IMAGE OF THE MONTH An Uncommon Cause of Gastrointestinal Bleeding in Patients With Portal Hypertension Sandra Rodriguez, Richard Arrigo, and Nikolaos Pyrsopoulos Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, New Jersey
40-year-old man with a history of Laennec cirrhosis was transferred to our tertiary care facility for the management of massive hematemesis and low hemoglobin. Patient was treated with multiple blood transfusions, and an esophagogastroduodenoscopy failed to reveal the bleeding source. Subsequently, a singleballoon push enteroscopy was performed, revealing large varices in the fourth portion of the duodenum with stigmata of active bleeding (Figures A–C). The patient was immediately referred for transjugular intrahepatic portosystemic shunt. Variceal bleeding is a common complication of portal hypertension. The most common locations for varices are the esophagus and the stomach. Duodenal varices are uncommon and can be seen in up to 0.4% of patients with portal hypertension.1 The most common sites are the duodenal bulb, followed by the second portion of the duodenum.2 When present, they can cause massive upper gastrointestinal bleeding associated with associated mortality of up to 40%.3 Multiple strategies have been described in the literature regarding management. Endoscopically, sclerotherapy has been used as a first-line therapeutic measure, although there is a risk of perforation, embolism, and tissue injury associated with its use.4 In addition, banding and the use of hemoclips have been reported, although in the presence of portal hypertension this is merely a
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Clinical Gastroenterology and Hepatology 2014;12:xxiv
temporary solution. As such, transjugular intrahepatic portosystemic shunt is a much safer and effective approach to the management of ectopic varices in patients with portal hypertension.5
References 1.
Hashizume M, Tanoue K, Ohta M, et al. Vascular anatomy of duodenal varices: angiographic and histopathological assessments. Am J Gastroenterol 1993;88:1942–1945.
2.
Wang CS, Jeng LB, Chen MF. Duodenal variceal bleeding successfully treated by mesocaval shunt after failure of sclerotherapy. Hepatogastroenterology 1995;42:59–61.
3.
Khouqeer F, Morrow C, Jordan P. Duodenal varices as a cause of massive upper gastrointestinal bleeding. Surgery 1987; 102:548–552.
4.
Norton ID, Andrews JC, Kamath PS. Management of ectopic varices. Hepatology 1998;28:1154–1158.
5.
García-Pagán JC, Caca K, Bureau CJ, et al. Early TIPS (Transjugular Intrahepatic Portosystemic Shunt) Cooperative Study Group: early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med 2010;24:2370–2379.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2014.07.050
40-year-old man with a history of Laennec cirrhosis was transferred to our tertiary care facility for the management of massive hematemesis and low hemoglobin. Patient was treated with multiple blood transfusions, and an esophagogastroduodenoscopy failed to reveal the bleeding source. Subsequently, a singleballoon push enteroscopy was performed, revealing large varices in the fourth portion of the duodenum with stigmata of active bleeding (Figures A–C). The patient was immediately referred for transjugular intrahepatic portosystemic shunt. Variceal bleeding is a common complication of portal hypertension. The most common locations for varices are the esophagus and the stomach. Duodenal varices are uncommon and can be seen in up to 0.4% of patients with portal hypertension.1 The most common sites are the duodenal bulb, followed by the second portion of the duodenum.2 When present, they can cause massive upper gastrointestinal bleeding associated with associated mortality of up to 40%.3 Multiple strategies have been described in the literature regarding management. Endoscopically, sclerotherapy has been used as a first-line therapeutic measure, although there is a risk of perforation, embolism, and tissue injury associated with its use.4 In addition, banding and the use of hemoclips have been reported, although in the presence of portal hypertension this is merely a
A
Clinical Gastroenterology and Hepatology 2014;12:xxiv
temporary solution. As such, transjugular intrahepatic portosystemic shunt is a much safer and effective approach to the management of ectopic varices in patients with portal hypertension.5
References 1.
Hashizume M, Tanoue K, Ohta M, et al. Vascular anatomy of duodenal varices: angiographic and histopathological assessments. Am J Gastroenterol 1993;88:1942–1945.
2.
Wang CS, Jeng LB, Chen MF. Duodenal variceal bleeding successfully treated by mesocaval shunt after failure of sclerotherapy. Hepatogastroenterology 1995;42:59–61.
3.
Khouqeer F, Morrow C, Jordan P. Duodenal varices as a cause of massive upper gastrointestinal bleeding. Surgery 1987; 102:548–552.
4.
Norton ID, Andrews JC, Kamath PS. Management of ectopic varices. Hepatology 1998;28:1154–1158.
5.
García-Pagán JC, Caca K, Bureau CJ, et al. Early TIPS (Transjugular Intrahepatic Portosystemic Shunt) Cooperative Study Group: early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med 2010;24:2370–2379.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2014.07.050
