S4626 Left Sided Portal Hypertension Presenting with Jejunal Varices and Massive GI Bleed

Introduction: Liver cirrhosis is the most common cause of portal hypertension (PH) in the western world. The development of collateral circulation, leading to varices (esophageal and gastric) and splenomegaly is the main hallmark of PH. However, compared to these relatively common complications, left-sided portal hypertension (LSPH) is a more complex and rarer manifestation of PH. Case Description/Methods: A 51-year-old man with past medical history of alcoholic liver cirrhosis (MELD score 16), chronic alcohol abuse, and polysubstance abuse who was transferred for higher care after being admitted for a week due to acute upper gastrointestinal (GI) bleed, melena, and acute metabolic encephalopathy secondary to decompensated liver cirrhosis. Upon transfer, the patient was hemodynamically stable with hemoglobin of 7.4 g/dL despite receiving 11 units of packed red blood cells, 5 units of platelets, and 1 unit of FFP's during his hospital course prior to the transfer. Patient continued with GI bleeding leading to altered mental status (AMS) leading to intubation to protect the airway. Three units of packed red blood cells, 2 units of platelets were additionally used to maintain homeostasis. Computed tomography and splenic vein venogram demonstrated a large collateral filling varices in the jejunal region anteriorly that appeared to drain into abdominal wall collaterals via the superior mesenteric vein. The patient underwent an interventional radiology guided transjugular intrahepatic portosystemic shunt (TIPS) procedure. No significant change was detected in the amount of collateral flow post procedure, which is consistent with left-sided portal hypertension. Additional collateral flow into the pelvis was seen with filling of the right external iliac, right common iliac and inferior vena cava. Coil embolization of the venous-venous malformation arising from the SMV was performed 10 days post TIPS procedure with a total of 15 coils were used. A second coil embolization procedure of multiple jejunal-jejunal venous malformation was performed 10 months later due to additional GI bleeding episodes. Discussion: We are presenting a case of LSPH with the formation of collateral veins in atypical locations (jejunal region). Jejunal varices are rare and an under-reported finding in LSPH due to the challenges in visualizing these varices using conventional endoscopy. Therefore, advanced imaging techniques, such as computed tomography angiography, or interventional radiology guided diagnostic and therapeutic techniques could prove beneficial in establishing the diagnosis and providing therapeutic value.