Published online Aug 28, 2019. doi: 10.4329/wjr.v11.i8.110
Peer-review started: July 26, 2019
First decision: August 2, 2019
Revised: August 14, 2019
Accepted: August 18, 2019
Article in press: August 19, 2019
Published online: August 28, 2019
Duodenal variceal bleeding is a rare cause of gastrointestinal bleeding. The most common site is the duodenal bulb. It is usually detected endoscopically but it can be very challenging to diagnose if it is located distal to the second part of duodenum. The pre- transjugular intrahepatic portosystemic shunt (TIPS) presence of SPSS was found to be associated with an increased risk of early morbidity and mortality after TIPS placement.
A 43-year-old cirrhotic male presented with melena for three days. Upper endoscopy was performed and showed active blood oozing from the distal duodenum concerning for ectopic duodenal varix. A computed tomography (CT) angiogram was performed and showed an enlarged cluster of venous collaterals around the distal duodenum. He underwent TIPS placement. He had another episode of melena three days later. Push enteroscopy with injection sclerotherapy into the duodenal varices was performed with no success. A repeat CT angiogram showed occluded TIPS shunt. Therefore, a TIPS revision was performed and there was an extensive portal venous thrombosis with a large shunt between the inferior mesenteric vein and left renal vein via the left gonadal vein. Thrombectomy and TIPS shunt balloon angioplasty was performed, followed by embolization of the portosystemic. The melena was resolved, and patient was discharged with arranged hepatology follow up.
It important to look and embolize the SPSS shunts in patients with early TIPS dysfunction and recurrent duodenal variceal bleeding.
Core tip: Portal hypertension leads to the formation of varices, which can be present at the gastroesophageal region or ectopic locations. Bleeding ectopic varices are challenging to manage, and in many cases, transjugular intrahepatic portosystemic shunt (TIPS) is a safe and effective therapy. The pre-TIPS presence of SPSS was found to be associated with an increased risk of early morbidity and mortality after TIPS placement. We have successfully treated a patient with duodenal variceal bleeding with TIPS and embolization of SPSS after he failed TIPS monotherapy.