Bleeding From a Duodenal Varix

Abstract

We report a case of a bleeding duodenal varix demonstrating excellent hemostasis achieved by endoscopic ultrasound (EUS)-directed placement of an embolization coil followed by cyanoacrylate. A 31-year-old man with decompensated Child's class C cirrhosis presented with hematemesis. An initial endoscopy revealed an actively bleeding duodenal varix. Subsequent attempt at hemostasis with ethanolamine oleate injection failed. A later attempt at hemostasis involving EUS-guided placement of an embolization coil followed by cyanoacrylate injection into the varix was successful. We reviewed the literature involving the treatment of bleeding ectopic varices and conclude that EUS provides a unique and advantageous modality for achieving variceal hemostasis of duodenal varices in patients who are not candidates for transjugular intrahepatic portosystemic shunt.

A case report of bleeding from a duodenal varix: Rare cause of upper gastrointestinal bleeding

“…However, caution must be exercised when using the cyanoacrylate injection as it can lead to complication such as migration to lungs (causing pulmonary embolism) [ 19 ], abdomen and pelvis [ 20 ]. Endoscopic haemostasis using mini loop ligation with detachable nylon loop [ 21 ], and endoscopic ultrasonography (EUS)-guided clipping [ 22 ], embolization coiling [ 23 , 24 ] were attempted, with good outcomes even in acute emergency setting. If the bleeding is not controlled by endoscopic therapy, the patient can either undergo interventional radiological treatment or emergency surgery, depending on the availability of expertise and status of the patient.…”

Complete Eradication of Bleeding Duodenal Varices with Endoscopic Polydocanol Sclerotherapy

“…5 Treatment options in duodenal variceal bleeding include endoscopic procedures (endoscopic varix band ligation (EVL), sclerotherapy, clipping), interventional radiological procedures (TIPS), percutaneous transhepatic obliteration (PTO), transileocolic vein obliteration (TIO), balloon-occluded retrograde transvenous obliteration (BRTO), and surgery (variceal ligation, duodenal resection, and extrahepatic portosystemic shunt creation). 6 7 Unfortunately, the case numbers of ectopic varices in the literature is small, and no definite conclusion can be made as to which is the ideal way to manage these varices. Endoscopic therapies include mechanical therapies (band ligation) and injection therapies (sclerotherapy with sclerosants or tissue adhesives).…”

EUS-guided vascular interventions

“…In a 2014 review of the literature, duodenal varices were treated with TIPS in 11 cases, balloon-occluded retrograde transvenous obliteration in 14, ethanolamine sclerotherapy in 1, endoscopic band ligation in 6, and CYA injection in 16. [ 45 ] The same group reported on a patient with a refractory bleeding duodenal varix after endoscopic sclerotherapy treated with EUS-guided coil placement followed by glue injection. [ 45 ] Additional cases of EUS-guided coil placement ± CYA injection of patients with bleeding duodenal varices have been reported.…”

“…[ 45 ] The same group reported on a patient with a refractory bleeding duodenal varix after endoscopic sclerotherapy treated with EUS-guided coil placement followed by glue injection. [ 45 ] Additional cases of EUS-guided coil placement ± CYA injection of patients with bleeding duodenal varices have been reported. [ 46 47 ]…”