A Case of Duodenal Varices

Abstract

A 73 year old woman with a history of untreated hepatitis B and C infection presented to the hospital with a complaint of acute onset jaundice and abdominal distension. Laboratory studies were notable for an anemia, transaminitis and a direct hyperbilirubinemia. An abdominal ultrasound revealed a cirrhotic liver with a hepatic mass, consistent with a hepatocellular carcinoma on CT. Upon presentation she was noted to pass melena and her hemoglobin fell from 8.5 g/dL to 6.2 g/dL. She was started on octreotide and antibiotics. An EGD revealed a non-bleeding esophageal ulcer, gastric varices at the cardia (without stigmata of bleeding), portal hypertensive gastropathy and a large duodenal varix with red spots; no intervention was performed. She then experienced coffee ground emesis and hypotension. Interventional radiology was consulted for treatment of duodenal varices, but the patient become mentally altered and the procedure was aborted. With lactulose her mental status returned to baseline. With regained capacity, she opted for no further therapies and decided to pursue home hospice, to which she was discharged. Duodenal varices are ectopic varices caused by dilated splanchnic veins or portosystemic collaterals and are outside the common pathologic sites (i.e. gastroesophageal and rectal sites). They are an effect of global portal hypertension or splanchnic venous occlusion. Despite responsibility for only 2-5% of gastrointestinal variceal bleeding, they have a four-fold increased risk of bleeding as compared to esophageal varices. Duodenal varices account for 17% of ectopic varices. Diagnosis can be difficult as endoscopy may overlook them if they are serosal or submucosal in location. They can sometimes be localized on CT angiography or with multiplanar reconstruction, as noted in some case reports. Given the limited data on duodenal varices there remains no definitive best treatment for these lesions. There are case reports of success with endoscopic therapies (injection sclerotherapy, variceal ligation) as well as shunt procedures. Some studies suggest that sclerotherapy may be an effective and safe alternative to a TIPS procedure. In our case, the patient likely experienced a significant gastrointestinal bleed from her duodenal varix. With further investigation, therapy for duodenal varices may become standardized. Clinicians must remain alert to this potential source of gastrointestinal bleeding, so appropriate and timely therapy can be implemented.Figure 1