Ruptured duodenal varices arising from the main portal vein successfully treated with endoscopic injection sclerotherapy: a case report

Abstract

Duodenal varices result from retroperitoneal portosystemic shunts that usually come from the pancreaticoduodenal vein and drain into the inferior vena cava. Because they are a rare but fatal cause of gastrointestinal bleeding, a prompt hemostatic intervention is mandatory. A 62-year-old man who had a history of excessive alcohol consumption presented with massive hematemesis and melena. Emergent endoscopy revealed ruptured varices with an adhering whitish fibrin clot on the postbulbar portion of the duodenum. Abdominal computed tomography demonstrated a cirrhotic liver with venous collaterals around the duodenum and extravasated contrast in the second and third portions. The collaterals originated from the main portal vein and drained via the right renal vein into the inferior vena cava. Endoscopic injection sclerotherapy with cyanoacrylate was successful in achieving hemostasis, and resulted in the near eradication of duodenal varices at a 6-month follow-up.

Endoscopic Sclerotherapy with a Large Volume of High Concentration of Cyanoacrylate for Jejunal Variceal Bleeding bys Single-Balloon Enteroscopy

“…Considering the risks and benefits in our case, we performed local treatment for the jejunal varices with endoscopic sclerotherapy using SBE after obtaining informed consent from the patient’s family. Endoscopic sclerotherapy has been used to treat bleeding duodenal varices and suggested as a practical and effective measure [ 17 ]; however, studies about jejunal varices are rare. SBE can be used examine the deep small intestine with the diagnostic and therapeutic approaches in cases of ectopic variceal bleeding [ 12 ].…”

“…The potential side effects of the endoscopic sclerotherapy for ectopic varices are perforation, tissue injury, embolism, and rebleeding from the varices or posttreatment ulcers [ 17 ]. Our choice of sclerosant is cyanoacrylate, which is a monomer-based tissue adhesive that instantly polymerizes and solidifies upon contact with the hemorrhage.…”

“…Our choice of sclerosant is cyanoacrylate, which is a monomer-based tissue adhesive that instantly polymerizes and solidifies upon contact with the hemorrhage. Compared to other sclerosants, cyanoacrylate causes less tissue injury [ 17 ]. Unlike gastric varices, jejunal varices are the result of dilatation of the proximal branches of the superior mesenteric vein [ 6 ] that are within a short distance from the intrahepatic portal vein, and a higher volume of sclerosant may increase the risk of embolism [ 18 ] and obstruction of portal venous flow.…”

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

“…Therapeutic options can be classified into [A] endoscopic (banding, ligation or sclerotherapy) [B] interventional radiology (transjugular intrahepatic portosystemic shunt, percutaneous transhepatic embolization or balloon occluded retrograde transvenous obliteration) or [C] surgery (variceal ligation, duodenectomy, shunt surgery), depending on the severity of the condition, availability of the technology and expertise. Endoscopic ligation or injection sclerotherapy with cyanoacrylate is a useful first-line therapy [ [16] , [17] , [18] ]. 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 ].…”

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).…”