Amaro, P

Ferreira, M

Gouveia, H

Gregório, C

Leitão, M

Romãozinho, JM

Sousa, HT

Repositório Institucional dos Hospitais da Universidade de Coimbra

Upper digestive bleeding caused by ruptured duodenal varices is a rare and often life-threatening condition, forwhich there is little agreement on the best therapeutic option (1-5). A 47-years-old male, with alcoholic liver cirrhosis(Child-Pugh class C; MELD 29) and previous oesophageal varices bleeding, was admitted for profuse hematochezia.He was tachycardic, hypotensive and had haemoglobin 2,7 g/dl. Fluid and blood resuscitation, intravenous octreotide,ciprofloxacin and PPI were promptly started. Emergent upper gastrointestinal endoscopy (UGIE) revealed scarcefresh blood in the stomach and grade II oesophageal varices with red signs, which were thought to be the source ofbleeding and treated with endoscopic banding. As hemodynamic instability and hematochezia persisted, UGIE wasrepeated with similar findings and no bleeding was identified on angiography. At 48 h from admission massive re-bleeding occurred and a 3rd UGIE showed a fresh clot-over-varix located at 2nd to 3rd portions of duodenum (Fig. 1).Injection of the varix with 1 cc of lipiodol and cyanoacrylate 1:1 mixture was performed (Fig. 2), but spurting begansoon after the procedure. Given the high surgical risk, yet another endoscopic approach was decided and successful 1-ring banding was accomplished (Fig. 3). A 3rd-day UGIE showed a clean, shallow ulcer at the site of the varix (Fig. 4).No rebleeding episodes occurred. Several authors reported endoscopic banding for bleeding duodenal varices (1-4),sometimes followed by other therapies for rebleeding (3,4). Others used cyanoacrylate for emergent treatment of thiscondition (5), including after banding failure (3). This is, to our knowledge, the first report in which banding was ap-Successful endoscopic banding after cyanoacrylate failure foractive bleeding duodenal varixH. T. Sousa, C. Gregório, P. Amaro, M. Ferreira, J. M. Romãozinho, H. Gouveia and M. C. LeitãoGastroenterology Department. Coimbra University Hospital. Portugal1130-0108/2008/100/3/171-172REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVASCopyright © 2008 ARÁN EDICIONES, S. L.REV ESP ENFERM DIG (Madrid)Vol. 100. N.° 3, pp. 171-172, 2008PICTURES IN DIGESTIVE PATHOLOGYFig. 1. Clot over ruptured duodenal varix located at 2nd to 3rd portion ofthe duodenum.Fig. 2. Ruptured duodenal varix immediately after cyanoacrylate injec-tion.11. IPD1120 - H. T. SOUSA -:Maquetación 1 15/4/08  09:16  Página 171172 H. T. SOUSA ET AL. REV ESP ENFERM DIG (Madrid)REV ESP ENFERM DIG 2008; 100 (3): 171-172plied as a salvage therapy after cyanoacrylate failure. The size of the varix could be of importance in decidingwhether banding should be an appropriate option (1,2), but the existing limited experience warrants that managementof ectopic varices should still depend on the physician experience (4).REFERENCES1. Yeh YY, Hou MC, Lin HC, Chang FY, Lee SD. Case report: Successful obliteration of a bleeding duodenal varix by using endoscopic ligation. JGastroenterol Hepatol 1998; 13: 591-3.2. Tan NC, Ibrahim S, Tay KH. Successful management of a bleeding duodenal varix by endoscopic banding. Singapore Med J 2005; 46: 723-5.3. Yoshida Y, Imai Y, Nishikawa M, Nakatukasa M, Kurokawa M, Shibata K, et al. Successful endoscopic injection sclerotherapy with N-butyl-2-cyanoacrylate following the recurrence of bleeding soon after endoscopic ligation for ruptured duodenal varices. Am J Gastroenterol 1997; 92:1227-9.4. Selçuk H, Boyvat F, Eren S, Korkmaz M, Gür G, Yilmaz U, et al. Duodenal varices as an unusual cause of gastrointestinal bleeding due to portal hy-pertension: A case report. Turk J Gastroenetrol 2004; 15: 104-7.5. Ota K, Shirai Z, Masuzaki T, Tanaka K, Higashihara H, Okazaki M, et al. Endoscopic injection sclerotherapy with N-butyl-2-cyanoacrylate for rup-tured duodenal varices. J Gastroenterol 1998; 33: 550-5.Fig. 3. Successful 1-ring banding of ruptured duodenal varix. Fig. 4. Third-day endoscopy showed a shallow ulcer with no bleedingstigmata.11. IPD1120 - H. T. SOUSA -:Maquetación 1 15/4/08  09:16  Página 172

Successful endoscopic banding after cyanoacrylate failure for active bleeding duodenal varix

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Successful endoscopic banding after cyanoacrylate failure for active bleeding duodenal varix

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Repositório Institucional dos Hospitais da Universidade de Coimbra

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