Duodenal varices successfully treated with cyanoacrylate injection therapy

Successful endoscopic cyanoacrylate injection therapy for ruptured duodenal varices immediately after balloon-occluded retrograde transvenous obliteration

We present a rare case of acute duodenal variceal rupture after B-RTO that was successfully treated with endoscopic CA injection therapy. A 74-year-old Japanese woman was transferred to our hospital due to progressive general malaise and hematemesis. Gastroduodenoscopy (GDS) showed duodenal varices without active bleeding in the second portion of duodenum. Balloon-occluded retrograde transvenous obliteration (B-RTO) was carried out to prevent duodenal variceal rebleeding. Good pooling of ethanolamine oleate with iopamidol (EOI) was observed in duodenal varices using balloon catheters. However, massive melena was observed immediately after B-RTO. Emergent GDS revealed a white plug on the treated varix, thus endoscopic cyanoacrylate (CA) injection therapy was performed. We speculated that the injection of EOI increased the pressure in the duodenal varices which resulted in rupture of duodenal varices. B-RTO was effective therapy to prevent duodenal variceal rebleeding, but postprocedural monitoring is required as illustrated by this case. We suggest that careful monitoring and backup system for endoscopy are required during or after B-RTO.

Small Intestine Varices in Cirrhosis at a High-Volume Liver Transplant Center: A Retrospective Database Study and Literature Review

INTRODUCTION

Esophageal varices are a well-characterized sequela of portal hypertension; however, less is known about varices arising in ectopic locations. We aimed to describe bleeding small intestine varices (SIV) in patients with cirrhosis and compare characteristics and outcomes to published case reports.

METHODS

We performed an institutional chart review using billing codes and natural language processing between 2008 and 2019. Inclusion criteria were adult patients with cirrhosis and SIV verified by endoscopy, video capsule, or imaging. Patients with noncirrhotic portal hypertension and stomal varices were excluded. We examined demographic and clinical factors, characteristics of SIV, bleeding, intervention, and outcomes in our series and collated data from published cases identified during a literature review.

RESULTS

We identified 71 patients with cirrhosis and SIV (18 bled). The literature search yielded 76 cases with bleeding SIV. Our series and published cases were matched for age, sex, liver disease etiology, and SIV location. Length of stay and transfusion requirements were similar. Aggregate initial treatments (number, hemostasis rate) included medical (n = 7, 57%), endoscopic (n = 48, 56%), interventional radiology (n = 31, 77%), and surgery (n = 8, 87%). Hospital and overall mortality rates were higher in our series (22% and 38%) compared with the published cases (5.3% and 18.4%), respectively (P = 0.02 and P = 0.07).

DISCUSSION

A quarter of patients with cirrhosis and SIV experience bleeding, with high transfusion requirements, frequent need for secondary interventions, and high mortality. These findings highlight the need for a multidisciplinary approach and second-line therapeutic modalities in the timely management of bleeding SIV in cirrhosis.

Effectiveness and safety of endoscopic treatment for duodenal variceal bleeding: a systematic review

Duodenal varix is a rare condition that involves massive bleeding, diagnostic difficulties, and a high rate of rebleeding and mortality. The purpose of this study was to systematically review endoscopic treatment for duodenal variceal bleeding to evaluate its effectiveness and safety. We searched PubMed, Embase, Web of Science, and the Cochrane Library up to 21 November 2019. Ninety-two studies containing 156 patients were finally included, and individual data from 101 patients (mean age: 52.67 ± 13.82 years, male: 64.4%) were collected and further analyzed. We used an analysis of variance and χ2 or Fisher's exact tests to analyze individual data from 101 patients. The cause of duodenal variceal bleeding was cirrhosis-related intrahepatic portal hypertension (IPH) in 76.2% of patients. The overall rates of initial hemostasis and treatment success of endoscopic treatment for duodenal variceal bleeding were 89.1 and 81.2%, respectively. The median duration of follow-up was 4.5 (1.0, 12.0) months. The overall rates of rebleeding and mortality were 8.9 and 13.9%, respectively. Among a variety of endoscopic treatments available, only the initial hemostasis rate was significantly different between the endoscopic injection sclerotherapy and endoscopic tissue adhesive (ETA) groups (72.7 vs. 94.7%, P = 0.023); differences in treatment success, rebleeding, mortality, and adverse events were not statistically significant among the four groups. Endoscopic intervention is a feasible, well tolerated, and effective modality for the treatment of duodenal variceal bleeding. Among the variety of endoscopic treatments available, ETA with cyanoacrylate may be preferable for duodenal variceal bleeding.

