Duodenal Varices: A Rare Cause of Massive Gastrointestinal Hemorrhage

Abstract

Purpose: Variceal bleeding is one of the leading causes of mortality in patients with portal hypertension. Although the development and bleeding from gastroesophageal varices occurs commonly in this patient population, bleeding from ectopic varices at other gastrointestinal sites is unusual. Here we present two cases of fatal gastrointestinal hemorrhage from ruptured duodenal varices, both in the setting of cirrhosis and portal hypertension. Both patients, a 27-year-old Caucasian and a 54-year-old African American male, had a history of chronic liver disease secondary to chronic hepatitis C infection and chronic alcohol abuse with previous episodes of gastrointestinal bleeding from esophageal varices. They presented to the hospital with hematemesis, hematochezia and hypovolemic shock. Continuous octreotide and pantoprazole intravenous infusions were started. After aggressive fluid resuscitation, transfusion of blood products and endotracheal intubation; an emergent esophagogastroduodenoscopy was performed revealing actively bleeding varices in the second portion of the duodenum that was controlled with band ligation. Their hospital course, however, was complicated with recurrent gastrointestinal bleeding. MELD scores were higher than 20. Though consideration was given to alternative therapeutic options such as balloon occluded retrograde transvenous obliteration (BRTO) and transjugular intrahepatic portosystemic shunt (TIPS), both patients were changed to category three (comfort care) by patient/family request and expired within a few days of their presentation. These cases illustrate the potential for massive and recurrent gastrointestinal hemorrhage from duodenal varices. These lesions are rare and a high index of suspicion is required to detect them. Ectopic varices comprise large portosystemic venous collaterals located anywhere other than the gastroesophageal region. Ectopic varices including duodenal varices account for between 1% and 5% of all variceal bleeding. The management of such ectopic varices is difficult, and although a few therapeutic options exist, there is no consensus as to the best treatment option.