Bleeding from intestinal varices after a Warren shunt

A 62-year-old man with alcoholic cirrhosis presented with massive gastrointestinal bleeding 4 years after a Warren operation. Angiographic examination suggested that the bleeding was due to ruptured jejunal varices. Treatment by propranolol and a side-to-side portacaval shunt failed to prevent further bleeding. An emergency laparotomy for life-threatening gastrointestinal (GI) rebleeding disclosed dense hypervascular adhesions between the second jejunal loop and the retroperitoneum, and a large submucosal varix of the jejunum that had ruptured. Development of intestinal varices after a Warren operation is facilitated by the persistence of a high pressure in the mesenteric territory and by adhesions between the initial part of the intestine and the area of dissection of the renal vein. This case illustrates one of the possible causes of rebleeding after a Warren operation.