A 61-year-old man with a remote history of idiopathic necrotizing pancreatitis complicated by need for multiple pancreatic necrosectomies and ultimately Roux-en-Y reconstruction presented with one day of epigastric pain radiating to the back and chills. He denied any recent trauma, alcohol ingestion, new medications, change in bowel habits, chest pain, palpitations, or dyspnea. On examination, vital signs were significant for a low-grade temperature of 37.6°C. He appeared in to be moderate distress secondary to acute abdominal pain which was worsened with palpitation. Physical exam revealed no stigmata of cirrhotic liver disease. Serum laboratory tests were notable for aspartate aminotransferase 99 U/L, alkaline phosphatase 570 U/L, bilirubin 0.5 mg/dL, and leukocyte count of 21.1x109/L; serum albumin and international normalized ratio were both normal. Computed tomography (CT) did not demonstrate any acute abdominal findings other than mild biliary ductal dilatation. Blood cultures revealed gram negative bacteremia, which in the context of the patient's history of pancreatobiliary disease and his current presentation, prompted referral for endoscopic retrograde cholangiopancreatography. During ERCP, gross pyobilia and a distal common bile duct stricture were found, necessitating biliary balloon dilation, sweeping, and stent placement. In addition, and intriguingly, there was an incidental finding of extensive and nearly circumferential isolated duodenal varices (IDVs; see Figure 1). On review of the patient's contrast-enhanced CT imaging, there was no evidence of cirrhosis or other varices (e.g. esophageal). In addition, abdominal ultrasound demonstrated normal hepatopedal flow in the portal vein. The patient was placed on a non-cardioselective beta blocker for variceal prophylaxis and was doing well at last follow-up six months later.Figure 1Discussion: IDVs are a rare manifestation of portal hypertension whose precise incidence and prevalence remain uncertain. Representing approximately 15% of all ectopic varices, duodenal varices may be subclinical or can present with acute hemorrhage with hematemesis and/or hematochezia and mortality rates approaching 40% per episode. IDVs are typically secondary to cirrhosis-associated portal hypertension, whereas here we report a case of cryptogenic IDVs which were likely consequent to extensive intra-abdominal surgeries resulting in impaired superior mesenteric venous outflow and development of noncirrhotic portal hypertension.