• ectopic varices
• endoscopy
• gastrointestinal bleeding
• histoacryl injection
• liver cirrhosis
• portal hypertension

Bioprosthetic valve thrombosis (BPVT) is considered a relatively rare but life-threatening clinical entity. Thus, there is the need of high clinical suspicion in order to make a timely diagnosis and related appropriate therapeutic interventions. In this regard, the management of BPVT is high risk, whatever the option taken (surgery and/or systemic fibrinolysis). The presence of severe comorbidities—as decompensated cirrhosis—further complicates the clinical decision-making process, calling for a patient-tailored integrated multidisciplinary approach. We report a challenging case of a 45-year-old patient with mitral bioprosthetic valve thrombosis and hepatitis C virus (HCV)-related cirrhosis complicated by active duodenal variceal bleeding.

Among the various causes for lower gastrointestinal bleeding, ectopic varices constitute a small chunk. Though rare, these can pose a diagnostic challenge with recurrent bleed leading to multiple admission and blood transfusions.

A 41-year-old male presented to our department with multiple episodes of melena. On further evaluation with CT angiography, a diagnosis of extrahepatic portal vein obstruction with moderate splenomegaly and ectopic jejunal varix was made. He underwent splenectomy with resection of involved jejunal segment with side to side anastomosis.

The diagnosis of ectopic varices remains elusive in a large number of cases in view of the varied etiology. Various newer endoscopic and imaging modalities can play a diagnostic as well as therapeutic role but this also further complicates the management as there is a lack of substantial guidelines directing the treatment protocol. As a result, we have to resort to a case by case approach for the optimal management in these cases.

The main modality of management for bleeding ectopic varices is percutaneous or endoscopic. Surgery is reserved for refractory cases, with decompressive shunts combined with segmental resection of involved intestine being at the forefront of surgical options.

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Ectopic varices are an unusual cause of lower GI bleeding caused by porto-systemic collaterals.

• Decompressive surgery
• EHPVO
• Ectopic varices
• Splenectomy

• Distal duodenal ectopic variceal bleed
• coil embolization
• portal Hypertension
• transjugular Intrahepatic portosystemic shunt (TIPS)

십이지장 정맥류는 간경화증에 의한 문맥압 고혈압 환자에서 발생할 수 있으며, 치명적인 심한 상부 위장관 출혈을 일으킬 수 있으나 아직까지 명확한 치료 지침이 정립되어 있지는 않다. 일차적으로 내시경으로 치료를 시도하고 지혈 실패 시 목정맥경유간속문맥전신순환연결술, 풍선 혹은 혈관 마개를 이용한 역행성 경정맥 폐색술, 피부간경유 폐색술 등과 같은 중재적 치료를 고려할 수 있다. 저자들은 내시경적 치료에 실패한 십이지장 정맥류 출혈 환자에게 저하된 간 기능과 해부학적인 구조의 제한으로 인해 코일을 이용한 역행성 경정맥 폐색술을 시행하여 성공적으로 치료한 1예를 경험하였기에 이를 보고하고자 한다.

• Case report
• Duodenal varix
• Upper gastrointestinal bleeding

Portal hypertension and liver cirrhosis may predispose patients to varices, which have a propensity to bleed and cause significant morbidity and mortality. These varices are most commonly located in the gastroesophageal area; however, rarely ectopic varices may develop in unusual locations outside of this region. Haemorrhage from these sites can be massive and difficult to control; thus early detection and management may be lifesaving. We present a case of occult gastrointestinal bleeding in a patient with underlying alcoholic liver disease where an ectopic varix was ultimately detected with push enteroscopy.

Obscure gastrointestinal bleeding is an uncommonly encountered and difficult-to-treat clinical problem in gastroenterology, but advancements in endoscopic and radiologic imaging modalities allow for greater accuracy in diagnosing obscure gastrointestinal bleeding. Ectopic varices account for less than 5% of all variceal bleeding cases, and jejunal variceal bleeding due to extrahepatic portal hypertension is rare. We present a 47-year-old man suffering from obscure gastrointestinal bleeding. Computed tomography of the abdomen revealed multiple vascular tufts around the proximal jejunum but no evidence of cirrhosis, and a visible hypodense filling defect suggestive of thrombus was visible in the superior mesenteric vein. Enteroscopy revealed several serpiginous varices in the proximal jejunum. Serologic data disclosed protein C deficiency (33.6%). The patient was successfully treated by therapeutic balloon-assisted enteroscopy and long-term anticoagulant therapy, which is normally contraindicated in patients with gastrointestinal bleeding. Diagnostic modalities for obscure gastrointestinal bleeding, such as capsule endoscopy, computed tomography enterography, magnetic resonance enterography, and enteroscopy, were also reviewed in this article.

