Successful management of ruptured duodenal varices by means of endoscopic variceal ligation: report of a case

Shiraishi, Masayuki; Hiroyasu, Shungo; Higa, Takeshi; Oshiro, Satoko; Muto, Yoshihiro

doi:10.1016/s0016-5107(99)70498-0

Cited by 32 publications

(22 citation statements)

References 2 publications

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“…Not only the aggressive fluid resuscitation combined with transfusion of sixteen units of blood through four initial days of care was essential, but also the emer-gency surgery had to be undertaken to cease it. Along with Shirashi et al (9) we confirm surgical ligation followed by excision of duodenal / small intestinal varices may be an effective method of their management -both cases have been free of recurrence at 15 months postoperatively.…”

Section: Discussionsupporting

confidence: 79%

“…Forty per cent of patients with PHT have duodenal varices at angiography; however their penetration unusually affects submucosa hence no symptoms develop. Isolated bleeding duodenal varices are scarcely reported in literature, although present a significant surgical problem: massive haemorrhage combined with failure to identify them as a source has led to catastrophic outcomes with mortality rate of 40% (8,9 On abdominal palpation the entire epigastrium was grossly distended, however bowel sounds were preserved and no peritoneal signs evident. Right sides epigastric scar was noted.…”

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confidence: 99%

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Varices of the Descending Duodenum Explored During Emergency Gastro-Duodenal Resection for Upper Gastrointestinal Haemorrhage. Case Report

Rudzki

Dryka

Wilczynski

et al. 2013

Polish Journal of Surgery

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Upper gastrointestinal haemorrhage is a major medical emergency and accounts for approximately 7,000 admissions to hospitals in Scotland each year. Over the last 10 years there has been a number of improvements in diagnosis and conservative management of the condition, which significantly reduced the ratio of life-threatening cases requiring an emergency surgery. Despite these achievements surgical intervention or, if accessible, endovascular procedures must be undertaken as emergency actions, should conservative management fail. Vascular malformations of the duodenum are less frequent causes of upper GI bleeding. Duodenal varices found endoscopically occur in 0.4% of patients with portal hypertension (PHT) and are believed to be caused mainly by liver cirrhosis, idiopathic PHT, extrahepatic PHT, or previous surgical trauma. The duodenal bulb is their most common site, followed by the second portion of the duodenum. Forty per cent of patients with PHT have duodenal varices at angiography; however, their penetration unusually affects submucosa, hence no symptoms develop. Isolated bleeding duodenal varices are scarcely reported in literature, although present a significant surgical problem: massive haemorrhage combined with failure to identify them as a source has led to catastrophic outcomes with mortality rate of 40%. The case hereby presented is unique in several aspects. Duodenal varices were explored on emergency laparotomy rather than on prior endoscopies, which, performed by the same well-established endoscopists, were twice negative. This corresponds to the study by Cottam et al. stating that duodenal varices may not penetrate the submucosa, hence haemorrhages of their origin may even be more difficult to diagnose on endocsopy. Secondly, the haemorrhage here reported was undoubtedly a life-threatening condition that required a multidisciplinary team to be managed successfully. Along with Shirashi et al. we confirm that surgical ligation followed by the excision of duodenal / small intestinal varices may be an effective method of their management -both cases have been free of recurrence at 15 months postoperatively. In contrast to the study by Hashizume et al. the duodenal varices here presented were not associated with portal hypertension (PTH). Finally, duodenal varices located in the posterolateral aspect of the descending duodenum are less common as the majority of cases reported so far were of duodenal bulb location.

