Duodenal Varix Rupture - A Rare Cause of Fatal Gastrointestinal Hemorrhage: A Case Report and Review of Literature

Outcomes of endoscopic treatment for acute duodenal ectopic variceal bleeding: a single-center retrospective case series

Duodenal ectopic variceal hemorrhage is a rare portal hypertension complication that can easily be clinically missed. Once hemorrhage occurs, the rebleeding and fatality rates are high. There is no unified standard for its treatment, we reported the endoscopic treatment of eight patients admitted to our department between January 2014 and May 2021, Endoscopic band ligation and endoscopic cyanoacrylate injection were performed in five and three cases, respectively. The hemostasis success rate was 100%, no postoperative bleeding occurred, and there were no serious complications. Duodenal varices disappeared in four cases after 2-12 months. In conclusion, Endoscopic therapy is an ideal treatment method for acute duodenal ectopic variceal hemorrhage.

Endoscopic Cyanoacrylate Glue Injection for Duodenal Varices—A Single-Center Study

Aim/Objectives Duodenal varices (DVs), although rare, can present with massive, potentially fatal upper gastrointestinal bleeding; however, there are no randomized trials regarding management of this relatively uncommon presentation. We aim to report our experience with endoscopic cyanoacrylate glue injection in patients with DVs.

Materials and Methods We retrospectively evaluated the medical records of all patients with portal hypertension at our center between January 2010 and December 2021. Demographic characteristics along with the etiology, location, and effectiveness of cyanoacrylate glue injection for bleeding DVs were collected and analyzed.

Results A total of 5,892 patients with portal hypertension underwent endoscopy during the study period, of whom 41 patients (M:F = 29:12) with mean age of 38 years were noted to have DVs. While extrahepatic portal vein obstruction was the commonest etiology (n = 26), the most common site of DVs was the duodenal bulb (n = 21). Twenty-one (51%) out of these 41 patients presented primarily with DV bleeding and underwent endoscopic cyanoacrylate glue injection with successful hemostasis achieved of the index bleed; however, four of these 21 patients had rebleeding between 2 weeks and 12 months of follow-up requiring repeat endotherapy.. While three patients underwent successful repeat glue injections, one patient had recurrent massive bleedings, not amenable to endotherapy and was subjected to duodenal resection with surgical shunt procedure.

Conclusion While the prevalence of DVs in portal hypertension patients was 0.7% (41/5892), DVs accounted for 0.42% (21/4889) of portal hypertension-related bleedings. Endotherapy with cyanoacrylate glue appears to be a safe and cost-effective treatment for acute DV bleeding in a resource-limited setting.

[Ectopic duodenal varices as a cause of difficult diagnosis of bleeding in extrahepatic portal hypertension]

Bleeding from ectopic varicose veins is a rare life-threatening cause of upper gastrointestinal hemorrhage. Alberti first described duodenal varices in 1931. According to the literature, incidence of duodenal varicose veins in patients with portal hypertension is 1-3% of all varicose veins. Bleeding from duodenal varices makes up 17% of all bleedings from other ectopic varices. Mortality in these patients may be up to 40%. The causes are delayed diagnosis, technical difficulties in endoscopic therapeutic procedures (sclerotherapy, endoscopic ligation), as well as ineffective Blackmore tube for hemorrhage in distal stomach and bowel. We report a rare case of upper gastrointestinal bleeding from ectopic duodenal varices.

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.