Multidetector computed tomography three-dimensional and multiplanar reconstruction diagnosis of a rare cause of gastrointestinal bleeding: A case report

BACKGROUND

Anastomosis of the testicular vein with the superior mesenteric vein rarely causes severe gastrointestinal bleeding. To date, there have been few studies describing its appearance on medical imaging. Here, we present multidetector computed tomography three-dimensional and multiplanar reconstruction (MPR) images of a typical digital subtraction angiography showing proven ectopic bleeding and provide the first review of the image performance.

CASE SUMMARY

A 68-year-old man who had been rushed to the hospital with a four-day history of melena and fainting underwent multiple esophagogastroduodenoscopy procedures that failed to identify the source of bleeding. We used MPR combined with three-dimensional reconstruction images, and found that the testicular vein had anastomosed with the superior mesenteric vein, and they clustered together in the jejunal vessel wall, which caused severe gastrointestinal bleeding. Digital subtraction angiography confirmed the location of bleeding. After transfusion and embolization therapy, the patient’s condition improved.

CONCLUSION

Computed tomography-MPR combined with three-dimensional images offers significant value in the localization and qualitative assessment of rare gastrointestinal hemorrhage. The features of multiphase spiral scanning can improve the accuracy of the diagnosis.

Duodenal giant stromal tumor combined with ectopic varicose hemorrhage: A case report

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are mesenchymal tissue tumors originating from Cajal cells, presenting diverse clinical manifestations due to the different sizes, locations, and growth patterns of the lesions. Duodenum is an uncommon site of GISTs, more with gastrointestinal obstruction and bleeding as the first symptoms. Ectopic duodenal varix, as a rare varix occurring outside the gastroesophageal region, is the main type of heterotopic varices and an unusual cause of gas-trointestinal hemorrhage. The etiology is mainly seen in liver cirrhosis, portal hypertension, vasculitis, portal vein embolism and obstruction caused by various factors. Reports of duodenal stromal tumor combined with ectopic variceal hemorrhage are rarely seen; however, when it occurs, the situation can sometimes be urgent and life-threatening, especially when traditional endoscopy and imaging fail to detect the lesion timely.

CASE SUMMARY

We report a 52-year-old female patient who had no obvious inducement to develop black stool. Gastroscopy in a local hospital revealed that the duodenal horizontal ectopic varices were ruptured and bleeding. After metal clamping hemostasis, she still had gastrointestinal bleeding and was transferred to our hospital. Gastroscopy showed that active bleeding was still seen in the horizontal part of duodenum, and suspicious submucosal eminence was seen in the bleeding part. Abdominal computed tomography showed a huge stromal tumor of duodenum, specimens were pathologically confirmed after surgery. After a 3-mo follow-up, no gastrointestinal hemorrhage and complications occurred.

CONCLUSION

Ectopic variceal hemorrhage is rare but sometimes fatal. It may be combined with stromal tumor, which can be diagnosed by multiple methods. Endoscopic and surgical treatment are effective.

Transesplenic access in the treatment of varicose gastrointestinal bleeding. Case and technical report

Varicose gastrointestinal bleeding is one of the major causes of morbidity and mortality in patients with chronic liver disease. Endoscopic treatment is the first therapeutic line for these patients, however, for those whom this therapeutic modality fail, a broad knowledge of alternative treatment options may improve the prognosis. We describe a case of a patient who were successfully embolized from gastroesophageal varices via transsplenic access.

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

INTRODUCTION

Ectopic variceal bleeding is uncommon, accounts for 2-5% of variceal bleeding, of which 17% is in duodenum.

PRESENTATION OF CASE

62-year-old lady with newly diagnosed liver cirrhosis on admission, presented with severe upper gastrointestinal bleeding (UGIB), was ultimately diagnosed with bleeding duodenal varices with single-balloon enteroscopy, after multiple oesophagogastroduodenoscopies (OGDs) and CT scans which failed to identify the varices. She was treated successfully with duodenectomy.

DISCUSSION

Endoscopy and CT angiography remain the diagnostic modalities of choice. However, diagnosis can be difficult as evidenced by three OGDs and two CTMAs yielding negative findings in this case. Endoscopic diagnosis is challenging and often delayed due to its rarity and unusual location.

