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AbstractsL ACCEPTED: CLINICAL VIGNETTES/CASE REPORTS - SMALL INTESTINE/UNCLASSIFIED

A Rare Cause of Upper GI Bleeding: Portal Hypertensive Duodenopathy Secondary to Noncirrhotic Portal Hypertension

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Katz, Kristina MD; Dalal, Ishita MD; Shingala, Prapti MD; Chokhavatia, Sita MD, FACG

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American Journal of Gastroenterology: October 2016 - Volume 111 - Issue - p S1063
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Introduction: Splenic and mesenteric vein thrombosis, leading to portal hypertension (pHTN), is a wellknown consequence of acute pancreatitis. Portal hypertensive gastropathy, esophageal varices and gastric varices are seen in pHTN, however portal hypertensive duodenopathy and duodenal varices are more rare phenomena. We present a case of recurrent upper gastrointestinal (GI) bleeding secondary to portal hypertensive duodenopathy.

Case: 65-year-old male with gallstone pancreatitis complicated by severe necrosis requiring debridement in 2010, cholecystectomy transferred to our hospital for further management. Patient presented to the outside hospital (OSH) several months prior with melena; upper endoscopy (EGD) revealed a polypoid lesion in the duodenal bulb and in the second portion, biopsies negative for malignancy. He was discharged on twice-daily PPI. He presented to the OSH this admission again with melena. EGD revealed congested and oozing mucosa in the duodenal bulb treated with Epinephrine. Upon transfer to our hospital, patient continued to have melena, so repeat EGD was done, revealing duodenitis with friability in the bulb with active oozing treated with Epinephrine and duodenal varices in the second portion without bleeding or evidence of recent bleeding. No esophageal or gastric varices were visualized. MRV abdomen revealed occlusion of the superior mesenteric vein (SMV) just proximal to the inferior portion of the pancreas near the confluence of the portal venous system, with numerous collateral mesenteric vessels extending to the periduodenal region. Splenic vein was patent and intrahepatic portal system was normal. Patient was discharged home on a non-selective B-blocker.

Discussion: Our patient's SMV occlusion was likely related to chronic pancreatitis, and thus lead to noncirrhotic pHTN. PHTN can result in “congestive gastroenteropathy”, which can manifest anywhere in the GI tract. Bleeding in these cases is usually related to erosions or ulcers; however there has been reports of active bleeding secondary to erythematous duodenopathy. About 25% of duodenal varices are caused by extrahepatic pHTN. Bleeding from duodenal varices account for only 0.4% of all variceal bleeding, but can be catastrophic. Surgical treatment options for duodenal variceal hemorrhage include mesocaval shunting, and can be considered for our patient if he continues to have recurrent bleeding from the portal hypertensive duodenopathy.

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