1mL of n-butyl-2-cyanoacrylate. The patient was then admitted in the intensive care unit and begun vasopressor treatment with terlipressine and received antibiotic prophylaxis. She was discharged from the hospital two weeks later without evidence of rebleeding.

Conclusions Ectopic varices comprise 1-5% of all cases of intrahepatic portal hypertensive bleeding. Management of this rare event might be particularly challenging, given its frequent presentation with massive bleeding, complex underlying vascular anatomy and absence of clear management guidelines in this setting.

 

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Conflicts of interest

Authors do not have any conflict of interest to disclose.

Publication History

Article published online:
14 April 2023