A rare case of bleeding duodenal varices from superior mesenteric vein obstruction -treated with transhepatic recanalization and stent placement

Abstract

Ectopic varices are complex and highly variable entities that are not fully understood. Duodenal varices from pancreatitis have rarely been reported. Ectopic varices have much higher bleeding rates than the more common gastro-esophageal varices, and are associated with higher mortality. The ideal management of this difficult problem is not only to ensure prompt hemostasis, but also address the etiology or hemodynamics of the ectopic varices. We discuss the endovascular management of bleeding duodenal varices, which developed from superior mesenteric vein occlusion, following repeated attacks of pancreatitis. This unusual case was managed by a multidisciplinary collaborative approach between the gastrointestinal service and Interventional radiology. The classification system for ectopic varices and management options has been discussed in some detail. Medium term follow-up (8 months), at the time of this writing, showed that the patient is doing well, without interval hematemesis, imaging findings of recurrent/new varices or stent occlusion.

Keywords

Balloon-occluded antegrade transvenous obliteration - balloon-occluded retrograde transvenous obliteration - ectopic varices - endoscopic procedures - Gastrointestinal bleeding - pancreatitis - SMV recanalization - SMV stent - Transjugular intrahepatic porto-sytemic shunt

Publication History

Received: 08 January 2019

Accepted: 05 June 2019

Article published online:
22 July 2021

• References

• 1 Saad WE, Lippert A, Saad NE, Caldwell S. Ectopic varices: Anatomical classification, hemodynamic classification, and hemodynamic-based management. Tech Vasc Interv Radiol 2013; 16: 158-75
• 2 Kochar N, Tripathi D, McAvoy NC, Ireland H, Redhead DN, Hayes PC. Bleeding ectopic varices in cirrhosis: The role of transjugular intrahepatic portosystemic stent shunts. Aliment Pharmacol Ther 2008; 28: 294-303
• 3 Khouqeer F, Morrow C, Jordan P. Duodenal varices as a cause of massive upper gastrointestinal bleeding. Surgery 1987; 102: 548-52
• 4 Bommana V, Shah P, Kometa M, Narwal R, Sharma P. A case of isolated duodenal varices secondary to chronic pancreatitis with review of literature. Gastroenterology Res 2010; 3: 281-6
• 5 Hashizume M, Tanoue K, Ohta M, Ueno K, Sugimachi K, Kashiwagi M. et al. Vascular anatomy of duodenal varices: Angiographic and histopathological assessments. Am J Gastroenterol 1993; 88: 1942-5
• 6 Cottam DR, Clark R, Hayn E, Shaftan G. Duodenal varices: A novel treatment and literature review. Am Surg 2002; 68: 407-9
• 7 Rajesh S, Mukund A, Arora A. Imaging diagnosis of splanchnic venous thrombosis. Gastroenterol Res Pract 2015; 2015: 101029
• 8 Jonnalagadda SS, Quiason S, Smith OJ. Successful therapy of bleeding duodenal varices by TIPS after failure of sclerotherapy. Am J Gastroenterol 1998; 93: 272-4
• 9 Mukund A, Deogaonkar G, Rajesh S, Shasthry SM, Sarin SK. Safety and efficacy of sodium tetradecyl sulfate and lipiodol foam in balloon-occluded retrograde transvenous obliteration (BRTO) for large porto-systemic shunts. Cardiovasc Intervent Radiol 2017; 40: 1010-6
• 10 Isaksson B, Jeppsson B, Bengtsson F, Hannesson P, Herlin P, Bengmark S. Mesocaval shunt or repeated sclerotherapy: Effects on rebleeding and encephalopathy--a randomized trial. Surgery 1995; 117: 498-504
• 11 Salzedas-Netto AA, Duarte AA, Linhares MM, Mattar RH, Medeiros KL, Cury EK. et al. Variation of the Rex shunt for treating concurrent obstruction of the portal and superior mesenteric veins. J Pediatr Surg 2011; 46: 2018-20
• 12 Sabri SS, Caldwell SH, Kumer SC, Schmitt TM, Maluf DG, Angle JF. et al. Combined transmesenteric and transhepatic recanalization of chronic portal and mesenteric vein occlusion to treat bleeding duodenal varices. J Vasc Interv Radiol 2014; 25: 1295-9
• 13 Martin EC, Laffey KJ, Bixon R. Recanalization of the superior mesenteric vein for massive bleeding in Crohn disease. J Vasc Interv Radiol 1995; 6: 703-5