• Angiography
• Computed tomography
• Enteroscopy
• Obscure gastrointestinal bleeding
• Protein C deficiency
• Superior mesenteric venous thrombosis

• Anticoagulants/therapeutic use
• Gastrointestinal Hemorrhage/blood
• Gastrointestinal Hemorrhage/diagnosis
• Gastrointestinal Hemorrhage/etiology
• Gastrointestinal Hemorrhage/surgery
• Hemostasis, Endoscopic
• Humans
• Jejunum/blood supply
• Male
• Mesenteric Vascular Occlusion/drug therapy
• Mesenteric Vascular Occlusion/etiology
• Mesenteric Veins/diagnostic imaging
• Middle Aged
• Phlebography/methods
• Protein C Deficiency/blood
• Protein C Deficiency/complications
• Protein C Deficiency/diagnosis
• Protein C Deficiency/drug therapy
• Tomography, X-Ray Computed
• Treatment Outcome
• Varicose Veins/blood
• Varicose Veins/diagnosis
• Varicose Veins/etiology
• Varicose Veins/surgery
• Venous Thrombosis/drug therapy
• Venous Thrombosis/etiology

• capsule endoscopy
• liver cirrhosis
• portal hypertensive enteropathy
• portosystemic shunts

• CBD, common bile duct
• DV, duodenal varices
• ECD, epicholedochal
• EHPVO, extra hepatic portal vein obstruction
• EUS, Endoscopic ultrasound
• EVL, endoscopic variceal ligation
• HDA, hemodynamic assessment
• IVC, inferior vena cava
• PCD, para-choledochal
• PDV, paraduodenal varices
• PV, portal vein
• SMV, superior mesenteric vein
• duodenal varices
• endoscopic ultrasound
• endoscopic variceal ligation
• portal hypertension

• Computed tomography
• Duodenum
• Surgical hemostasis
• Varices

Ectopic varices (EcV) comprise large portosystemic venous collaterals located anywhere other than the gastro-oesophageal region. No large series or randomized-controlled trials address this subject, and therefore its management is based on available expertise and facilities, and may require a multidisciplinary team approach. EcV are common findings during endoscopy in portal hypertensive patients and their bleeding accounts for only 1–5% of all variceal bleeding. EcV develop secondary to portal hypertension (PHT), surgical procedures, anomalies in venous outflow, or abdominal vascular thrombosis and may be familial in origin. Bleeding EcV may present with anaemia, shock, haematemesis, melaena or haematochezia and should be considered in patients with PHT and gastrointestinal bleeding or anaemia of obscure origin. EcV may be discovered during panendoscopy, enteroscopy, endoscopic ultrasound, wireless capsule endoscopy, diagnostic angiography, multislice helical computed tomography, magnetic resonance angiography, colour Doppler-flow imaging, laparotomy, laparoscopy and occasionally during autopsy. Patients with suspected EcV bleeding need immediate assessment, resuscitation, haemodynamic stabilization and referral to specialist centres. Management of EcV involves medical, endoscopic, interventional radiological and surgical modalities depending on patients’ condition, site of varices, available expertise and patients’ subsequent management plan.

• Adult
• Duodenum
• Embolization, Therapeutic/methods
• Esophageal and Gastric Varices/diagnosis
• Esophageal and Gastric Varices/etiology
• Esophageal and Gastric Varices/therapy
• Humans
• Hypertension, Portal/complications
• Male
• Mesenteric Veins
• Middle Aged
• Portasystemic Shunt, Transjugular Intrahepatic
• Vena Cava, Inferior

• Aged
• Diagnosis, Differential
• Duodenal Diseases/diagnostic imaging
• Duodenal Diseases/therapy
• Embolization, Therapeutic
• Endoscopy, Gastrointestinal
• Humans
• Image Processing, Computer-Assisted
• Male
• Tomography, X-Ray Computed
• Varicose Veins/diagnostic imaging
• Varicose Veins/therapy

AIM: To assess the feasibility and usefulness of multi-detector CT enterography with orally administered iso-osmotic mannitol as negative contrast in demonstrating small bowel disease.

METHODS: Thirteen volunteers and 38 patients with various kinds of small bowel disease were examined. We administered about 1500 mL iso-osmotic mannitol as negative contrast agent and then proceeded with helical CT scanning on a Siemens Sensation 16 scanner. All volunteers and patients were interviewed about their tolerance of the procedure. Two radiologists post-processed imaging data with MPR, thin MIP, VRT and INSPACE when necessary and then interpreted the scans, and adequacy of luminal distention was evaluated on a four-point scale. Demonstration of features of various kinds of small bowel disease was analyzed.

RESULTS: The taste of iso-osmotic mannitol is good (slightly sweet) and acceptable by all. Small bowel distention was excellent and moderate in most volunteers and patients. CT features of many kinds of diseases such as tumors, Crohn’s disease,and small bowel obstruction, etc. were clearly displayed.

CONCLUSION: Multi-detector CT enterography with iso-osmotic mannitol as negative contrast to distend the small bowel is a simple, rapid, noninvasive and effective method of evaluating small bowel disease.

• Small bowel
• Contrast
• Enterography

• Administration, Oral
• Adult
• Aged
• Aged, 80 and over
• Crohn Disease/diagnostic imaging
• Diuretics, Osmotic
• Feasibility Studies
• Female
• Humans
• Intestine, Small/diagnostic imaging
• Ischemia/diagnostic imaging
• Male
• Mannitol
• Middle Aged
• Tissue Adhesions/diagnostic imaging
• Tomography, X-Ray Computed/methods

• Adult
• Duodenal Diseases/complications
• Duodenal Diseases/surgery
• Duodenum/pathology
• Duodenum/surgery
• Endoscopy, Digestive System/methods
• Female
• Gastrointestinal Hemorrhage/complications
• Gastrointestinal Hemorrhage/surgery
• Hematemesis/etiology
• Humans
• Ligation
• Treatment Outcome