Abstract
Introduction: Small bowel varices are a rare manifestation of portal hypertension, accounting for only 1–5% of variceal gastrointestinal bleeding. Their diagnosis and management remain challenging because of their uncommon occurrence, difficult anatomical accessibility, and lack of standardized treatment strategies. We report a case of refractory small bowel variceal bleeding successfully treated with splenic artery embolization after failure of conventional therapeutic options. Case presentation: A 45-year-old man with liver cirrhosis, cholangiocarcinoma with bone metastases, ulcerative colitis, and previous partial hepatectomy presented with haemorrhagic shock secondary to severe lower gastrointestinal bleeding. Endoscopic evaluation suggested a small bowel source, while computed tomography angiography demonstrated portal vein stenosis, superior mesenteric vein thrombosis, portal hypertension, and actively bleeding small bowel varices. Portal vein stenting failed to control the haemorrhage, and transjugular intrahepatic portosystemic shunt (TIPS) placement was unsuccessful because of extensive hepatic vein thrombosis related to tumour burden. Salvage splenic artery embolization was subsequently performed using two vascular plugs, resulting in immediate haemostasis without recurrent bleeding. Follow-up imaging confirmed the absence of active bleeding. The only post-procedural complication was partial splenic infarction, which was managed conservatively. Discussion: Splenic artery embolization reduces portal venous inflow by decreasing splenic blood flow, thereby lowering portal pressure and decompressing ectopic varices. Although primarily described for esophagogastric varices and other complications of portal hypertension, its use in small bowel variceal bleeding remains rarely reported. This case highlights splenic artery embolization as an effective rescue therapy when TIPS is technically impossible or unsuccessful. Conclusion: Splenic artery embolization may represent a safe, minimally invasive, and life-saving therapeutic option for refractory small bowel variceal bleeding in carefully selected patients who are not candidates for conventional interventions. Multidisciplinary collaboration is essential to optimize outcomes, and further studies are needed to better define the role of this technique in the management of ectopic variceal bleeding.