Korean J Gastroenterol.  2020 Dec;76(6):331-336. 10.4166/kjg.2020.123.

Percutaneous Trans-splenic Obliteration for Duodenal Variceal bleeding: A Case Report

• Kim HW
• Yoon JS
• Yu SJ
• Kim TH
• Seol JH
• Kim D
• Jung JY
• Jeong PH
• Kwon H
• Lee HS
• Lee SH
• Choi JS
• Park SJ
• Jee SR
• Lee YJ
• Seol SY

• KMID: 2509711
• DOI: http://doi.org/10.4166/kjg.2020.123

Abstract

Duodenal varices are a serious complication of portal hypertension. Bleeding from duodenal varices is rare, but when bleeding does occur, it is massive and can be fatal. Unfortunately, the optimal therapeutic modality for duodenal variceal bleeding is unclear. This paper presents a patient with duodenal variceal bleeding that was managed successfully using percutaneous trans-splenic variceal obliteration (PTVO). A 56-year-old man with a history of alcoholic cirrhosis presented with a 6-day history of melena. Emergency esophagogastroduodenoscopy revealed a large, bluish mass with a nipple sign in the second portion of the duodenum. Coil embolization of the duodenal varix was performed via a trans-splenic approach (i.e., PTVO). The patient no longer complained of melena after treatment. The duodenal varix was no longer visible at the follow-up esophagogastroduodenoscopy performed three months after PTVO. The use of PTVO might be a viable option for the treatment of duodenal variceal bleeding.

Keyword

Duodenum; Varicose veins; Gastrointestinal hemorrhage; Embolization; therapeutic

Figure

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  Fig. 1 Esophagogastroduodenoscopy (EGD) and dynamic computed tomography (CT) at the time of initial diagnosis. (A) EGD reveals a large varix measuring >5 mm with a nipple sign (arrow) in the second portion of the duodenum. (B, C) The portal phase of dynamic CT shows a varix in the second portion of the duodenum (arrows). (D) A hepatic nodule in segment 5 (arrows) measures about 1 cm and exhibits enhancement in the arterial phase (E) without washout in the portal phase or (F) delayed phase.

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  Fig. 2 Percutaneous trans-splenic variceal obliteration for the treatment of duodenal variceal bleeding. (A) Direct portography shows a shunt between the afferent feeding vein, originating from the portal vein, and the duodenal varix. (B) Coil embolizationis successfully performed. (C) Complete obliteration is confirmed in the following portography.

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  Fig. 3 Esophagogastroduodenoscopy (EGD) and dynamic computed tomography (CT) performed 3 days after percutaneous trans-splenic variceal obliteration. (A) EGD reveals a varix in the second portion of the duodenum that decreased in size from the initial examination (B, C) The portal phase of dynamic CT shows a duodenal varix decreased in size from the time of initial imaging (arrows).

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  Fig. 4 Esophagogastroduodenoscopy (EGD) and dynamic computed tomography (CT) performed 3 months after percutaneous trans-splenic variceal obliteration. (A) EGD reveals that the varix in the second portion of the duodenum are no longer visible. (B, C) The portal phase of dynamic CT shows that the size of the duodenal varix (arrows) have decreased in size compared with the imaging performed 3 days after treatment. (D) The hepatic nodule in segment 5 (arrows) exhibits faint enhancement in the arterial phase (E) without washout in the portal phase or (F) delayed phase. It has not changed in size compared with the imaging obtained at the time of diagnosis.

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