Post written by Chaitanya Allamneni, MD, from the Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.

A young woman with a medical history of primary sclerosing cholangitis/autoimmune hepatitis overlap syndrome diagnosed at age 2, complicated by decompensated cirrhosis, underwent orthotopic liver transplantation (OLT). During OLT she underwent a standard Roux-en-Y hepaticojejunostomy. Twenty-four hours after OLT, she experienced hematochezia and acute anemia, raising concern for a luminal bleed as an adverse event of hepaticojejunostomy formation. She was subsequently referred for double-balloon enteroscopy, which revealed a patent jejuno-jejunal anastomosis. However, the anastomosis was actively oozing with a spurting visible vessel visualized. The anastomosis was injected with epinephrine for hemostasis, and 1 hemostatic clip was successfully placed. No further hematochezia occurred.

This case illustrates the effectiveness of endoscopy in treating an anastomotic leak and avoiding surgical intervention. Reaching such an anastomosis is technically difficult and requires single-balloon versus double-balloon enteroscopy. Deep enteroscopy, when available, assists in diagnosis and treatment at a major liver transplantation center.

Luminal GI bleeding immediately after Roux-en-Y creation should always raise suspicion for an anastomotic bleed. In this case, a spurting visible vessel was successfully managed with dual therapy of epinephrine injection and clipping.

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