University of Alabama at Birmingham Birmingham, AL
Award: Presidential Poster Award
Mark Cromer, MD1, Christopher Truong, BS2, Husameddin El Khudari, MBChB3, Mohamed Shoreibah, MD1, Shajan Peter, MD4 1University of Alabama at Birmingham, Birmingham, AL; 2University of Alabama at Birmingham, Heersink School of Medicine, Birmingham, AL; 3UAB, Birmingham, AL; 4Basil I. Hirschowitz Endoscopic Center of Excellence, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL
Introduction: Gastric bypass surgery (GBS) is an effective treatment for weight loss and fatty liver disease in patients with severe obesity. Roun-en-Y is the most commonly performed GBS in the United States. Complications of the excluded stomach pouch are uncommon and pose a diagnostic and therapeutic challenge for access and intervention. Gastric variceal bleeding in cirrhosis is associated with up to 45% mortality, thus successful intervention is critical.
Case Description/Methods: A 75-year-old female with compensated NASH cirrhosis, Roux-en-Y gastric bypass, and recent hospitalization for a GI bleed with an unremarkable EGD presented with 3 weeks of melena. Repeat EGD showed no evidence of bleeding or gastroesophageal varices; findings were notable for gastrojejunal anastomosis ulceration, intact bypass staple line, normal jejunojejunal anastomosis. Colonoscopy found old blood in the terminal ileum and cecum. Follow up video capsule endoscopy noted melena in the jejunum, though a lesion could not be identified due to poor prep. Ongoing melena prompted a double balloon enterosocopy (DBE) which revealed normal gastrojejunal and jejunojejunal anastomosis sites and pouch-to-jejunum limb mucosa; however, there was fresh blood with large clots in the gastric fundus of the excluded stomach. Follow up abdominal CT showed large gastric wall varices and incidentally noted a right segmental pulmonary embolism. She ultimately underwent successful plug-assisted retrograde transvenous obliteration (PARTO) of the gastrorenal shunt and gastric varices. Follow up transjugular hepatic vein pressure gradient (HVPG) measurement was 4mmHg, thus transjugular intrahepatic portosystemic shunt placement was deferred.
Discussion: DBE is an effective tool for accessing the excluded stomach after GBS ( >85% efficacy), previously inaccessible due to endoscopic limitations and altered anatomy. The most common endoscopically observed complications of the excluded stomach are variations of gastritis (erythematous, erosive, hemorrhagic, and atrophic). In cirrhotic patients, gastric varices (GVs) are less common than esophageal varices (20% vs 50%) but bleed more severely, are associated with higher risk of mortality, and pose greater therapeutic challenges based on anatomic location (especially following GBS), size, and presence of gastrorenal shunts. PARTO is an effective intervention for management of GV bleeding with success rates near 100%. This case highlights the unique challenges of diagnosing and treating GVs following GBS.
Figure: Figure 1: Images of the case A: Enteroscopy image showing fresh blood and a large clot in the gastric fundus of the excluded stomach. B: Contrast enhanced axial CT image (venous phase) showing large gastric varices (white arrow); note surgical clips from prior Roux-en-Y gastric bypass. C: Anteroposterior fluoroscopic image immediately following plug assisted retrograde transvenous obliteration (PARTO) procedure showing Amplatzer vascular plug (black arrow) at the gastrorenal shunt, and sclerosant mixture (3% sodium tetradecyl sulfate, lipiodol and air) filling the gastric varices (black star). D: Axial CT image 5 days following PARTO procedure showing sclerosant mixture filling the gastric varices (black star).
Mark Cromer indicated no relevant financial relationships.
Christopher Truong indicated no relevant financial relationships.
Husameddin El Khudari indicated no relevant financial relationships.
Mohamed Shoreibah indicated no relevant financial relationships.
Shajan Peter indicated no relevant financial relationships.
Mark Cromer, MD1, Christopher Truong, BS2, Husameddin El Khudari, MBChB3, Mohamed Shoreibah, MD1, Shajan Peter, MD4. P0667 - Gastrointestinal Bleeding From Gastric Varices in the Excluded Stomach of a Roux-en-Y Gastric Bypass in a Cirrhotic Patient, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.