P5275 - Iatrogenic Transperitoneal Jejunal-Abdominal Wall Ectopic Varix at Prior Jejunostomy-Tube Site in a Patient With Chronic Portal Vein Thrombosis and Recurrent Hemorrhage

Elvis Arteaga, MD¹, Kenneth S. Zurcher, MD², Karn Wijarnpreecha, MD, MPH³, Rawad Mounzer, MD⁴, Joshua Valbuena, MS⁵
1University of Arizona College of Medicine, Phoenix VA Medical Center, Phoenix, AZ; 2Banner University Medical Center, Phoenix, AZ; 3Banner University Medical Center Phoenix, Phoenix, AZ; 4Interventional Endoscopy Associates, Phoenix, AZ; 5University of Arizona College of Medicine, Phoenix, Scottsdale, AZ

Introduction: Ectopic varices are rare but potentially life-threatening portosystemic collaterals outside the gastroesophageal region, often arising in the lower GI tract. Causes include cirrhotic portal hypertension (PHTN) or pre-sinusoidal obstruction, such as portal vein thrombosis (PVT). While ectopic varices account for a minority of variceal bleeds, they are associated with high mortality and lack standardized treatment algorithms. Multidisciplinary approaches are often required. A transperitoneal jejunal-to-epigastric varix at a prior jejunostomy site has not been previously reported.

Case Description/

Methods: A 55-year-old man with alcohol-related cirrhosis and PHTN (MELD 15), complicated by prior jejunal variceal bleeding treated with endoscopic clipping and epinephrine injection, presented with recurrent hematochezia and hemoglobin of 5.8 g/dL. CT imaging revealed chronic PVT with cavernous transformation, splenorenal shunting, and a jejunal varix tethered to the abdominal wall. The varix received inflow from a jejunal branch of the superior mesenteric vein (SMV) and drained transperitoneally into a dilated left inferior epigastric vein (IEV). This location correlated with a prior jejunostomy tube placed during 2018 esophagectomy for esophageal carcinoma.
Endoscopy identified a large jejunal varix with prior clips, treated with 1:1 histoacryl-lipiodol injection. Due to persistent PVT and recurrent bleeding, TIPS was pursued. The thrombosed right portal vein was accessed under ultrasound guidance, followed by recanalization, 8-mm TIPS placement, and portal vein stenting to the SMV-splenic vein confluence. SMV venography confirmed a patent jejunal varix with transperitoneal outflow to the IEV. Selective coil embolization via microcatheter achieved complete stasis. The patient remained stable with no further bleeding.

Discussion: This case illustrates a unique, iatrogenic transperitoneal jejunal–IEV varix likely related to prior jejunostomy. It highlights the diagnostic and therapeutic challenges of ectopic varices in the setting of chronic PVT. Combined endoscopic, interventional radiologic, and TIPS-guided therapy successfully controlled bleeding, emphasizing the need for individualized, multidisciplinary care in complex variceal presentations.


Figure: A. Axial contrast CT demonstrating jejunal luminal varix (orange arrowhead), surgical clip with tethering to abdominal wall (blue arrow), and dilated left inferior epigastric vein outflow within the rectus muscle (red arrow)

B. Coronal CT demonstrating similar findings, including inferior epigastric vein outflow to left common external iliac vein (star)

C-D. Upper endoscopy demonstrating large dilated varix within the distal jejunum, status post clipping and sclerosant injection



Figure: A. Coronal contrast CT reformat demonstrating chronic main portal vein (MPV) thrombosis / cavernous transformation, with patent enhancing splenic vein (SV) and SMV

B. Digital subtraction venogram demonstrating chronic obliterated MPV, with patent SV and hepatofugal flow towards a massive splenorenal shunt. Endoscopic clips are seen (orange arrowhead)

C-D. SMV / jejunal venogram demonstrating large complex varix involving proximal jejunum at site of endoscopic clips (orange arrowhead), with outflow via left inferior epigastric vein (IEV), to left iliac vein (star)

E. Completion portal venogram demonstrating coil embolization of jejunal varix with patent TIPS and hepatopedal flow via SMV


Disclosures:
Elvis Arteaga indicated no relevant financial relationships.
Kenneth Zurcher: Boston Scientific – Consultant.
Karn Wijarnpreecha indicated no relevant financial relationships.
Rawad Mounzer indicated no relevant financial relationships.
Joshua Valbuena indicated no relevant financial relationships.

Elvis Arteaga, MD¹, Kenneth S. Zurcher, MD², Karn Wijarnpreecha, MD, MPH³, Rawad Mounzer, MD⁴, Joshua Valbuena, MS⁵. P5275 - Iatrogenic Transperitoneal Jejunal-Abdominal Wall Ectopic Varix at Prior Jejunostomy-Tube Site in a Patient With Chronic Portal Vein Thrombosis and Recurrent Hemorrhage, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.