University of Arizona College of Medicine, Banner University Medical Center Phoenix, AZ
Introduction: Variceal bleeding is a life-threatening complication of portal hypertension (PH), affecting 25-35% of patients with cirrhosis. Duodenal varices are uncommon, accounting for 0.4% of variceal bleeds from PH, but are associated with poor outcomes. Presented is a rare case of a bleeding duodenal varix (DV) causing hemodynamic instability in a patient with cirrhosis.
Case Description/Methods: A 42-year-old male with polysubstance abuse and alcoholic cirrhosis complicated by PH and esophageal varices (EV) presented via emergency medical services after being found down in the street. The patient was hypotensive, tachycardic to the 140s, and febrile to 40.4 degrees Celsius. Physical exam was remarkable for blood covering his lower extremities and a large blood clot in his rectum. Labs were significant for a hemoglobin of 6.7 g/dl, platelet count of 68 K/MM3, white blood count of 15.6, bilirubin of 4.4 mg/dL, ammonia of 76 umol/L, and lactic acid of 4.2. Triphasic computed tomography of the abdomen and pelvis with intravenous (IV) contrast showed cirrhotic liver morphology and thickening of the ascending colon. Two units of packed red blood cells, IV pantoprazole, and IV octreotide were given. An emergent esophagogastroduodenoscopy demonstrated PH gastropathy, non-bleeding EV, and a 5-millimeter bleeding DV (figure 1a). To achieve temporary hemostasis, two clips were placed over the DV with plan for Interventional Radiology (IR) to definitively control bleeding with embolization (figure 1b). Abdominal ultrasound with Doppler demonstrated a patent portal venous system. Venogram showed DV fed by inflow from the superior mesenteric venous circulation with outflow via an enlarged right gonadal vein. Retrograde coil embolization resulted in complete resolution of bleeding (figure 1c).
Discussion: Common sites of variceal bleeding include the esophagus and stomach. Though DVs are rare, it is essential to gain consensus on the optimal approach to treatment as the mortality rate is up to 40% due to origination of DVs in the deep serosal layer and high vascularity of the duodenum. In this case, clips were used to achieve hemostasis followed by embolization for definitive cessation of bleeding. Clips also served as a landmark for IR to target during the venogram and coil embolization. Clips on their own may not be sufficient to control duodenal bleeding as there is risk of inadequate occlusion of vessels or tissue perforation. This multimodal approach offers an effective path to managing bleeding DV.
