Peripapillary Duodenal Varices as a Rare Cause of Severe Bleeding in a Patient with No Other Signs of Portal Hypertension – Successful Endoscopic Treatment with Cyanoacrylate Injection

Zusammenfassung

Duodenalvarizen (DV) sind eine seltene Ursache der oberen gastrointestinalen Blutung und werden eher bei Patienten mit portaler Hypertonie erwartet. Die Duodenalvarizenblutung ist eine therapeutische Herausforderung und endet aufgrund verzögerter Diagnosestellung oft fatal. Wir berichten über einen 71-jährigen Patienten mit massiver oberer gastrointestinaler Blutung, der keine klinischen Zeichen der portalen Hypertonie aufwies; allerdings war in der Vorgeschichte eine Segmentresektion des Duodenums erfolgt. Die Blutungsquelle konnte zunächst mit verschiedenen bildgebenden Verfahren (Angiografie, Computertomografie) nicht identifiziert werden. Schließlich zeigten sich bei einer oberen Intestinoskopie jedoch eine direkt neben der Majorpapille lokalisierte DV. Die endoskopische Injektion von n-Butyl-2-Cyanoacrylat brachte die Blutung unmittelbar zum Stillstand und der Patient stabilisierte sich rasch. Trotz der peripapillären Lage traten keine Zeichen der Pankreatitis oder Cholangitis auf; während des bisherigen 10-monatigen Follow-up haben sich die DV deutlich zurückgebildet und es kam zu keiner weiteren Varizenblutung.

Abstract

Duodenal varices (DVs) are a rare cause of upper gastrointestinal bleeding and rather suspected in patients with portal hypertension. Bleeding DVs are difficult to manage and often fatal due to delayed diagnosis. We report on a 71-year-old patient with massive upper gastrointestinal haemorrhage, who did not show any clinical signs of portal hypertension; however, he had a history of duodenal segmental resection 8 years before. The source of bleeding could not be detected with different imaging methods such as angiography and computed tomography. Upper gastrointestinal endoscopy finally revealed DVs, which were located just adjacent to the papilla. After endoscopic injection therapy with n-butyl 2-cyanoacrylate the bleeding stopped immediately and the patient soon stabilised. Despite the peripapillar localisation no signs of pancreatitis or cholestasis occurred; during 10-month follow-up a marked regression of the varices without further signs of variceal bleeding was observed.

Schlüsselwörter

obere gastrointestinale Blutung - duodenale Varizen - Cyanoacrylat-Injektion

Key words

upper gastrointestinal bleeding - duodenal varices - cyanoacrylate injection

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