A 57-year old patient was admitted with hematochezia and
hematemesis. The patient’s history included portal vein cavernous
transformation after posttraumatic splenectomy 34 years ago.
A nonbleeding elevated lesion with a small ulcer was detected in the
descending duodenum, within a large convolute of varices ( [Fig. 1]). Sigmoidoscopy showed considerable amount of
fresh blood without a defined bleeding source. Colonoscopy on the following day
revealed nonbleeding rectal varices. Duplex ultrasonography confirmed portal
vein cavernous transformation. Given both upper and lower gastrointestinal
collaterals and bleeding, portosystemic decompression was considered. However,
magnetic resonance imaging (MRI) angiography could not identify a patent vein
adequate for a transjugular intrahepatic portosystemic stent shunt (TIPSS) or
surgical shunting. Therefore, the patient was scheduled for endoscopic
therapy.
During upper endoscopy, a massive amount of blood began to spurt
from the previously identified ulcerated area on the varix ([Fig. 2], [Video 1]). The
bleeding was stopped by band ligation ([Fig. 3]).
Band ligation of the rectal varices was carried out using a gastroscope in
retroflexion. The patient was stable after successful ligation, and propranolol
and a proton pump inhibitor were started. Follow-up endoscopy showed scarring
after band ligation without stigmata of re-bleeding ([Fig. 4]).
Fig. 1 At the distal border of
an extensive variceal convolute in the descending duodenum, a small ulcer was
found on the tip of a large varix.
Fig. 2 During band ligation,
spurting bleeding was observed.
Video
1 Spurting bleeding from a
large varix, which was successfully stopped with band ligation.
Fig. 3 The bleeding was
successfully treated by band ligation (follow-up esophagogastroduodenoscopy 4
hours later). The initial bleeding site is clearly visible on the tip of the
pseudopolyp.
Fig. 4 Four months after band
ligation, scarring is seen at the site of the previous ligation in the center
of the star-shaped variceal convolute. Residual varices were again band
ligated.
Ectopic varices are rare source of gastrointestinal bleeding, and
account for 1 – 5 % of all variceal bleeding
[1]. In a 10-year follow-up study, the incidence of
duodenal varices in portal hypertension was only 0.4 %
[2]. In 750 patients with significantly elevated portal
pressure gradient receiving a TIPSS, in 14 years only four were carried out for
duodenal and 12 for rectal varices [3]. Duodenal bleeding
often occurs from erosions on the varix, as in our patient, and has unanimously
been reported as severe. The red colour sign seen in oesophageal varices is
usually absent [4]. Because of the infrequency of ectopic
variceal bleeding, treatment modalities have not been validated prospectively.
This case report shows that bleeding from ectopic varices of the upper and
lower gastrointestinal tract can be successfully treated by endoscopic band
ligation.
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