Successful management of bleeding ectopic small bowel varices secondary to portal hypertension: A retrospective study

Abstract

BACKGROUND

Bleeding ectopic varices located in the small bowel (BEV-SB) caused by portal hypertension (PH) are rare and life-threatening clinical scenarios. The current management of BEV-SB is unsatisfactory. This retrospective study analyzed four cases of BEV-SB caused by PH and detailed the management of these cases using enteroscopic injection sclerotherapy (EIS) and subsequent interventional radiology (IR).

AIM

To analyze the management of BEV-SB caused by PH and develop a treatment algorithm.

METHODS

This was a single tertiary care center before-after study, including four patients diagnosed with BEV-SB secondary to PH between January 2019 and December 2023 in the Air Force Medical Center. A retrospective review of the medical records was conducted. The management of these four patients involved the utilization of EIS followed by IR. The management duration of BEV-SB in each patient can be retrospectively divided into three phases based on these two approaches: Phase 1, from the initial occurrence of BEV-SB to the initial EIS; phase 2, from the initial EIS to the initial IR treatment; and phase 3, from the initial IR to December 2023. Descriptive statistics were performed to clarify the blood transfusions in each phase.

RESULTS

Four out of 519 patients diagnosed with PH were identified as having BEV-SB. The management duration of each phase was 20 person-months, 42 person-months, and 77 person-months, respectively. The four patients received a total of eight and five person-times of EIS and IR treatment, respectively. All patients exhibited recurrent gastrointestinal bleeding following the first EIS, while no further instances of gastrointestinal bleeding were observed after IR treatment. The transfusions administered during each phase were 34, 31, and 3.5 units of red blood cells, and 13 units, 14 units, and 1 unit of plasma, respectively.

CONCLUSION

EIS may be effective in achieving hemostasis for BEV-SB, but rebleeding is common, and IR aiming to reduce portal pressure gradient may lower the rebleeding rate.

Keywords: Suspected small bowel bleeding; Transjugular intrahepatic portosystemic shunt; Enteroscopic injection sclerotherapy; Bleeding ectopic varices; Portal hypertension

Core Tip: Bleeding ectopic varices located in the small bowel (BEV-SB) caused by portal hypertension is a rare, life-threatening clinical scenario. This retrospective study presented the treatment experience using enteroscopic injection sclerotherapy (EIS) and subsequent interventional radiology (IR) for BEV-SB. From January 2019 to December 2023, 4 of 519 patients with portal hypertension were identified as having BEV-SB. The management duration of phases from the first episode of BEV-SB to the first EIS, from the first EIS to the first IR, and from the first IR to December 2023 were 20 person-months, 42 person-months, and 77 person-months, respectively. The corresponding transfusions at each phase were 34 units, 31 units, and 3.5 units of red blood cells and 13 units, 14 units, and 1 unit of plasma, respectively. After the comprehensive management, no further gastrointestinal bleeding was observed. We conclude that EIS may be effective in achieving hemostasis in BEV-SB, although rebleeding is common, and IR aiming to reduce portal venous pressure may lower the rebleeding rate.