Abstracts: ACCEPTED: CLINICAL VIGNETTES/CASE REPORTS—GI BLEEDING
Duodenal Varices: A Rare Cause of Gastrointestinal Bleeding
Duodenal varices are a relatively rare manifestation of portal hypertension accounting for 0.4% of all cases, with chronic liver diseases mainly cirrhosis being the most common etiological factor. Duodenal varices usually occur in the duodenal bulb and the second portion of the duodenum. The prognosis in patients with duodenal varices is very poor with a mortality rate of 40% owing to the high vascularity of the duodenum which can cause profuse bleeding. Approximately 25% of patients with duodenal varices also have associated esophageal varices, however it is very rare to find an isolated case of duodenal varices. A 60 year-old female with alcoholic cirrhosis was admitted with a three day history of intermittent hematochezia and melena. Physical exam was suggestive of a significantly distended abdomen with tenderness in all four abdominal quadrants. Initial laboratory values noted a hemoglobin (Hb) of 7 g/dl and she received one unit of packed red blood cells. Computed Tomography (CT) Abdomen showed cirrhosis with numerous prominent gastroesophageal varices, a large degree of ascites, and mild mural thickening involving the majority of the small bowel. Further evaluation with Esophagogastroduodenoscopy (EGD) showed duodenal varices in the second portion of the duodenum with stigmata (cherry red spots), grade 2 distal esophageal varices without stigmata both of which were treated with band ligation. Hb remained stable at 8.6g/dl, and her hematochezia and melena subsequently resolved. She is closely being followed up as an outpatient with serial Hb monitoring and surveillance endoscopy. The optimal treatment for patients with bleeding duodenal varices remains unclear. Endoscopic intervention with band ligation is considered to be the first line therapy for duodenal varices. Current literature review have supported the use of secondary interventional procedures like transjugular intrahepatic portosystemic shunting (TIPS), balloon occluded retrograde transvenous obliteration band ligation(B-RTO), sclerosant injection therapy and liquid adhesive techniques. Surgical procedures such as duodenectomy and gastro-duodenectomy are indicated if all other treatments have failed. Our case illustrates the importance of close monitoring of this rare condition considering that there have been no clinical trials to compare the efficacy of one treatment modality.© The American College of Gastroenterology 2017. All Rights Reserved.