Background

Segmental (sinistral) portal hypertension is a rare and often under-recognized cause of upper gastrointestinal bleeding, usually secondary to splenic or portal branch obstruction. We describe a unique case of ectopic peri-anastomotic gastric variceal bleeding after subtotal gastrectomy and Roux-en-Y reconstruction, successfully managed with endoscopic band ligation.

Case Presentation

A 76-year-old man, with no relevant medical history, underwent subtotal gastrectomy for gastric adenocarcinoma in July 2024. The patient remained asymptomatic until October 2024, when he developed postprandial fullness, nausea and weight loss. In April 2025, he underwent conversion from Billroth II procedure to a Roux-en-Y due to symptomatic gastric stump gastritis. Pre-surgical CT scan was unremarkableIn September 2025, a routine postoperative surveillance endoscopy was performed. The examination revealed large esophageal and gastric varices (GOV2), as well as peri-anastomotic ectopic gastric varices (IGV2). During the procedure, one of the IGV2 developed sudden spurting bleeding. Hemostasis was achieved with a single band ligation, as cyanoacrylate was unavailable. The patient completed a 5-day continuous infusion of octreotide and received prophylactic ceftriaxone. No rebleeding occurred nor transfusion was required. CT angiography demonstrated a patent portal vein with a markedly thinned left portal branch and atrophy of hepatic segments II–III, consistent with localized (sinistral) portal hypertension. The spleen and the splenic vein were unremarkable.. He was discharged on carvedilol 3.125 mg twice daily, adjusted due to bradycardia. 

At one-month follow-up, the patient remained asymptomatic and free of recurrent bleeding. Transient elastography (FibroScan®) confirmed the absence of chronic liver disease (F0).

Discussion

Ectopic gastric varices secondary to segmental portal hypertension are extremely uncommon, particularly after gastric surgery. In this case, focal obstruction of the left portal branch likely resulted in localized venous hypertension and collateral veins formation at the gastrojejunal anastomosis. The absence of cirrhosis and normal spleen size supported a diagnosis of left-sided (segmental) portal hypertension probably due to the surgical procedure. Endoscopic band ligation, though less commonly used for ectopic varices, proved to be an effective alternative when cyanoacrylate was unavailable.

Conclusion

This case highlights a rare cause of variceal bleeding following Roux-en-Y reconstruction, secondary to segmental portal hypertension. Endoscopic band ligation provided effective hemostasis and may represent a valuable therapeutic option in similar challenging scenarios.