S4679 A Case of Small Bowel Varices in Patient With Kidney Transplant, Pancreas Transplant, Partial Left Hepatectomy, and Right Hemicolectomy

Introduction: Small bowel varices are a form of ectopic varices that are a rare but significant cause of gastrointestinal bleeding. Diagnosis often requires imaging such as video capsule endoscopy and computed tomography angiography. Given the rarity of the condition, there is a lack of systematic data to guide its management. Case Description/Methods: A 59 year-old man with a history of type 1 diabetes mellitus, chronic kidney disease status post kidney transplant and subsequent concurrent pancreas - kidney transplant on immunosuppression, nodular regenerative hyperplasia, colon adenocardinoma status post right hemicolectomy, liver angiosarcoma status post partial left hepatectomy, and recent admission for bright red bleeding per rectum status post colonoscopic clipping of anastomosis, presents with melena and altered mental status for 3 days. In the emergency department, his vitals were notable for hemorrhagic shock with hemoglobin of 5.9. Upon admission to the medical intensive care unit, the patient underwent an upper endoscopy which revealed grade II esophageal varices status post 2 clips. Colonoscopy revealed a few ulcers at the anastomosis site status post 3 new clips. Video enteroscopy was complicated by loss of progression. Given transplant acute kidney injury, computed tomography angiography was deferred, and push enteroscopy was pursued which revealed bleeding varices in the jejunum. The patient ultimately underwent clip placement, varix embolization, and transjugular intrahepatic portosystemic shunt (TIPS). Discussion: Small bowel varices should be suspected as a gastrointestinal bleeding site in patients with a history of portal hypertension and abdominal surgery that alters venous drainage - such as history of pancreas transplant. Patients with a history of prior venous drainage altering surgery and noncirrhotic portal hypertension, such as nodular regenerative hyperplasia, are especially at higher risk of small bowel varices development when compared to those with cirrhotic portal hypertension and prior venous drainage altering surgery. Though there is a lack of evidence on the management of this condition, in this patient, stabilizing the bleeding was critical to minimize acute bleeding. TIPS was important to reduce portal hypertension necessary to prevent further bleeding.