Case Presentation: A 62 year old man with a past medical history of decompensated alcoholic cirrhosis, esophageal varices (no previous episode of hemorrhage), previous H. Pylori treatment, peptic ulcer disease was admitted to the intensive care unit for bright red blood per rectum and found to be hypotensive with a hemoglobin of 7.0, hematocrit of 19.7. He was discharged the day before for which his hemoglobin was 11.4, hematocrit 31.3. He was intubated for airway protection. Emergent esophagoduodenoscopy showed esophagitis and a large duodenal varix. At the time, the varix was not amenable to banding due to size. Massive transfusion was performed during his admission (13 units packed red blood cells, 6 units fresh frozen plasma, 1 unit platelets, 2 units cryoprecipitate). Due to continued rebleeds, a transjugular intrahepatic portosystemic shunt was created from right hepatic vein to right portal vein. The pre-right atrial pressure was 20 mmHg, post-procedure right atrial pressure was 41 mmHg. The post-procedure portal pressure was 44 mmHg. A repeat EGD was done for continued bloody melanotic stool several days later, showing the same large duodenal varix in the third portion of the duodenum. A nipple sign was visualized, which correlated positively with recent severe bleeding. A 2ml cyanoacrylate injection was used for hemostasis. The patient remained stable for the duration of the hospitalization with no further episodes of melena or hematochezia.
Discussion: In portal hypertension from decompensated cirrhosis, duodenal varix bleeding is rare but potentially fatal. Duodenal varices are in the serosal layer, which lies deeper than the submucosal layer of esophageal varices. These sites of bleed are harder to visualize and often require more than endoscopy. Abdominal CTs, mesenteric angiography, and surgery may need to be considered for severe hemorrhage. In our case, a combination of emergent TIPS procedure and cyanoacrylate were used to control the bleeding. There have been a few reports in the literature discussing hemoclips, injection sclerotherapy for duodenal varix. Cyanoacrylate glue injections have been used primarily for patients with gastric variceal bleeds not candidates for TIPS. However as we demonstrate here, a combination of TIPS and cyanoacrylate due to the large size of the varix, can be efficaciously performed to control acute bleed and repair portosystemic shunt function.
Conclusions: In portal hypertension from decompensated cirrhosis, duodenal varix bleeding is rare but potentially fatal. Duodenal varices are in the serosal layer, which lies deeper than the submucosal layer of esophageal varices. These sites of bleed are harder to visualize and often require more than endoscopy. Abdominal CTs, mesenteric angiography, and surgery may need to be considered for severe hemorrhage.
To cite this abstract:Shi, H; Chavez, C. DUODENAL VARICES — A DANGEROUS BLEED FIXED WITH GLUE AND TIPS. Abstract published at Hospital Medicine 2019, March 24-27, National Harbor, Md. Abstract 987. https://www.shmabstracts.com/abstract/duodenal-varices-a-dangerous-bleed-fixed-with-glue-and-tips/. Accessed December 15, 2019.