A150 A RARE CASE OF OBSCURE GI BLEEDING SECONDARY TO ECTOPIC SMALL INTESTINAL VARICES POST ROUX-EN-Y GASTRIC BYPASS

Ectopic varices (EV) are a rare cause of gastrointestinal bleeding. Here we present a challenging case of obscure gastrointestinal bleeding (OGIB) that was found to be due to EV at her jejunojejunostomy. 39 year old female referred for a 5 year history of OGIB requiring over 300 units of PRBC. She had a Roux-en-Y gastric bypass in 2009. Starting in 2012, she presented with recurrent episodes of melena and underwent extensive investigations where the only abnormality found were esophageal varices without high risk stigmata. Work up for liver diseases including liver biopsy and pressure measurements was unremarkable. Esophageal varices were banded however her bleeding persisted, culminating with a TIPS procedure that thrombosed within 24 hours. She then underwent antegrade double balloon enteroscopy where clean base ulcers were found in the defunctioned stomach. This was managed medically although she continued to bleed, eventually undergoing a laparotomy, transgastric endoscopy, and a partial gastrectomy. Given her recurrent OGIB, we repeated antegrade double balloon enteroscopy. At the biliopancreatic limb 10 cm proximal to the jejunojejunostomy, multiple EV with high risk stigmata were seen and marked with hemostatic clips for interventional radiology. Prior imaging was reviewed and chronic superior mesenteric vein (SMV) thrombosis was identified and deemed to be present since 2012. She underwent embolization of the ectopic small bowel varices around the jejunojejunostomy by intervention radiology and her hemoglobin stabilized and she did not require blood transfusions for the first time in 5 years. Unfortunately, her melena resumed after a 2 month hiatus and a multidisciplinary meeting was held. Overall, it was felt revascularization would have a low probability of success due to a high risk of recurrent thrombosis. Resection of the jejunojejunostomy and Roux-en-Y reconstruction was pursued. Post operatively, her melena resolved. One year after surgery, her melena has recurred. EV are rare and usually develop in patients with portal hypertension. Interestingly, our patient had SMV thrombosis rather than portal hypertension, which was likely the cause for early TIPS thrombosis. In regards to management, bleeding EV should be approached in a similar manner to gastroesophageal varices although the therapy may be more challenging due to location. For SMV thrombosis, revascularization carries a high risk of recurrent thrombosis due to a low flow state. As such, we chose to surgically resect the involved portion of small intestine with the understanding from the patient that the varices will likely recur given the persistence of the SMV thrombus, ultimately leading to multiple small bowel resections, short gut syndrome, and combined liver and small bowel transplant. Biliopancreatic limb varices None

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