Case Report
Copyright ©2009 The WJG Press and Baishideng. All rights reserved.
World J Gastroenterol. Aug 14, 2009; 15(30): 3823-3826
Published online Aug 14, 2009. doi: 10.3748/wjg.15.3823
Percutaneous paraumbilical embolization as an unconventional and successful treatment for bleeding jejunal varices
Lee-Guan Lim, Yin-Mei Lee, Lenny Tan, Stephen Chang, Seng-Gee Lim
Lee-Guan Lim, Yin-Mei Lee, Seng-Gee Lim, Department of Gastroenterology and Hepatology, National University Hospital, Singapore 119074, Singapore
Lenny Tan, Department of Diagnostic Radiology, National University Hospital, Singapore 119074, Singapore
Stephen Chang, Department of Surgery, National University Hospital, Singapore 119074, Singapore
Author contributions: Lim LG, Lee YM, Tan L, Chang S, Lim SG were all involved in the care of the patient in this report; Lim LG wrote the manuscript and performed the literature review; Lee YM, Tan L, Chang S, Lim SG revised the manuscript; Lim SG made the final decision to submit the manuscript.
Correspondence to: Dr. Lee Guan Lim, MBBS, MRCP, Department of Gastroenterology and Hepatology, National University Hospital, 5 Lower Kent Ridge Road, 119074, Singapore 119074, Singapore. lee_guan_lim@nuhs.edu.sg
Telephone: +65-67724354
Fax: +65-67794112
Received: March 10, 2009
Revised: June 30, 2009
Accepted: July 7, 2009
Published online: August 14, 2009
Abstract

A 48-year-old Indian male with alcoholic liver cirrhosis was admitted after being found unresponsive. He was hypotensive and had hematochezia. Esophagogastroduodenoscopy (EGD) showed small esophageal varices and a clean-based duodenal ulcer. He continued to have hematochezia and anemia despite blood transfusions. Colonoscopy was normal. Repeat EGD did not reveal any source of recent bleed. Twelve days after admission, his hematochezia ceased. He refused further investigation and was discharged two days later. He presented one week after discharge with hematochezia. EGD showed non-bleeding Grade 1 esophageal varices and a clean-based duodenal ulcer. Colonoscopy was normal. Abdominal computed tomography (CT) showed liver cirrhosis with mild ascites, paraumbilical varices, and splenomegaly. He had multiple episodes of hematochezia, requiring repeated blood transfusions. Capsule endoscopy identified the bleeding site in the jejunum. Concurrently, CT angiography showed paraumbilical varices inseparable from a loop of small bowel, which had herniated through an umbilical hernia. The lumen of this loop of small bowel opacified in the delayed phase, which suggested variceal bleeding into the small bowel. Portal vein thrombosis was present. As he had severe coagulopathy and extensive paraumbilical varices, surgery was of high risk. He was not suitable for transjugular intrahepatic porto-systemic shunt as he had portal vein thrombosis. Percutaneous paraumbilical embolization via caput medusa was performed on day 9 of hospitalization. Following the embolization, the hematochezia stopped. However, he defaulted subsequent follow-up.

Keywords: Embolization; Jejunal varices; Obscure bleed; Capsule endoscopy; Angiography