Successful Treatment of Duodenal Variceal Bleeding by Endoscopic Clipping

Duodenal varix bleeding is an uncommon cause of gastrointestinal bleeding in patients with portal hypertension but can cause severe and potentially fatal bleeding. However, the incidence is low and a good treatment method has not been well established yet. Duodenal variceal bleeding can be treated surgically or nonsurgically. We have successfully treated a patient with duodenal variceal bleeding secondary to liver cirrhosis using hemoclips to control the bleeding.

A Case of Bleeding from a Periampullary Duodenal Varix that Developed after Biliary Metal Stent Placement in a Patient with Pancreatic Cancer / 대한소화기내시경학회지

Duodenal varices bleed less commonly than gastro-esophageal varices in patients with portal hypertension. However, if there is no stigmata of recent esophageal or gastric variceal bleeding, clinicians should suspect the presence of an extra gastro-esophageal site of variceal bleeding. Duodenal variceal bleeding can be difficult to diagnose and treat. Therefore, the bleeding may be life threatening in most cases and has a poor prognosis. We experienced a case of variceal bleeding that developed in a patient with far advanced pancreatic cancer after placement of a self- expanding metal stent into a strictured bile duct via the peroral and transpapillary route. The patient had a duodenal varix near the major papilla and the bleeding was treated with an injection of Histoacryl(R). We thought the bleeding of the periampullary varix resulted from injury due to exposure to the free end of the alloy wires in the distal portion of the inserted biliary metal stent.

Duodenal Variceal Bleeding Treated with a Combination of Endoscopic Ligation and Injection Sclerotherapy: Two Case Reports and a Review of the Korean Clinical Literature / 대한소화기내시경학회지

A duodenal varix is a rare cause of hemorrhage in patients with intrahepatic and extrahepatic portal hypertension. However, bleeding in these patients is serious and often life threatening. Treatments for duodenal variceal bleeding include endoscopic injection sclerotherapy, endoscopic ligation, surgical procedures and interventional radiology. We report two cases of duodenal variceal bleeding in a 53- year-old male patient and a 63-year-old female patient with liver cirrhosis that presented with hematemesis and melena. Emergency upper endoscopy examinations revealed the presence of large nodular varices with ruptured erosion on the top of the second portion of the duodenum. A combination of the use of endoscopic ligation and endoscopic injection sclerotherapy was performed and successful hemostasis and eradication of duodenal varices was possible in all cases. Another 19 cases of duodenal variceal bleeding that have been reported in the Korean clinical literature were reviewed.

A Case of Spurting Duodenal Variceal Bleeding Treated with an Endoscopic Sclerotherapy in a Patient with Biliary Cirrhosis / 대한소화기내시경학회지

Duodenal varices can result from portal hypertension regardless of the etiologies of liver cirrhosis. Bleeding from duodenal varices is rare but often severe and life threatening. Treatment modalities of duodenal varices include endoscopic sclerotherapy, transjugular intrahepatic portosystemic shunt, and surgery. As an initial treatment, endoscopic sclerotherapy is recommended due to easy accessibility but has limited success in controlling active duodenal variceal bleeding. In this case, we report a spurting duodenal varix treated with Histoacryl(R) injection in a 48-year-old woman with secondary biliary cirrhosis. Endoscopic sclerotherapy with Histoacryl(R) is a useful therapeutic measure in the treatment of bleeding duodenal varix.

A case of bleeding duodenal varix treated by endoscopic band ligation / 대한내과학회지

The occurrence of duodenal varices is rare. They are often overlooked as a source of upper gastrointestinal bleeding in patients with portal hypertension. Experience in control of bleeding duodenal varices is limited. Endoscopic variceal ligation (EVL) is generally considered a safer alternative than endoscopic injection sclerotherapy for treatment of bleeding esophageal varices. Recently EVL has been described as a successful treatment for ruptured duodenal varices. We present a case of bleeding duodenal varices in a 46-year-old man with liver cirrhosis and cholangiocarcinoma who presented with melena. Emergency endoscopy revealed no esophagogastric varices, but several nodular varices were found in the second portion of the duodenum. A punctate ulcer overlying the varix with intermittent bleeding was observed. The hemorrhagic lesion was successfully treated by endoscopic ligation after failure of hemostasis with ethanolamine injection theapy. Endoscopic ligation may be a therapeutic choice to arrest active duodenal variceal bleeding.

