Alcoholic cirrhosis and non-alcoholic fatty liver disease on the continuous rise in the United States, there is also a congruent rise in portal hypertension. Far more familiar complications of portal hypertension include esophageal varices, ascites and hepatorenal syndrome. Portal hypertensive duodenopathy is a rare but known consequence of portal hypertension, which serves as a potentially devastating source of gastrointestinal (GI) bleeding. A 46 year old man with a past medical history of Liver Cirrhosis (MELD 24, child pugh class B) complicated by esophageal varices presented with abdominal pain and hematochezia for the past 3 days. He reported worsening ascites and generalized malaise. Patient also reported associated chills, shortness of breath, lightheadedness, and decreased appetite. He undergoes frequent paracentesis for refractory ascites, last presentation 1 month prior. Patient endorsed diet and medication compliance. Physical exam was significant for ascites, generalized abdominal tenderness, and splenomegaly without rebound or guarding. Scant blood noted on rectal exam. Laboratory findings revealed stable hemoglobin of 12.4 g/dL, hematocrit of 36.8 %, platelet of 83 K/UL, leukocytosis of 15.4 K/UL with 78% neutrophils and 16% bands, sodium of 130 mmol/L, ammonia of 83 Umol/L, alanine aminotransferase of 40 U/L, aspartate aminotransferase of 42 U/L and alkaline phosphatase of 127 U/L. INR was 2.02. Diagnostic paracentesis revealed serosanguinous fluid, PMN count of 686 cells/mm3 consistent with culture negative neutrocytic ascites. Blood cultures obtained revealed no growth of organisms. Patient completed course of intravenous (IV) Ceftriaxone therapy. Endoscopy performed revealed erosions, mucosal edema and erythema with minimal oozing of blood in the duodenum. Colonoscopy and video capsule endoscopy revealed no active bleeding. Patient was referred for evaluation for transugular intrahepatic portosystemic shunt (TIPS) amidst significant complications of portal hypertension. Management of portal hypertensive duodenopathy with acute bleeding is same as in patients with other causes of upper GI bleed. Endoscopic thermal coagulation could be effective if bleeding lesions are identified. Clinicians should consider TIPS as a management strategy in patients with other significant complications of portal hypertension.Figure: EGD picture of duodenum with snake skin like picture of portal hypertensive duodenopathy.Figure: EGD picture of duodenum with snake skin like picture of portal hypertensive duodenopathy.Figure: EGD picture of duodenum with snake skin like picture of portal hypertensive duodenopathy.