Question: A 51-year-old man experiencing repeated hematochezia and anemic symptoms for 9 months was transferred to our center. He had a history of hepatitis B virus infection for 6 years. Before admission, enhanced abdominal computer tomography (CT) in a local hospital showed liver cirrhosis, splenomegaly, and gastroesophageal varices. On admission, the bleeding had stopped. He had a heartbeat of 106 beats/min, respiratory rate of 21 beats/min, and blood pressure of 92/57 mm Hg. A blood test revealed hemoglobin level of only 5.1 g/dL. Standard medical treatments including proton pump inhibitor and vasoactive agents and restrictive blood transfusion were administered. Endoscopic evaluation (Figure A) was performed and disclosed esophageal varices signified with a red sign and a gastric varix in the lesser curvature. No other varices or ulcers were observed. Based on this evidence, gastroesophageal varices were considered as the sources of bleeding, and endoscopic ligation for esophageal varices and cyanoacrylate injection for gastric varix were performed for secondary prophylaxis. About 4 weeks later, the patient was admitted for hematochezia again. After admission, he underwent an episode of hematemesis (about 350 mL) under standard medical treatments. Based on a previous CT report from a local hospital and the latest endoscopic treatment, the origin of rebleeding was considered to be potential residual varices or gastric ulcer resulting from glue clot excretion. Once stable hemodynamics were achieved with fluid resuscitation and blood transfusion, a repeat endoscopy was performed and revealed portal hypertensive gastropathy and erosive lesions on the previous injection site of the fundus of the stomach. There were no visible varices or ulcers in the esophagus, stomach, bulb portion, or descending portion of the duodenum. For further investigation, a repeat abdominal computed tomography venography (CTV) (Figure B) was obtained. Portal phase of the CTV showed liver cirrhosis and a tortuous shunt between superior mesentery vein and left renal vein next to the distal duodenum. Patient informed consent and authorization were obtained before submission. What is the most likely cause of the gastrointestinal bleeding of this patient? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. Considering the shunt next to the duodenum might play a role in the massive bleeding, a second repeat gastroscopy was performed farther intentionally, and it disclosed crowded nodules with active bleeding at the transverse-ascending junction of the duodenum (Figure C), which were further confirmed as varices using endoscopic ultrasonography (Figure D). A transjungular balloon-occluded retrograde transvenous obliteration (BRTO) procedure was carried out (Figure E), and the bleeding stopped the next day. The patient was regularly followed up after discharge, and he underwent no gastrointestinal bleeding episode thereafter. Two months later, follow-up CTV demonstrated elimination of the shunt and the varices (Figure F). Eradication of the duodenal varices were also confirmed using follow-up endoscopy (Figure G). Gastroesophageal varices were common causes of gastrointestinal bleeding in patients with liver cirrhosis. Relatively speaking, duodenal varices, first reported by Alberti in 1931, were thought to be still an unusual disorder today. Especially for those with simultaneous occurrence of gastroesophageal varices, duodenal varices may be easily ignored, but subsequent bleeding could make it difficult to achieve hemostasis and lead to poor prognosis. In this case, the initial enhanced abdominal CT reported only the gastroesophageal varices, which were confirmed and treated well using regular endoscopy. Existence of gastroesophageal varices constituted a reasonable explanation for the bleeding, and decreased the expectation for further exploration of other bleeding sources. The bulb is the most frequent reported site of occurrence of duodenal varices, whereas the other parts, especially the transverse and ascending portions, were extremely rare, accounting for only 4.6% according to a Japanese nationwide survey.1Watanabe N. Toyonaga A. Kojima S. et al.Current status of ectopic varices in Japan: results of a survey by the Japan Society for Portal Hypertension.Hepatol Res. 2010; 40: 763-776Crossref PubMed Scopus (76) Google Scholar During regular gastroscopy, the endoscope is usually introduced into the descending duodenum, leading to difficult identification of varices in farther portions. In this case, the bleeding varices at the transverse-ascending junction were finally identified, but not until the endoscope was introduced farther intentionally into the distal duodenum based on the shunt observed on repeat CTV. With regard to the treatment, endoscopic therapies are recommended as the first-line regimen for gastroesophageal varices.2de Franchis R. Bosch J. Garcia-Tsao G. et al.Baveno VII - Renewing consensus in portal hypertension.J Hepatol. 2022; 76: 959-974Abstract Full Text Full Text PDF PubMed Scopus (273) Google Scholar However, there is currently no standard treatments for duodenal varices. According to the latest published Baveno VII criteria, either endovascular or endoscopic therapies could be considered.2de Franchis R. Bosch J. Garcia-Tsao G. et al.Baveno VII - Renewing consensus in portal hypertension.J Hepatol. 2022; 76: 959-974Abstract Full Text Full Text PDF PubMed Scopus (273) Google Scholar To avoid ulcers or intraluminal obstruction of the duodenum after endoscopic injection as reported,3Mondal D. Dey M. Kishalaya et al.Spontaneously resolving duodenal obstruction after balloon-occluded retrograde transvenous obliteration-assisted endoscopic Histoacryl injection in duodenal varices.Gastrointest Endosc. 2021; 93: 265-266Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar BRTO was selected in this case. BRTO allows complete obstruction of the shunt and eradication of the varices with minimal invasion and high cost-effectiveness ratio. In summary, this case report highlights the close cooperation of endoscopy and portal venography of CT in identification of the varices at the distal parts of the duodenum.