Case Report
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Radiol. Aug 28, 2019; 11(8): 110-115
Published online Aug 28, 2019. doi: 10.4329/wjr.v11.i8.110
Duodenal variceal bleeding with large SPSS treated with transjugular intrahepatic portosystemic shunt and embolization: A case report
Rohit Anand, Saad Emhmed Ali, Driss Raissi, Wesam M Frandah
Rohit Anand, Saad Emhmed Ali, Departament of Internal Medicine, University of Kentucky, Lexington, KY 40536, United States
Driss Raissi, Wesam M Frandah, Department of Interventional Radiology, University of Kentucky, Lexington, KY 40536, United States
Author contributions: Emhmed Ali S, Anand R, Raissi D and Frandah WM designed the paper. Emhmed Ali S, Anand R, Raissi D and Frandah WM wrote the paper. All authors contributed equally to this paper. An author may list more than one contribution, and more than one author may have contributed to the same aspect.
Informed consent statement: Informed consent was obtained from the patient.
Conflict-of-interest statement: No conflict of interest declared.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Saad Emhmed Ali, FACP, MD, Assistant Professor, Departament of Internal Medicine, University of Kentucky, 800 Rose St, Lexington, KY 40536, United States.
Telephone: +1-859-2184991 Fax: +1-859-2283352
Received: July 13, 2019
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.

Keywords: Portasystemic shunt, Gastrointestinal hemorrhage, Liver cirrhosis, Duodenum, Endoscopy, Angioplasty, Case report

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.