Neeraj Vinayakumar¹*, Meenakshi Nayanar² and Paul Chethalan³

¹Consultant Gastroenterologist, SriRamakrishna Ashrama Hospital, Trivandrum, Kerala, India
²Consultant Pediatrician, Dr VC Nayanar Memorial Hospital, Payyannur, Kerala, India
³Consultant Radiologist, Aarupadai Veedu Medical College, Puducherry, India

*Corresponding Author: Neeraj Vinayakumar, Consultant Gastroenterologist, SriRamakrishna Ashrama Hospital, Trivandrum, Kerala, India

Received: February 16, 2021; Published: February 25, 2021

Citation: Neeraj Vinayakumar., et al. “An Interesting Case of Upper Gastrointestinal Bleed”. Acta Scientific Clinical Case Reports 2.3 (2021): 15-16.

Abstract

  Duodenal varices are ectopic varices which are seen commonly in the first and second part of duodenum. They are uncommon as compared to esophageal and gastric varices. Bleeding duodenal varices if unidentified, may result in torrential upper gastrointestinal bleed with a mortality of upto 40%. Here is a case of middle aged man with chronic liver disease who presented with melena and on evaluation had duodenal varices on endoscopy. Endoscopic variceal ligation was done after which the melena subsided and patient is doing well on follow up.

Keywords: Duodenal Varices; Ectopic Varices; Gastric Varices

Introduction

Duodenal varices are ectopic varices which are seen commonly in the first and second part of duodenum.

Case Report

  A 50 year old gentleman came to the outpatient department with intermittent melena since 3 days. He was a chronic alcoholic with last drink 1 week back. On examination he had pallor. Abdominal examination was normal. Hemoglobin was 6 g/dL. He was given 2 units of packed red cells. Platelet count, Liver function tests were normal with an INR of 1.2. Ultrasound abdomen revealed chronic liver disease with mild splenomegaly. Upper GI endoscopy revealed small esophageal varices and large duodenal varices in first and second parts of duodenum. He underwent endoscopic ligation of the varices. His melena subsided and hemoglobin is now stable at 10 g/dL. He is now on Propranolol 40 mg/day. He is on frequent OPD follow up and surveillance endoscopies.

Figure: Large esophageal varices in duodenum.

Discussion and Conclusion

  Duodenal varices are ectopic varices and even though rare, may present without esophageal or gastric varices [1]. If untreated, the mortality due to upper gastrointestinal bleed approaches 40% [1,2]. Large duodenal varices are usually treated with endoscopic variceal ligation [3]. Other treatment modalities include sclerosant injection or application of clips using endoscopy, endoscopic ultrasound guided coil embolization, balloon retrograde transvenous obliteration (BRTO), transjugular intrahepatic portosystemic shunts (TIPS) [4,5]. Appropriate management of these varices are important as they may result in torrential upper gastrointestinal bleed.

Bibliography

1. Malik A., et al. “Duodenal Varices: A Rare Cause of Gastrointestinal Bleeding: 1876”. The American Journal of Gastroenterology 112 (2017): S1032.
2. House T., et al. “Massive Hemorrhage from Ectopic Duodenal Varices: Importance of a Multidisciplinary Approach”. Case Reports in Gastroenterology 1 (2017): 36-41.
3. A Clark Gunnerson., et al. “Endoscopic duodenal variceal ligation: a series of 4 cases and review of the literature (with video)”. - PubMed - NCBI (2020).
4. Sato T. “Treatment of ectopic varices with portal hypertension”. World Journal of Hepatology 12 (2015):1601-1605.
5. Kinzel J., et al. “Bleeding from a duodenal varix: a unique case of variceal hemostasis achieved using EUS-guided placement of an embolization coil and cyanoacrylate”. Journal of Clinical Gastroenterology 4 (2014): 362-364.

Copyright: © 2021 Neeraj Vinayakumar., et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.