A241 MASSIVE OBSCURE GI BLEEDING FROM IDIOPATHIC JEJUNAL VARICES IDENTIFIED USING SINGLE BALLOON ENTEROSCOPY

Obscure GI bleeding from idiopathic small bowel varices is both a diagnostic and management challenge for physicians. There are very few cases reported in the literature and there is no consensus on management recommendations. To present the case of a 34-year-old male with bleeding from idiopathic jejunal varices and to review the literature. A case of idiopathic jejunal varices is reported. A literature review was conducted which identified 24 articles describing idiopathic small bowel varices. A 34-year-old male was referred for obscure GI bleeding and anemia requiring >20 pRBC transfusions over one month. The patient reported intermittent melena and anemia over the last year. He had no risk factors for portal hypertension. Upper and lower endoscopies were non-diagnostic. Anterograde single balloon enteroscopy revealed petechial like lesions that were not classic for angiodysplasia. They were treated with argon plasma coagulation and clipped. Distal to these lesions, in the mid to distal jejunum, small bowel varices were suspected but not treated pending further evaluation. No venous abnormalities were identified on CTA. The patient returned to emergency three weeks later with anemia (Hgb 69g/L). He received 2 u pRBC. The single balloon enteroscopy was repeated. There was no evidence of bleeding and the varices were tattooed (fig. 1). The patient underwent an endoscopically assisted exploratory laparoscopy that was converted to a laparotomy upon finding a grossly abnormal distal jejunum. Dilated and tortuous varicosities were identified involving approximately 150cm of small bowel. It was decided to resect the 40cm segment in which varices were visible endoscopically (fig 1). There was no evidence of thrombosis in the resected specimen. Post operatively the patient convalesced well except for a pulmonary embolism that was treated with warfarin. This event was believed to be provoked by the surgery. The patient has had no re-bleeding 12 months post-resection. Literature Review: Both familial and non-familial accounts of small bowel varices in the absence of a primary cause have been reported in the literature. When supportive therapy is insufficient, the most common treatment modality chosen is surgical resection. Select cases have also demonstrated that sclerotherapy and varix dissection can be used for to treat these lesions. Idiopathic small bowel varices pose both diagnostic and therapeutic challenges for physicians. In the literature, several treatment modalities have been shown to be successful; these include surgical resection, varix dissection and sclerotherapy. There is no consensus on the preferred treatment strategy. This report demonstrates that endoscopically assisted surgical resection is a viable management strategy for bleeding of idiopathic small bowel varices, an uncommon cause of occult GI bleeding. Fig. 1 – Top: varices viewed endoscopically. Bottom: varices visible on the exterior of the bowel wall None

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