CONCLUSION

Ectopic variceal bleeding is a rare but important cause of UGIB. Diagnosis is challenging and management of this condition should take a multidisciplinary approach, involving experienced gastroenterologists, interventional radiologists and surgeons. Endoscopic ligation or sclerotherapy is the first-line of treatment.

Duodenal variceal bleed: an unusual cause of upper gastrointestinal bleed and a difficult diagnosis to make

We present a case of recurrent upper gastrointestinal (GI) bleeding in a man aged 57 years with primary biliary cholangitis who was ultimately diagnosed with an isolated duodenal variceal bleed, which was successfully treated with histoacryl glue injection. Duodenal varices are an uncommon presentation of portal hypertension and can result in significant GI bleeding with a high mortality. Diagnosis can be difficult and therapeutic options limited. Endoscopic variceal sclerotherapy with histoacryl glue provides an effective treatment, though endoscopists need to remain aware of and vigilant for the serious complications of this treatment option.

Upper gastrointestinal ectopic variceal bleeding treated with various endoscopic modalities: Case reports and literature review

RATIONALE

Ectopic variceal bleeding is a rare (2-5%) but fatal gastrointestinal bleed in patients with portal hypertension. Patients with ectopic variceal bleeding manifest melena, hematochezia, or hematemesis, which require urgent managements. Definitive therapeutic modalities of ectopic varices are not yet standardized because of low incidence. Various therapeutic modalities have been applied on the basis of the experiences of experts or availability of facilities, with varying results.

PATIENT CONCERNS

We have encountered eight cases of gastrointestinal ectopic variceal bleeding in five patients in the last five years.

DIAGNOSES

All patients were diagnosed with liver cirrhosis presenting melena or hematemesis.

INTERVENTIONS

All patients were treated with various endoscopic modalities (endoscopic variceal obturation [EVO] with cyanoacrylate in five cases, endoscopic variceal band ligation (EVL) in two cases, hemoclipping in one case).

OUTCOMES

Satisfactory hemostasis was achieved without radiologic interventions in all cases. EVO and EVL each caused one case of portal biliopathy, and EVL induced ulcer bleeding in one case.

LESSONS

EVO generally accomplished better results of variceal obturations than EVL or hemoclipping, without serious adverse events. EVO may be an effective modality for control of ectopic variceal bleeding without radiologic intervention or surgery.

Treatment and follow-up of a case of bleeding duodenal varix

Duodenal varices (DV) are rare in patients with portal hypertension secondary to liver disease. Their tendency to bleed is less common than in gastroesophageal varices, but can sometimes produce a life-threatening bleed. They are often difficult to diagnose and treat. We present a case of a 35-year-old man with parenchymal liver disease admitted with complaints of hematemesis and melena. Upper gastrointestinal endoscopy was performed and a duodenal varix, with stigmata of a recent bleed, was noted in the second part of the duodenum. Five milliliters of N-butyl-2-cyanoacrylate glue was injected into the varix leading to obliteration. A follow-up study with an endoscopic ultrasound and repeat endoscopy showed near total obturation of the varix and success of the therapy. This report concludes that glue injection can effectively be used as a first-line treatment for bleeding duodenal varices.

Upper gastrointestinal bleeding in cirrhosis: varix or no varix?

Upper gastrointestinal bleeding from variceal origin is a frequent complication in the cirrhotic population. Duodenal variceal haemorrhage, however, is infrequent and the endoscopic management of such lesions is not straightforward. Non-endoscopic options include vasoactive drugs, transjugular intrahepatic portosystemic shunt (TIPS), transvenous obliteration and surgery as rescue therapy. We present a patient with Child-Pugh A hepatitis C virus-cirrhosis with acute bleeding from a duodenal varix. It was managed with elastic band ligation but late rebleeding occurred after 6 weeks. Gastroduodenoscopy revealed active bleeding from the ligation eschar. Band ligation and sclerosis were attempted but unsuccessful. Terlipressin was started and the patient referred for TIPS. Surprisingly, angiography showed a normal hepatic vein pressure gradient; therefore, TIPS was not performed. Haemorrhage ceased with medical treatment alone. The patient remained stable and was discharged after 10 days, being currently under evaluation for hepatitis C therapy.