Duodenal variceal bleeding treated with a transjugular intrahepatic portosystemic shunt

Safety and efficacy of angiographic occlusion of duodenal varices as an alternative to TIPS: review of 32 cases

BACKGROUND/RATIONALE OF STUDY: Analyze safety and efficacy of angiographic-occlusion-with-sclerotherapy/embolotherapy-without-transjugular-intrahepatic-portosystemic-shunt (TIPS) for duodenal varices. Although TIPS is considered the best intermediate-to-long term therapy after failed endoscopic therapy for bleeding varices, the options are not well-defined when TIPS is relatively contraindicated, with scant data on alternative therapies due to relative rarity of duodenal varices. Prior cases were identified by computerized literature search, supplemented by one illustrative case. Favorable clinical outcome after angiography defined as no rebleeding during follow-up, without major procedural complications.

RESULTS

Thirty-two cases of duodenal varices treated by angiographic-occlusion-with-sclerotherapy/embolotherapy- without-TIPS were analyzed. Patients averaged 59.5 ± 12.2 years old (female = 59%). Patients presented with melena-16, hematemesis & melena-5, large varices-5, growing varices-2, ruptured varices-1, and other- 3. Twenty-nine patients had cirrhosis; etiologies included: alcoholism-11, hepatitis C-11, primary biliary cirrhosis- 3, hepatitis B-2, Budd-Chiari-1, and idiopathic-1. Three patients did not have cirrhosis, including hepatic metastases from rectal cancer-1, Wilson's disease-1, and chronic liver dysfunction-1. Thirty-one patients underwent esophagogastroduodenoscopy before therapeutic angiography, including fifteen undergoing endoscopic variceal therapy. Therapeutic angiographic techniques included balloon-occluded retrograde-transvenous-obliteration (BRTO) with sclerotherapy and/or embolization-21, DBOE (double-balloon-occluded-embolotherapy)-5, and other-6. Twenty-eight patients (87.5%; 95%-confidence interval: 69-100%) had favorable clinical outcomes after therapeutic angiography. Three patients were therapeutic failures: rebleeding at 0, 5, or 10 days after therapy. One major complication (Enterobacter sepsis) and one minor complication occurred.

CONCLUSIONS

This work suggests that angiographic-occlusion-with sclerotherapy/ embolotherapy-without-TIPS is relatively effective (~90% hemostasis-rate), and relatively safe (3% major-complication-rate). This therapy may be a useful treatment option for duodenal varices when endoscopic therapy fails and TIPS is relatively contraindicated.

Duodenal varices successfully treated with cyanoacrylate injection therapy

Duodenal varices are a rare complication of portal hypertension secondary to liver cirrhosis. Compared to oesophageal varices, they bleed less often but are also more difficult to diagnose and treat. There is no established treatment for bleeding duodenal varices and different treatment strategies have been employed with variable results. The authors present a case of 52-year-old male who was admitted with melaena. Upper gastrointestinal endoscopy was performed which identified bleeding varices in the second part of duodenum. The varices were injected with cyanoacrylate and the outcome was favourable. Subsequent endoscopies showed complete resolution of the varices. The authors conclude that cyanoacrylate injection is an effective first-line treatment for bleeding duodenal varices.

Hemorrhagic duodenal varices treated successfully with endoscopic injection sclerotherapy using cyanoacrylate and ethanolamine-oleate: a case report

We report a case of a 50-year-old man with a medical history of alcoholic cirrhosis, in addition to esophagogastric and duodenal varices (DV), who was transferred to our institution because of hemorrhagic DV. Emergent esophagogastroduodenoscopy showed hemorrhagic varices in the horizontal portion of the duodenum. Abdominal contrast-enhanced CT showed hemodynamics of DV derived from anastomosis between the superior mesenteric vein and right renal vein. Cyanoacrylate was injected into the DV. Subsequently, 5% ethanolamine-oleate was injected endoscopically as a sclerosant into the DV feeding vein. Radiographic fluoroscopic findings revealed that the injected cyanoacrylate and sclerosant remained, respectively, in the varices and its feeder. Five days later, CT showed that the injected cyanoacrylate occupied the DV, and thrombus formation of the afferent vein led to bifurcation of superior mesenteric vein. This case showed the usefulness of endoscopic injection sclerotherapy using cyanoacrylate and sclerosant for the management of DV.

Bleeding ectopic varices--treatment with transjugular intrahepatic porto-systemic shunt (TIPS) and embolisation

BACKGROUND/AIMS

Bleeding ectopic varices due to cirrhosis can be difficult to manage. We report our experience of uncontrolled bleeding from ectopic varices treated with transjugular intrahepatic porto-systemic shunt (TIPS).

METHODS

We selected the 21 cirrhotics who underwent TIPS for bleeding ectopic varices from our database: Child-Pugh grade A (2), B (11) and C (8). Site of bleeding was rectal (11), colonic (2), ileal 1, jejunal 1, duodenal 1, and stomal (5).

RESULTS

TIPS was performed successfully in 19/21 (90%) patients. All except 1 had either a reduction in portosystemic pressure gradient < or = 12 mmHg (n=12) or reduction by 25-50% of baseline (n=6). TIPS alone was used in 12/19: 7 of these 12 had no further bleeding; 5 (42%) rebled within 48 h, and had embolisation, 4 without further bleeding. In 7 of 19, TIPS and embolisation were performed together: 2 patients (28%) rebled; further embolisation stopped the bleeding.

CONCLUSIONS

Ectopic varices do rebleed despite a reduction of porto-systemic pressure gradient < or = 12 mmHg or by 25-50% of baseline, following TIPS. Embolisation stopped bleeding in all but 1 patient. We recommend performing embolisation at the time of the initial TIPS to control bleeding from ectopic varices.

Rectal variceal bleeding treated by transjugular intrahepatic portosystemic shunt. Potentials and pitfalls

Bleeding from anorectal varices can be massive and life threatening. Prompt differentiation between hemorrhoids and anorectal varices is crucial in treating these patients. Many different treatments are available for bleeding anorectal varices, but none has proved efficacy. We report a case of successful transjugular intrahepatic portosystemic shunt (TIPS) in controlling massive rectal variceal bleeding in an elderly patient with primary biliary cirrhosis and portal hypertension. After TIPS, rapid decompensation of liver function and encephalopathy developed and led to her death. Although TIPS may be effective in controlling acute life-threatening bleeding from anorectal varices, it can be associated with life-threatening complications.