Successful Treatment of Small Intestinal Bleeding in a Crohn's Patient with Noncirrhotic Portal Hypertension by Transjugular Portosystemic Shunt Placement and Infliximab Treatment

Benjamin Heimgartner; Heather Dawson; Andrea De Gottardi; Reiner Wiest; Jan Hendrik Niess

doi:10.1159/000450541

Successful Treatment of Small Intestinal Bleeding in a Crohn's Patient with Noncirrhotic Portal Hypertension by Transjugular Portosystemic Shunt Placement and Infliximab Treatment

Case Rep Gastroenterol. 2016 Oct 18;10(3):589-595. doi: 10.1159/000450541. eCollection 2016 Sep-Dec.

Authors

Benjamin Heimgartner¹, Heather Dawson², Andrea De Gottardi³, Reiner Wiest¹, Jan Hendrik Niess⁴

Affiliations

¹ Division of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University of Bern, Bern, Switzerland.
² Clinical Pathology Division, Institute of Pathology, University of Bern, Bern, Switzerland.
³ Division of Hepatology, University Clinic for Visceral Surgery and Medicine, University of Bern, Bern, Switzerland.
⁴ Division of Gastroenterology, University Clinic for Visceral Surgery and Medicine, University of Bern, Bern, Switzerland; Departments of Gastroenterology and Hepatology, University Hospital Basel, Basel, Switzerland.

Abstract

Small intestinal bleeding in Crohn's disease patients with noncirrhotic portal hypertension and partial portal and superior mesenteric vein thrombosis is a life-threatening event. Here, a case is reported in which treatment with azathioprine may have resulted in nodular regenerative hyperplasia, portal hypertension and portal vein thrombosis. The 56-year-old patient with Crohn's disease developed nodular regenerative hyperplasia under treatment with azathioprine. He was admitted with severe bleeding. Gastroscopy showed small esophageal varices without bleeding stigmata. Blood was detected in the terminal ileum. CT scan revealed a partial portal vein thrombosis with extension to the superior mesenteric vein, thickening of the jejunal wall and splenomegaly. Because intestinal bleeding could not be controlled by conservative treatment, the thrombus was aspirated and a transjugular intrahepatic portosystemic shunt (TIPS) was placed. Switching the immunosuppressive medication to infliximab controlled Crohn's disease activity. Bleeding was stopped, hemoglobin normalized, and thrombocytopenia and bowel movements improved. In summary, small intestinal bleeding in a Crohn's patient with nodular regenerative hyperplasia, portal hypertension and portal vein thrombosis can be efficiently treated by TIPS. TIPS placement together with infliximab treatment led to the improvement of the blood panel and remission in this patient.

Keywords: Crohn's disease; Infliximab; Nodular regenerative hyperplasia; Portal hypertension; Small intestinal bleeding; Transjugular intrahepatic portosystemic shunt.