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Section: Discussionsupporting

confidence: 79%

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confidence: 99%

Varices of the Descending Duodenum Explored During Emergency Gastro-Duodenal Resection for Upper Gastrointestinal Haemorrhage. Case Report

Rudzki

Dryka

Wilczynski

et al. 2013

Polish Journal of Surgery

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“…EVL EVL for bleeding duodenal varices is challenging because of limited visibility from the banding hood. It may be useful for temporary hemostasis but rebleeding is a problem [110,111] . However, several cases of successful treatment of rectal varices using EVL have been reported [112,113] .…”

Section: Ectopic Varices Obliterationmentioning

confidence: 99%

Endoscopic Management of Variceal Haemorrhage

Dell’Era

Iannuzzi

Franchis

2015

Journal of Gastroenterology and Hepatology Research

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One of the most important complications of portal hypertension, in the setting of liver cirrhosis or of non-cirrhotic portal hypertension, is upper gastrointestinal bleeding from ruptured gastroesophageal varices and portal hypertensive gastropathy. The management of the acute variceal bleeding is a multidisciplinary process that includes the initial assessment of the patient, effective resuscitation, timely diagnosis, control of bleeding and prevention of early rebleeding and complications such as infection, hepatorenal syndrome, or hepatic encephalopathy. Antibiotic prophylaxis, conservative targets for blood transfusions and combination therapy with vasoactive drugs and endoscopic treatments are the first-line measures in the management of acute variceal bleeding; transjugular intrahepatic portosystemic shunts should be proposed early to high-risk patients or as a rescue therapy for those who fail first-line treatment.

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“…In Japan, duodenal varices are observed more commonly in the second portion of the duodenum. 13,14 However, duodenal varices in the distal third portion are rare. 15,16 Precise diagnosis of the site of bleeding in the duodenum is diffi cult.…”

Section: Discussionmentioning

confidence: 99%

“…Although maintaining the fi eld of vision during EVL for bleeding duodenal varices can be diffi cult, EVL may be useful for temporary hemostasis. 13,14,19 Nonetheless, rebleeding of duodenal varices is a problem with EVL. Additional treatment is recommended after duodenal varices have been treated with EVL.…”

Section: Discussionmentioning

confidence: 99%

Efficacy of color Doppler ultrasonography for the diagnosis of duodenal varices successfully treated with percutaneous transhepatic obliteration

et al. 2007

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We treated a 74-year-old woman who complained of tarry stool. Neither endoscopic examination of the upper gastrointestinal tract nor colonoscopy revealed any finding indicative of bleeding, and (99m)Tc-HSA-D pool scintigraphic imaging showed no accumulation of blood in the digestive tract. Small tortuous collateral veins were observed on computed tomography (CT) in the distal third portion of the duodenum. Color Doppler ultrasonography obtained color flow images of varices in the distal third portion of the duodenum indicating turbulent flow, and color flow imaging showed the outflow vessel from duodenal varices. Duodenoscopy revealed tortuous varices, with erosions and blue in appearance, in the same area. Percutaneous transhepatic portography was carried out 18 days after the treatment of ascites, and hepatofugal blood flow was confirmed in the pancreatic duodenal vein originating near the junction between the splenic and inferior mesenteric veins with the passage of contrast medium into the duodenal varices, which drained into the left ovarian vein. We performed selective catheterization into the afferent vein of the varices, and injected 8 ml of a 5% solution of ethanolamine oleate containing iopamidol. Microcoil embolization using steel coils was added because the therapeutic effect resulting after the relatively rapid washout of sclerosant was insufficient. CT and color Doppler ultrasonography showed absence of blood flow in the varices 1 week after the therapy. This patient has had no episodes of rebleeding in the 24 months after therapy. Color Doppler ultrasonography was useful in diagnosing this case of duodenal varices and in evaluating therapeutic effect.

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Successful management of ruptured duodenal varices by means of endoscopic variceal ligation: report of a case

Cited by 32 publications

References 2 publications

Varices of the Descending Duodenum Explored During Emergency Gastro-Duodenal Resection for Upper Gastrointestinal Haemorrhage. Case Report

Varices of the Descending Duodenum Explored During Emergency Gastro-Duodenal Resection for Upper Gastrointestinal Haemorrhage. Case Report

Endoscopic Management of Variceal Haemorrhage

Efficacy of color Doppler ultrasonography for the diagnosis of duodenal varices successfully treated with percutaneous transhepatic obliteration

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