Duodenal varices result from retroperitoneal portosystemic shunts that usually come from the pancreaticoduodenal vein and drain into the inferior vena cava. Because they are a rare but fatal cause of gastrointestinal bleeding, a prompt hemostatic intervention is mandatory. A 62-year-old man who had a history of excessive alcohol consumption presented with massive hematemesis and melena. Emergent endoscopy revealed ruptured varices with an adhering whitish fibrin clot on the postbulbar portion of the duodenum. Abdominal computed tomography demonstrated a cirrhotic liver with venous collaterals around the duodenum and extravasated contrast in the second and third portions. The collaterals originated from the main portal vein and drained via the right renal vein into the inferior vena cava. Endoscopic injection sclerotherapy with cyanoacrylate was successful in achieving hemostasis, and resulted in the near eradication of duodenal varices at a 6-month follow-up.
Duodenal varices represent an ectopic portosystemic shunt, usually originating from pancreaticoduodenal vein.
A 62-year old man who had a history of excessive alcohol consumption presented with massive hematemesis and melena. He had no medical history of other systemic disease. On arrival at emergency room, his systolic blood pressure was about 45 mmHg. Melena was seen on digital rectal examination and fresh blood was drained through L-tube during gastric irrigation. Complete blood counts showed hemoglobin of 3.6 g/dL and platelet count of 68,000/mm3. Other laboratory tests were followings; total bilirubin 0.9 mg/dL, albumin 1.5 g/dL, prothrombin time 18.8 seconds. Child-Pugh's classification was B. Hepatitis B surface antigen, anti-hepatitis C virus antibody and anti-human immunodeficiency virus antibody were all seronegative.
An emergent upper endoscopy was immediately performed following fluid resuscitation with blood transfusion. It revealed minimal esophageal varices without a stigmata of hemorrhage (
For hemostasis, we intravariceally injected 1.0 mL of cyanoacrylate into the duodenal varices. After EIS, the bulging varices were not collapsed during luminal aeration. The patient was getting hemodynamically stable and hemoglobin level was recovered up to 8.9 g/dL with transfusion of the packed red blood cells.
An endoscopy after 5 days showed a tubular-shaped venous bulging, by previous injection of cyanoacrylate, with a hard consistency and hyperemic covering mucosa. Endoscopic biopsy was done at the ulcer scar on the bulb, showing a chronic inflammation with granulation tissue microscopically. After 2 weeks, an endoscopy revealed post-EIS ulceration with yellow plaque and venous bulging.
Six months later, a follow-up endoscopy revealed much collapsed duodenal varices with small yellow plaque on the surface (
Portosystemic communications in splanchnic hypertension occur through the several venous routes, and the duodenal varices are one of ectopic varices resulting from retroperitoneal portosystemic shunts. These are caused by increased hepatofugal blood flow through cystic branches of superior mesenteric vein, superior and inferior pancreaticoduodenal veins, gastroduodenal veins, and pyloric veins.
The most common cause of duodenal varices is portal hypertension in cirrhotic liver and the others are obstruction of splenic vein, portal vein, superior mesenteric vein or inferior vena cava.
In review by Amin et al, most of the duodenal varices are located in the duodenal bulb and they may also occur in the second and third portions of the duodenum.
Various treatment modalities have been reported to be available for bleeding from duodenal varices, including endoscopic variceal ligation (EVL), EIS, transjugular intrahepatic portosystemic shunt (TIPS), balloon-occluded retrograde transvenous obliteration (BRTO), beta-blocker therapy, and resection of a segment of bleeding site.
Accordingly, some investigators prefer cyanoacrylate which causes less tissue injury. Lee et al reported that a combination therapy of the EVL and EIS was applied to all of 4 cases resulting in the successful hemostasis and eradication of duodenal varices.
We report a case of endoscopic treatment in a patient with a massive bleeding from duodenal varices directly arising from the main portal vein. We recommend EIS with cyanoacrylate as a first line of treatment for bleeding duodenal varices.
The present research was conducted by the research fund of Dankook University in 2009.
balloon-occluded retrograde transvenous obliteration
computed tomography
endoscopic injection sclerotherapy
endoscopic variceal ligation
transjugular intrahepatic portosystemic shunt
Initial endoscopy results. (A) Minimal esophageal varices without stigmata of recent hemorrhage. (B) Blood-stained cardiac and fundal gastric mucosae without evidence of varices. (C) Dumbbell-shaped varices with an adhering whitish fibrin clot (arrow) on the postbulbar portion of the duodenum.
Initial abdominal CT results. (A) Venous collaterals (arrow) around the duodenum. (B) Extravasated contrast (arrow) in the second and third portions of the duodenum. (C) The afferent collateral vessel (arrow) originated directly from the main portal vein. (D) The efferent collateral vessel (arrow) drained throughout the inferior vena cava via the right renal vein.
Results of follow-up endoscopy and CT performed 6 months after EIS. (A) Endoscopy revealed more collapsed varices with small yellow plaques on the postbulbar portion of the duodenum. (B) Abdominal CT disclosed collapsed and greatly decreased portosystemic venous collaterals in the retroperitoneum of the paraduodenal space.