LAUSR

DIS 5.4.0 DTD YGAST60918 proof 29 June 2017 5:14 pm 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 Question: A 55-year-old Caucasian woman was admitted to the hospital with recurrent melena and hematochezia. Her past medical history was significant for a well-differentiated neuroendocrine tumor of the head of the pancreas for which she had undergone Whipple’s procedure 10 years ago. Her postoperative course was complicated by portal vein thrombosis. She also had a history of compensated 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 liver cirrhosis secondary to nonalcoholic fatty liver disease. She was extensively evaluated in the past 2 years for recurrent gastrointestinal (GI) bleeding with upper and lower endoscopy, double balloon enteroscopy, video capsule endoscopy, and angiography. However, the underlying diagnosis was uncertain despite this extensive workup. She had received a total of 12 units of packed red blood cell transfusion over 2 years. There was no evidence of esophageal or gastric varices. She denied nonsteroidal anti-inflammatory drugs or anticoagulants and antiplatelet use. Physical examination revealed splenomegaly without jaundice. Rectal examination showed bright red blood in the rectal vault. Laboratory data showed normocytic normochromic anemia (hemoglobin 7.4 g/dL), platelet count of 114,000/mm, and an International Normalized Ratio of 1. Magnetic resonance imaging of abdomen showed hepatic cirrhosis with portal hypertension and cavernous transformation of the portal vein. Push enteroscopy was performed and ruled out peptic ulcer disease, and esophageal and gastric varices. She had worsening hematochezia and melena with a persistent decrease in hemoglobin requiring 5 units of packed red cell transfusions. A Tc-99–labeled red cell scan failed to identify active bleeding. Colonoscopy showed fresh blood in the colon and terminal ileum. However, no area of active bleeding was visualized. Antegrade double balloon enteroscopy was performed next day to evaluate the persistent bleeding that revealed 2 lesions at the choledochojejunostomy site with stigmata of recent bleeding (Figure A, B). What is the diagnosis? How is this condition diagnosed and managed? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. 102 103 104 105 106 107 108 Conflicts of interest The authors have made the following disclosures: Udayakumar Navaneethan is a consultant for AbbVie and Janssen, and on the speaker bureau for Takeda and Janssen.