RESUMO
BACKGROUND: The varices after proximal or total gastrectomy are uncommon because the supplying vessels are all divided. Emergent upper gastrointestinal endoscopy is the cornerstone of first-line management for the diagnosis and treatment of esophageal varices. However, there is no widely accepted standard strategy for esophagojejunal varices. We report a patient with esophagojejunal varices rupture 3 months after proximal gastrectomy treated with percutaneous transhepatic obliteration. CASE PRESENTATION: A 50-year-old man who had undergone proximal gastrectomy with double-tract reconstruction for esophagogastric junctional cancer 3 months before was admitted to the hospital due to gastrointestinal perforation. We performed emergency surgery and abdominal symptoms and inflammatory response improved postoperative. However, on POD3, he had eruptive bleeding at the just anal side of esophagojejunal anastomosis. Endoscopic clipping was unsuccessful because the mucosa was fragile and easily lacerated. Contrast-enhanced CT scan revealed the dilatation of the jejunal vein flowing into the ascending jejunal limb. Therefore, he was diagnosed as esophagojejunal varices rupture and percutaneous transhepatic obliteration (PTO) was tried for hemostasis. The portal and superior mesenteric veins were catheterized with the percutaneous transhepatic approach. Contrast agent injection into the jejunal branch demonstrated retrograde flow to the azygos vein through esophagojejunal varices. The microcatheter was inserted into the variceal blood supply branch and 10 mL of 5% ethanolamine oleate with iopamidol was injected. After obliteration therapy, the superior mesenteric venogram showed complete occlusion of the variceal supply branch. The patient was discharged from the hospital without any complications after 14 days. CONCLUSION: PTO can be effective for gastroesophageal varices rupture with a dilated jejunal vein of the ascending limb, few supplying vessels, and little ascites.
RESUMO
INTRODUCTION: Bleeding from jejunal varices formed at the site of a bilioenteric anastomosis due to portal vein hypertension is relatively rare and difficult to treat. PRESENTATION OF CASE: An 80-year-old man with melena, slight fever, and abdominal pain was referred to our hospital. He had undergone subtotal stomach-preserving pancreaticoduodenectomy for cancer of the ampulla of Vater six years earlier. Follow-up computed tomography (CT) three years earlier showed occlusion of the extrahepatic portal vein and the growth of collateral flow into the lateral segment of the liver, but there were no signs of recurrence of the cancer of the ampulla of Vater. The patient underwent prophylactic endoscopic variceal ligation for esophageal varices one year earlier. On admission, blood tests showed anemia and elevated liver enzyme and bilirubin levels. Esophagogastroduodenoscopy and colonoscopy failed to identify the site of bleeding. Double-balloon endoscopy showed the dilated blood vessels around the stenotic anastomosis of the choledochojejunostomy. A CT scan was consistent with total occlusion of the portal vein and varices around the choledochojejunostomy site. With a diagnosis of jejunal varices, laparotomy-assisted transcatheter variceal embolization was performed. Double-balloon endoscopy performed one month after laparotomy-assisted transcatheter variceal embolization showed no varices, and dilation of the stenotic anastomosis of the choledochojejunostomy was performed safely. CONCLUSION: Jejunal varices should be included in the differential diagnosis of melena in patients with a previous history of surgery with a bilioenteric anastomosis and portal vein hypertension. Laparotomy-assisted transcatheter variceal embolization is one of the options for the treatment of jejunal varices.
