Cyanoacrylate to the Rescue: Successful Treatment of Duodenal Variceal Bleeding by Glue Injection

Abstract

Duodenal varix bleeding is an uncommon cause of gastrointestinal bleeding in patients with portal hypertension but can cause severe and potentially fatal bleeding. However, the incidence is low and a good treatment method has not been well established yet. We have successfully treated a patient with duodenal variceal bleeding secondary to liver alcoholic cirrhosis after the patient was found to be a poor candidate for transjugular intrahepatic portosystemic shunt (TIPS). A 55-year-old male with a recently diagnosed alcoholic cirrhosis presented with hematemesis of 24 hours in duration, and acute post-hemorrhagic anemia. After resuscitation, the patient was taken for emergent upper endoscopy. Four columns of Grade 1-esophageal varices, which easily collapsed with insulfation and had no stigmata of recent bleed. A single 3cm duodenal varix with a single umbilication was seen in the second portion of the duodenum. The ampulla was situated distant from the varix. The varix was examined with a duodenoscope as well as EUS probe. Examination suggested that lesion was consistent with a vein. Thereafter, 4 cc of lipiodol and indermal was injected in 1 cc aliquots followed by 3 cc of sterile water. The varix was noted to be hard after the glue injections. Transient bleeding was seen from the varix, which was self-limited. Polyermized glue was seen to extruding from the umbilicated region of the varix. Retroflexion showed no further gastric varices (fundic or cardia). Follow up radiology demonstrated no migration of the cyanoacrylate injection. Duodenal variceal bleeding is not a common cause of gastrointestinal bleeding. It is important to always consider duodenal variceal bleeding in patients with portal hypertension. Although an effective treatment method has not been established yet, successful management of duodenal variceal bleeding can be expected by using glue injection.