A Case of Successful Endoscopic Injection Sclerotherapy with N-butyl-2-cyanoacrylate for Bleeding Duodenal Varices Misdiagnosed Initially / 대한소화기내시경학회지

Duodenal varices are a rare site of hemorrhage in patients with intrahepatic and extrahepatic portal hypertension, but their bleeding is life-threatening complication. Diagnosis of duodenal varices may be difficult, requiring careful inspection of the duodenal bulb during endoscopy. Diagnosis of duodenal varices may also be revealed using angiography and transhepatic portography. Treatment of duodenal varices include endoscopic injection sclerotherapy (EIS), endoscopic variceal ligation (EVL), surgical procedures, and interventional radiology. A 50-year-old woman with liver cirrhosis was admitted with melena and hematochezia. An endoscopy on admission showed esophageal and fundal varices without any bleeding stigma. Colonoscopy showed moderate amount of fresh blood in the terminal ileum. 99mTc-labelled RBC scan showed a suspicion of a distal jejunal bleeding. She had explo-laparotomy of small bowel segmental resection based on 99mTc-labelled RBC but rebleeding occured. Selective mesenteric angiography failed to reveal the source of bleeding. Repeat endoscopy revealed undetected duodenal varix which was covered with fresh blood clots. Endoscopic injection sclerotherapy with n-butyl-2-cyano acrylate (Histoacryl) was performed and achieved succesful hemostasis.

A Successful Endoscopic Therapy for Uncontrolled Duodenal Varix after Transjugular Intrahepatic Portosystemic Shunt / 대한소화기내시경학회지

Duodenal varix is a rare site of bleeding in patient with portal hypertension and frequently causes massive bleeding. Treatment modalities are endoscopic sclerotherapy, endoscopic ligation, transjugular intrahepatic portosystemic shunt (TIPS), and shunt operation. A patient with duodenal varix was hemodynamically unstable and an emergent salvage transjugular intrahepatic portosystemic shunt was performed. In spite of TIPS procedure, varix bleeding was not controlled and endoscopic band ligation and endoscopic sclerotherapy were performed with successful hemostasis and eradication of duodenal varix.

Duodenal Variceal Bleeding Treated with a Transjugular Intrahepatic Portosystemic Shunt / 대한소화기내시경학회지

Most cases of upper gastrointestinal bleeding in patients with portal hypertension are caused by esophagogastric varices. Less often, bleeding originates in varices located elsewhere. If ectopic varices are found, the same hemostatic technique tend to be used. However, there is no evidence that such techniques are useful in these cases. Duodenal varices are quite common, although they rarely bleed due to their location deep in the duodenal wall. Consequently, if emergency endoscopy is not conducted, hemorrhage may be wrongfully attributed to coexisting esophagogastric varices in a patient with portal hypertension without active bleeding. Hemorrhage from duodenal varices may be severe and life threatening. We report a patient with portal hypertension and bleeding duodenal varices caused by cirrhosis of the liver. Hemorrhage was subsequently controlled by placement of a transjugular intrahepatic portosystemic shunt. We recommend that in patients with life-threatening hemorrhage from duodenal varices caused by cirrhosis of the liver, transjugular intrahepatic portosystemic shunt (TIPS) be considered in the man-agement.

A Successful Endoscopic Injection Sclerotherapy of a Bleeding Duodenal Varix / 대한소화기내시경학회지

Bleeding frorn the duodenal varix is an unusual event. Upper gastrointestinal endoscopy is the diagnostic procedure of choice in diagnosing duodenal varices. If performed during active bleeding, it can differentiate between esophageal and duodenal varices as the source, which has important therapeutic implications. A thorough examination of the duodenum for varices is important in an upper gastrointestinal hemorrhage. Treatment modalites for bleeding duodenal varices are sclerotherapy, varix suture ligation, portocaval shunt, and duodenal resection. Although endoscopic sclerotherapy has lirnited success in controlling active duodenal varix as initial treatment, endoscopic injection sclerotherapy is a useful first-line therapeutic measure in the treatment of bleeding duodenal varices. In this study we present a case of a ruptured duodenal varix, which was defected by an endoscopy, in a 61-year-old male. An endoscopic examination showed small and nonbleeding esophageal varices and a prominant ulcerated varix was identified in the 2nd portion of the duodenum. Endoscopic sclerotherapy was performed by injecting ethanolamine oleate into the varix. Our report demonstrate that endoscopic sclerotherapy can be efficient even in the presence of acute bleeding and that it can provide a definitive method of curing of a bleeding duodenal varix.