Duodenal Varices Causing Massive Lower Gastrointestinal Hemorrhage

Abstract

Bleeding from ectopic varices accounts for 1.6%-6% of all bleeding related to portal hypertension due to cirrhosis. [1][2][3][4][5] The prevalence of ectopic varices is higher in extrahepatic portal hypertension. 2 Of all the bleeding ectopic varices, the varices at the enterostomy site are the most common, followed by anorectal, colon, duodenum, and jejunum or ileum.1-2 Bleeding from the duodenal varices, although rare, is often massive and life-threatening, possibly because they are more difficult to detect and to treat than esophageal varices.Treatment options for bleeding duodenal varices include intra-operative suture ligation, 6 endoscopic varix ligation, 7 duodenal resection, 8 portacaval shunt 9 and injection sclerotherapy. [10][11][12][13][14][15][16] There is no consensus on the best management of bleeding duodenal varices, and randomized studies are unlikely to be feasible because of the rarity of the condition. Only eight cases of endoscopic injection sclerotherapy have been reported in the literature. [10][11][12][13][14][15][16][17] We report the ninth case of successful endoscopic injection sclerotherapy of actively bleeding duodenal varices, where the patient was admitted with massive lower gastrointestinal hemorrhage. We also reviewed the literature, focusing mainly on the etiopathogenesis, and various options of medical and surgical treatment of duodenal varices. Case ReportIn August 1996, a 45-year-old male patient with a 15-year history of alcohol abuse was admitted in a private hospital with the complaint of massive lower gastrointestinal bleeding, without any preceding past history of abdominal illness. He was managed with 12 units of blood transfusion, 10 units of fresh frozen plasma and 4 units of platelet concentrate within four days. Upper and lower gastrointestinal endoscopies were performed, but could not determine the source of bleeding. He was referred to Dammam Central Hospital for possible early selective angiography and radioisotope scan to determine the source of bleeding.On admission, the patient had a pulse of 115/min. and a blood pressure of 100/60. His nutritional status was good, and there was no evidence of encephalopathy. Head and neck examinations were normal. There was severe pallor with mild icterus. The patient had palmar erythema, but no gynecomastia or spider angiomata were seen. Chest and cardiovascular examinations were normal. Abdominal examination showed tender and smooth hepatomegaly 7 cm below the subcostal margin. Bowel sounds were hyperactive. There was no ascites, splenomegaly, mass, or abdominal tenderness. Rectal examination demonstrated the presence of maroon-colored, liquid stool. The laboratory findings were as follows: hemoglobin 6.4 g/dL; hematocrit 20 vol%; WBC 24,600; platelets 35,000/mm 3 ; albumin level 3.8 g/dL; total bilirubin level 2.9 mg/dL; prothrombin time 14 sec. (control 12 sec.) with INR 1.3; SGOT 47 IU/L, SGPT 67 IU/L; GT 309 U/L; and alkaline phosphatase 143 U/L. HBV and HCV serological markers were negative. Abdominal ultrasound sugge...

Clinical, endoscopic and endoscopic ultrasound features of duodenal varices: A report of 10 cases

“…DV usually co-exist with varices in esophagus and stomach or the varices have been eradicated earlier and bleeding 1 st time from DV is very rare. [456789101112] Two of our patients presented 1 st time with bleed form DV.…”

“…[123] The bleeding from duodenal varix usually occurs as a result of erosion on the varix and is usually severe because of rapid blood flow with high mortality rates. [456] They are usually detected on endoscopy as submucosal bulge and needs further evaluation for confirmation as a duodenal varix. Endoscopic ultrasound (EUS) is an excellent investigational modality for evaluating GI submucosal lesions and DV varices as well as the feeding vessels can be evaluated on EUS.…”

“…However, the published experience on DV especially the role of EUS is limited. [456789101112] We retrospectively evaluated patients with DV seen at our institution over past 4 years and analyzed their clinical, endoscopic and EUS features as well as the outcome of treatment offered to them.…”

Enteroscopic Management of Ectopic Varices in a Patient with Liver Cirrhosis and Portal Hypertension

“…Patients usually present with hematemesis, melaena, or lower gastrointestinal bleeding, which may range from mild spotting to gross, life-threatening haemorrhage [13]. While initial medical management aims to stabilise the patient haemodyamically with blood transfusions and splanchnic vasoconstrictors such as terlipressin, emergent upper gastrointestinal endoscopy has been the cornerstone of first-line management in patients presenting with gross upper gastrointestinal bleeding.…”

Identification of Perforators in Patients with Duodenal Varices by Endoscopic Ultrasound—A Case Series [with video]

“…The rarity of bleeding from DV may be related to their smaller diameter, shorter length and deeper location on the outer wall of the duodenum (paraduodenal varices). [2][3][4] Paraduodenal varices (PDV) can communicate through perforators with vascular channels in the submucosa of the duodenum which gradually enlarge over a period of time to form DV. In the submucosa, DV may be endoscopically inevident initially, appearing as thickened duodenal folds, but generally become endoscopically evident before they bleed.…”