ENDOSCOPIC INJECTION SCLEROTHERAPY FOR ESOPHAGEAL VARICES INDUCED THE DEVELOPMENT OF OBSTRUCTIVE JAUNDICE BY COMPRESSION OF BILE DUCTS DUE TO BILE DUCT VARICES THAT REQUIRED CONTINUOUS BILIARY DRAINAGE: REPORT ON TWO CASES

Abstract

Endoscopic injection sclerotherapy (EIS) and variceal ligation (EVL) for esophageal varices are the standard treatments for prevention of esophageal varices bleeding. On the other hand, these treatments for varices may induce the development of ectopic varices. Ectopic varices are rare, but have a higher risk of bleeding. Among the ectopic varices, bile duct varix is extremely rare. However, patients with bile duct varix are at risk for jaundice as well as bleeding. Extra-hepatic portal obstruction is often complicated with bile duct varices as collateral circulations, and EIS may increase the intravessel pressure of the bile duct varices and compress the bile duct. We report two patients who developed obstructive jaundice after EIS. Case 1: A 21-year-old male developed idiopathic extra-hepatic portal thrombosis. Three years later, EIS was performed for esophageal varices with red color signs. After EIS, he developed obstructive jaundice. Cholangiography showed multiple compressions due to biliary varices at the distal and intra-hepatic bile ducts. The patient requires continuous endoscopic biliary stenting. Case 2: The female patient has a congenital extra-hepatic portal obstruction. EIS and EVL were performed for esophageal varices with red color signs at 18 years of age, and she developed obstructive jaundice 12 years after EIS. Cholangiography showed multiple compressions due to biliary varices at the distal and intra-hepatic bile ducts. Endoscopic biliary stenting was performed. Five months after biliary stenting, she developed re-exacerbation of esophageal varices and EIS was performed again. After the second EIS procedure, stenosis of the distal bile duct worsened and she required continuous endoscopic biliary drainage. In conclusion, in cases with esophageal varices associated with extra-hepatic portal obstruction, the treatment for esophageal varices should be decided very carefully while paying attention to the biliary varices.