BLOG: A 52 year old male with hematemesis and melena

by Tripti R. Chopade, MD, Clinical Research Fellow in the division of gastroenterology and hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania.

Case:

A 52 year old male with a past medical history of idiopathic non-cirrhotic portal hypertension since childhood, was transferred to our hospital for management of hematemesis and melena. His past medical history was significant for recurrent gastric and esophageal variceal bleeds; which were treated with sclerotherapy. He underwent splenorenal shunt surgery and splenectomy approximately 23 years ago with good response.

Tripti R. Chopade

On physical examination, the patient was lethargic with anicteric sclera and mild abdominal distension.

Diagnostic imaging with abdominal contrast tomography was done with the findings as seen in Figure 1 (A, B, C): Post Contrast CT Abdomen.

Figure 1A: Postcontrast axial image

Figure 1B: Postcontrast axial image

Figure 1C: Postcontrast coronal reconstruction

On laboratory evaluation, hemoglobin was 7.4 g/dL at admission despite of receiving 5 units of packed Red Blood Cells (RBCs) at another hospital. Total bilirubin 3.9 mg/dL, AST 20 IU/L, ALT 23 IU/L, INR 1.2.

Esophagogastroduodenoscopy (EGD) was done with the findings as shown in Figure 2 as visualized in second part of duodenum.

Figure 2: Active bleed in second part of duodenum

What is your diagnosis?

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Answer: Duodenal Varix

Duodenal varices (DV) are rare but potentially serious complication of portal hypertension due to high risk of massive gastrointestinal bleeding. Ectopic varices (other than the esophagogastric region) account for only 1–5% of all cases of variceal bleeding. DV occur in 0.4% in all patients with portal hypertension and account for one third of bleeding from ectopic varices. Duodenal varices are more common in patients having extraheaptic portal hypertension and those having thrombosed portosytemic shunts.

It is formed by the developed collateral veins originating from the portal vein trunk or superior mesenteric vein, which empty into the inferior vena cava. Blood flow in DV is frequently high and results in profuse bleeding. Prognosis is poor with mortality rates as high as 40%. The most common locations of DV are the first (duodenal bulb-posterior wall) and second (duodenal sweep) portions of the duodenum, although they can also be rarely seen in the distal duodenum (third and fourth portions of the duodenum). The diagnosis is frequently made at endoscopy or by other means (e.g. barium studies, angiography or laparotomy/laparoscopy). Treatment options such as endoscopic band ligation (EBL), clipping or sclerotherapy, endovascular interventions such as transjugular intrahepatic portosystemic shunt (TIPS), balloon-occluded retrograde transvenous occlusion (BRTO) and surgery (e.g. portocaval shunt/resection) are described in literature with variable outcome.

Management of our patient: EBL of DV with one band was performed and hemostasis achieved (Figure 3). Post EBL patient was hemodynamically stable and his melena resolved. As demonstrated on abdominal contrast tomography images in figure 1A, thrombosis of main portal vein and right hepatic vein precluded the management with TIPS.

Figure 3. Status post band ligation of bleeding duodenal varix

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Follow up: EGD 2 weeks later showed obliteration of the banded DV. Surveillance EGD 5 months later showed complete regression of banded DV with scarring at the site and nonbleeding varices on opposite duodenal wall (Figure 4).

Figure 4. Obliteration of the banded duodenal varix but additional noted on opposite wall

EBL is widely accepted as a primary therapy for esophageal variceal bleeding; however, there is no widely accepted treatment modality for duodenal varices. EBL is a minimally invasive, fast and effective way to secure hemostasis. The success of EBL may depend on location and size of varices as well as on expertise availability. The serosal location of DV limits the visualization and thus makes the band ligation more challenging.

With this case we share our experience of successful EBL as a treatment for DV hemorrhage in a patient where other modalities, such as TIPS, are impossible or contraindicated. However, one must monitor for the formation of additional varices in other intestinal sites after EBL with surveillance endoscopy or capsule endoscopy.

Key points:

DV occur in 0.4% of all patients with portal hypertension and account for one third of bleeding from ectopic varices.
Blood flow in DV is frequently high and results in profuse bleeding.
Prognosis is poor with mortality rates as high as 40%.
EBL is widely accepted as a primary therapy for esophageal variceal bleeding; however, there is no widely accepted treatment modality for duodenal varices.
This case represents successful EBL as a treatment for DV hemorrhage in a patient where other modalities, such as TIPS, were impossible or contraindicated.
Due to the formation of additional varices in other intestinal sites after EBL, surveillance endoscopy or capsule endoscopy should be used to monitor for their development.

References:

Cottam DR, et al. Am Surg. 2002;68:407-409.

Khouqeer F, et al. Surgery. 1987;102:548-52.

Lebrec D, Benhamou JP. Clin Gastroenterol. 1985;14:105-21.

Linder S, Wiechel KL. Surg Endosc. 1991;5:31-5.

Norton ID, et al. Hepatology. 1998;28:1154-8.

Sato T, et al. Int J Hepatol. 2011;doi:10.4061/2011/960720.

Saad W, et al. Tech Vasc Interv Radiol. 2013; doi:10.1053/j.tvir.2013.02.004.

Sousa HT, et al. Rev Esp Enferm Dig. 2008;100:171–172.

For more information:

Tripti Chopade, MD, can be reached at tripti.chopade@jefferson.edu.

Dina Halegoua-De Marzio, MD, can be reached at dina.halegoua@jefferson.edu.