Management of Duodenal Varix With Coiling

Abstract

We present a case of a 65-year-old male with past medical history of intravenous drug abuse, ETOH abuse and dependence, chronic HCV, and decompensated liver cirrhosis. He presented to our facility with complaints of bright red blood per rectum for one day, reporting approximately 6 episodes of large volume liquid red stool. Upon arrival to hospital, he had several episodes of hematochezia with hemodynamic instability. SBP was 80 and HR 110. Initial labs revealed a hemoglobin of 6.0 g/dl, HCT of 19%, MCV: 79.1u3, platelet count of 118 k/mm3, INR of 1.7, BUN of 14, and Cr of 0.53. His calculated MELD-Na at the time was 14. Patient was admitted to ICU and he was started on a protonix and octreotide drip, and transfused 2 units of PRBC. EGD was performed which revealed bright red blood in duodenum, and a serpiginous vessel in the duodenum which was believed to be a varix, with stigmata of recent bleed(white nipple sign). Varix was not actively bleeding at the time of endoscopy. Decision was made to send patient for urgent TIPS. However, after TIPS, the patient rebled, requiring 4 more units of PRBC. Doppler study of TIPS, revealed a patent TIPS shunt. Given the continued bleeding he was sent to interventional radiology, for coil embolization of the varix which ultimately resolved the bleeding. Duodenal varix bleeding is an uncommon cause of gastrointestinal bleeding in patients with portal hypertension but can cause severe and potentially fatal bleeding. Duodenal variceal bleeding can be treated surgically or non-surgically. Treatment of duodenal variceal bleeding includes endoscopic sclerotherapy, endoscopic ligation, and trans jugular intrahepatic portosystemic shunt (TIPS). Given the low incidence there is not one uniform means of treating duodenal varices. In patients that are poor surgical candidates TIPS procedure is generally safest, but it too has complications such as hepatic encephalopathy and restenosis of the stent which is common with incidence of 55-70%. Surgical options such as variceal ligation, duodenectomy have high rebleeding rates and usually require further interventions. Other options such as shunt surgery carry up to a 30% mortality and require good hepatic function which in most patients is compromised. Coil embolization has not been adequately studied or performed. We present a case of a patient with a large duodenal varix that was refractory to TIPS, and was eventually coiled with complete cessation of bleeding.2500_A Figure 1. EGD, showing large duodenal varix2500_B Figure 2. Large Varix shown under fluoroscopy2500_C Figure 3. Duodenal Varix status post coiling