Duodenal Variceal Bleeding: A Rare Complication of Portal Hypertension

Abstract

IntroductionDuodenal varices are a rare complication of portal hypertension and are labeled as ectopic varices. These are portosystemic collaterals in locations besides the gastroesophageal region and represent 2-5% of all variceal bleeding. Duodenal varices represent 17% of these bleeds. Although they are rare, duodenal varices are challenging to treat and often fatal. Case A 57 year-old female patient with a history of decompensated alcoholic cirrhosis initially presented to an outside hospital for melena. Esophagogastroduodenoscopy (EGD) done there reported an ulcer in the second part of duodenum that was treated with three hemoclips. She was then transferred to our institution for further management. She had melena on presentation resulting in hemodynamic instability. Initial hemoglobin was 8.6, which quickly declined to 6.0. Urgent EGD showed small esophageal varices, portal hypertensive gastropathy and bright red blood in the first and second parts of duodenum without an actively bleeding source readily identifiable. Shortly after the procedure she developed additional melenic bowel movements. On review of imaging, duodenal varices were identified incidentally on computed tomography of the abdomen. She subsequently underwent emergent TIPS and coil embolization of cecal and a duodenal varices. Unfortunately, over the next eight days, she continued to have recurrent bleeding episodes despite upsizing of TIPS and cyanoacrylate injection directly into the duodenal varix. The bleeding ceased after a repeat coil embolization of residual duodenal varices. The patient subsequently developed fungemia and septic shock, shortly after which she passed away. Conclusion Duodenal varices are usually seen in either the first or second part of the duodenum. They arise due to portosystemic communication via veins of Retzius. Due to its rarity, there have been no randomized trials on the management of this condition and treatment guidelines have not been established. Case reports showed various treatment modalities including sclerotherapy, varix ligation, resection and portocaval shunt. Despite this, mortality rate remains as high as 40%. Bleeding from duodenal varices should always be considered in the differential diagnosis of a patient with portal hypertension who presents with upper gastrointestinal bleeding.1995_A Figure 1 No Caption available.1995_B Figure 2 No Caption available.1995_C Figure 3 No Caption available.