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

Abstract

Background:Duodenal varices (DV) although an uncommon cause, are an important cause due to the severe nature of the bleed and associated adverse outcome.Materials and Methods:We retrospectively evaluated patients with DV seen at our institution over past 4 years.Results:A total of 10 patients (nine males; mean age was 35.8 ± 7.68 years) with DV were studied. Five patients had underlying cirrhosis and five had DV because of non-cirrhotic portal hypertension (four patients had extra-hepatic portal venous obstruction and one patient had non-cirrhotic portal fibrosis). Five patients presented with upper gastrointestinal (GI) bleed, whereas in the remaining five patients DV were detected on endoscopy performed for evaluation of portal hypertension. Endoscopy revealed submucosal lesion in nine patients, whereas in one patient an initial endoscopic diagnosis of Dieulafoy's lesion was made. However endoscopic ultrasound (EUS) could clearly identify DV in all patients. Of five patients presenting with upper GI bleed, three had the esophageal varices eradicated and two presented 1st time with bleed form DV and did not have esophagogastric varices. All patients with acute upper GI bleed were initially treated with intravenous terlipressin followed by glue (n-butyl cyanoacrylate) injection in 4/5 patients with one patient refusing further endoscopic therapy. The variceal obliteration was documented by EUS in all these four patients and there has been no recurrence of bleed in these four patients over a follow-up period of 4-46 months. The five non-bleeding DV were already on beta- blockers and the same were continued. Two of these five patients succumbed to progressive liver failure with none of these five patients having GI bleed on follow-up.Conclusion:EUS is a useful investigational modality for evaluating patients with DV and endoscopic injection of glue is an effective therapy for controlling and preventing recurrence of bleed from DV.

The role of endoscopy in subepithelial lesions of the GI tract

“…107 Varices in the esophagus and stomach are diagnosed easily in the appropriate clinical setting, but they may present incidentally during routine endoscopy. 108 Varices can be found in more atypical locations such as the duodenum and rectum, even when absent in the esophagus and stomach. On endoscopy they appear as a bulge and are soft to forceps probing.…”

Update on the management of gastrointestinal varices

“…Duodenal varices are noted on endoscopy as submucosal dilated veins, usually arising from anastomosis between tributaries of the superior mesenteric vein and portal vein draining into inferior vena cava. EUS is notably superior in diagnosing duodenal varices compared to EGD[110]. Acute duodenal variceal bleeding is usually treated with endoscopic glue injection.…”

Endoscopic ultrasound guided emergency coil and glue for actively bleeding duodenal varix after failed endoscopy

“…[6,7] EUS offers several advantages in the management of ectopic varices like establishing a diagnosis, targeted injection of sclerosant into varix, the anatomy of varix or collaterals and confirmation of variceal obliteration. [8] Thus, EUS guided coil embolization and glue therapy can be very useful for ectopic varices as shown in the present case with life-threatening bleed that could not be controlled by conventional endotherapy.…”