Duodenal variceal bleeding secondary to idiopathic portal hypertension treated with transjugular intra-hepatic porto-systemic shunt plus embolization: A case report

Figure 1 Imaging features of endoscopy and hepatic pathology. A: An esophagogastroduodenoscopy (EGD) showed mild varices (white arrow) located in the esophagus without bloody scab; B and C: An EGD displayed a large submucosal vermicular mass (white arrow) located in the first and second duodenum with bloody scab; D and E: Liver samples were observed pathologically with Hematoxylin and Eosin staining. There was an integrated structure in the hepatic lobule with small sporadic necrotic foci, in which hepatic cells were moderately swollen with uneven nuclear size and fibrosis in portal triads. The extreme extension (D) and occlusion (E) of portal branches in portal regions are denoted by the black arrow; F: Perisinusoidal fibrosis (black arrow) was surrounded by hepatic lobule, as shown by Masson staining.

Figure 2 Imaging features of the transjugular intra-hepatic porto-systemic shunt procedure. A: Transhepatic portogram using iodinated contrast material showed dilated main portal vein (white arrow) and mild gastric coronary vein (black arrow) after successful hepatic vein puncture to the port vein; B: Mesenteric angiography indicated the remarkably dilated duodenal varices (black arrow) extending from the proximal superior mesenteric vein (white arrow); C: The shunt (black arrow) extends from the superior mesenteric vein towards the inferior vena cava (white arrow); D: Mesenteric angiography illustrates that the dilated duodenal varices were obliterated by stainless-steel coils and Histoacryl. The deployed coils (white arrow) and reduced duodenal varices (black arrow) are clearly denoted in the fluoroscopic image; E: Balloon dilatation (white arrow) of a tract interposed between the hepatic and portal veins is shown in the fluoroscopic image; F: Portal venogram after transjugular intra-hepatic porto-systemic shunt insertion with a metallic bare stent and a covered stent (white arrow) demonstrates that the indicated iodinated contrast flows easily towards the heart. Peripheral portal vein branches are reduced because of flow reversal. The deployed coils and reduced duodenal varices (black arrow) are shown by portography.