Spontaneously resolving duodenal obstruction after balloon-occluded retrograde transvenous obliteration–assisted endoscopic Histoacryl injection in duodenal varices

Abstract

A 46-year-old woman with cirrhosis presented with recurrent upper GI bleeding. EGD revealed small esophageal varices and large ectopic varices in the second part of the duodenum without any active bleeding (A). CT portovenogram revealed a branch of superior mesenteric vein as afferent and right gonadal vein as efferent for the varices (B). Balloon-occluded retrograde transvenous obliteration (BRTO) was done with the balloon inflated in the right gonadal vein. Because superselective cannulation of the ectopic varices could not be achieved, BRTO-assisted endoscopic injection of 12 mL N-butyl-2-cyanoacrylate (Histoacryl) and lipoidal (1:2 ratio) was done into the varices to minimize systemic embolization. Two weeks after discharge, the patient presented with repeated vomiting. EGD revealed partial occlusion of the duodenal lumen by the Histoacryl cast (C). Her symptoms resolved on conservative management (nothing by mouth, nasogastric drainage, and intravenous fluids). She continued to experience intermittent vomiting for the next 2 months. Because spontaneous expulsion of Histoacryl casts after variable intervals is known and each episode of duodenal obstruction subsided with conservative management, we did not plan any surgery. After about 2 months, she became asymptomatic. EGD after 2 months showed no residual Histoacryl cast (D).