Anam Malik, MD, Reema Vaze, MD, Ricky Buckshaw, DO, Michal Kloska, MD, Eric Nellis, MD, She Yan Wong, MD
Lehigh Valley Health Network, Allentown, PA
Introduction: The small intestine is the most common cause of obscure gastrointestinal (GI) bleeding. Approximately 5% of GI bleeding occurs from the small bowel, defined as the region between the ligament of Treitz and the ileocecal valve. Controlling the bleed in this area is challenging because of its intra-peritoneal location and long length. Patient with small bowel bleeding typically undergo multiple diagnostic evaluations because of the inability to visualize the small bowel properly. However, wireless capsule endoscopy, double balloon enteroscopy, and computed tomography enterography (CTE) have improved the ability to investigate these bleeds. We report a case of small bowel varices successfully treat by percutaneous coil embolization via the superior mesenteric vein (SMV).
Case Description/Methods: A 60-year-old female with non-alcoholic steatohepatitis (NASH) cirrhosis was admitted due to dark stools and acute encephalopathy. Prior to this, the patient was worked-up extensively at another facility for the same complaints with EGD, colonoscopy, CTE, and push enteroscopy which was minimally revealing. Initial laboratory values showed a hemoglobin (Hgb) of 9.8 g/dl with a drop to 7.0 g/dl which required transfusion of three units packed red blood cells. She underwent wireless capsule endoscopy that revealed a large, active bleed in the mid small bowel due to varices. Immediately following, the patient underwent successful direct percutaneous access of the small bowel venous varix, supplied by a prominent SMV branch, by coiling a portion of the varix and the venous inflow. After the procedure, there was clinical resolution of the gastrointestinal bleeding and her hemoglobin returned to baseline.
Discussion: Even though small bowel variceal bleeding is rare, it can be life threatening without treatment. Early recognition and prompt management is useful in reducing unnecessary diagnostic tests for the patient. The treatment of small bowel varices includes surgery, transjugular intrahepatic portosystemic shunt (TIPS), dilatation of a stenosed portal vein, enteroscopic sclerotherapy, and percutaneous embolization. Intervention angiography was selected for this patient rather than TIPS due to the presence of hepatic encephalopathy. Though further studies are needed to confirm the use of embolization as first line therapy for small bowel variceal bleeding, it should be considered when evaluating small bowel bleeds as it can offer successful outcomes.
Citation: Anam Malik, MD, Reema Vaze, MD, Ricky Buckshaw, DO, Michal Kloska, MD, Eric Nellis, MD, She Yan Wong, MD. P1358 - SMALL BOWEL VARICEAL BLEEDING SUCCESSFULLY TREATED WITH PERCUTANEOUS COIL EMBOLIZATION. Program No. P1358. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.