Life-Threatening Acute Jejunal Variceal Bleeding in a Crohn’s Disease Patient
AIBD 2023
Background:
Lower gastrointestinal (GI) bleeding is a rare complication in Crohn’s disease and occurs in 1.4% of patients. The treatment is challenging in clinical practice due to difficulties in localizing the hemorrhage site and the risk of extensive small bowel resections. Recent advances in interventional radiology have reduced the rate of complications in managing GI hemorrhage.
Methods:
This is a case report of a 51-year-old man with long-standing small bowel Crohn’s disease who presented to a quaternary hospital with melena for two weeks. He reported extreme fatigue, weakness, and shortness of breath. He denied abdominal pain, vomiting, or previous episodes of bleeding. On physical examination, he was pale and hemodynamic unstable with low blood pressure and tachycardia. Abdominal palpation was otherwise normal. A digital rectal exam revealed dark red blood without masses or hemorrhoids. Medical history was consistent with extensive stenosing small bowel Crohn’s disease, diagnosed 22 years before. At that time, he complained of abdominal pain without diarrhea. Previous medications included azathioprine, optimized adalimumab, ustekinumab, vedolizumab, and several courses of steroids during flares. He had been refractory to medical therapy for the past four years. On admission, his hemoglobin was 4.0 g/dL and CRP of 8.1 mg/L (normal range < 5.0 mg/L). An abdominal CT scan showed acute massive jejunal-ileum variceal bleeding to the lumen of the small bowel. Previous outpatient MR enterography was consistent with chronic mesenteric venous thrombosis with giant collateral veins secondary to active small bowel inflammation. He was transferred to the intensive care unit and treated with supportive blood transfusions.
Results:
After hemodynamic stabilization, the patient underwent super-selective transcatheter arteriovenous embolization of the bleeding vessels with Onyx 18, and an adequate reduction in the collateral blood flow was obtained. The lower GI bleeding resolved within 2 days, and the patient was discharged.
Conclusions:
Overt gastrointestinal bleeding resulting from jejunal varices is extremely rare in CD and has been described in a handful of cases. Herein, we report a life-threatening case managed successfully with noninvasive techniques. Reducing the inflammatory burden is crucial in this setting to avoid further thromboembolic complications.
