1933 A Case of a Hidden Varix: Massive Duodenal Variceal Hemorrhage Requiring Emergent TIPS

Abstract

INTRODUCTION: Variceal hemorrhage is a potentially life-threatening cause of bleeding in cirrhotic patients. While typically associated with esophageal or gastric varices, clinically significant variceal hemorrhage may occasionally originate from the small bowel, colon, rectum or biliary tract. Duodenal variceal hemorrhage is an uncommon cause of GI tract bleeding and is associated with a mortality rate up to 40%. We present a case of severe duodenal variceal hemorrhage necessitating emergent transjugular intrahepatic portosystemic shunt (TIPS) and variceal coil embolization. CASE DESCRIPTION/METHODS: A 58-year-old female with a history of cryptogenic cirrhosis decompensated by ascites presented to the ER with melena and dull, generalized abdominal pain over 2 days. Vital signs were notable for tachycardia to 114 bpm and she was normotensive. Her abdomen was non-tender to palpation and rectal exam was notable for melenic stools. Her hemoglobin was 9.5 g/dL on presentation. She continued to have melena over the course of the day with associated tachycardia and a decrease in hemoglobin to 5.6 g/dL. She was transferred to the intensive care unit where she underwent an upper endoscopy revealing small esophageal varices with no stigmata of bleeding and a normal duodenum. However, she continued to have melena unresponsive to blood product resuscitation leading to profound hypotension. A stat CT Angiogram showed intraluminal hyperdensities within the second portion of the duodenum due to hemorrhage from adjacent varices. Interventional Radiology was consulted and performed a right hepatic vein to right portal vein TIPS. They also performed fluoroscopic guided coil embolization of large duodenal varices arising from the main portal vein. The patient’s hemoglobin stabilized and she had no further bleeding during the course of her hospitalization. DISCUSSION: Duodenal variceal hemorrhage is a rare and life-threatening manifestation of portal hypertension. Due to the rarity of the condition, there are no established guidelines regarding treatment. Endoscopic therapy aimed at achieving hemostasis, such as sclerotherapy and clipping have shown limited success in case reports. TIPS, as seen in this case, is a viable treatment option. Our case illustrates the importance of considering ectopic varices in cirrhotic bleeders. Moreover, it highlights the importance of utilizing angiographic evaluation for patients in whom the source of bleeding is not identified on endoscopy.