Abstract
Duodenal varices are ectopic varices that are rare but can involve any site along the digestive tract outside the gastroesophageal region. Ectopic variceal bleeding is generally massive and life threatening; the mortality rate is approximately 40%. Up to 17% of ectopic varices occur in the duodenum. However, duodenal varices pose a significant therapeutic challenge due to the lack of standard treatment guidelines. We report a case of duodenal variceal bleeding secondary to portal vein stenosis in a 77-year-old woman receiving chemotherapy for unresectable perihilar cholangiocarcinoma. The patient presented with melena, nausea, vomiting and unstable vital signs suggestive of hemorrhagic shock. Emergency esophagogastroduodenoscopy revealed large nodular varices with a ruptured erosion on top in the superior duodenal angle, and variceal bleeding had stopped by the time of the procedure. Subsequent computed tomography showed the development of portosystemic collaterals; therefore, we performed percutaneous portal vein stent placement to reduce portal vein pressure. Since persistent bleeding was suspected, we also performed endoscopic injection sclerotherapy and achieved successful hemostasis with an improvement in liver function. This case revealed that a combination of portal vein stent placement and endoscopic injection sclerotherapy might be an effective therapy for duodenal variceal bleeding caused by portal vein stenosis.
![](http://media.springernature.com/m312/springer-static/image/art%3A10.1007%2Fs12328-020-01213-5/MediaObjects/12328_2020_1213_Fig1_HTML.jpg)
![](http://media.springernature.com/m312/springer-static/image/art%3A10.1007%2Fs12328-020-01213-5/MediaObjects/12328_2020_1213_Fig2_HTML.jpg)
![](http://media.springernature.com/m312/springer-static/image/art%3A10.1007%2Fs12328-020-01213-5/MediaObjects/12328_2020_1213_Fig3_HTML.jpg)
![](http://media.springernature.com/m312/springer-static/image/art%3A10.1007%2Fs12328-020-01213-5/MediaObjects/12328_2020_1213_Fig4_HTML.jpg)
![](http://media.springernature.com/m312/springer-static/image/art%3A10.1007%2Fs12328-020-01213-5/MediaObjects/12328_2020_1213_Fig5_HTML.png)
![](http://media.springernature.com/m312/springer-static/image/art%3A10.1007%2Fs12328-020-01213-5/MediaObjects/12328_2020_1213_Fig6_HTML.jpg)
Similar content being viewed by others
Abbreviations
- EIS:
-
Endoscopic injection sclerotherapy
- Bpm:
-
Beats per minute
- Hb:
-
Hemoglobin
- AST:
-
Aspartate aminotransferase
- ALT:
-
Alanine aminotransferase
- Alb:
-
Albumin
- EGD:
-
Esophagogastroduodenoscopy
- CT:
-
Computed tomography
- TIPS:
-
Transjugular intrahepatic portosystemic shunt
- B-RTO:
-
Balloon-occluded retrograde transvenous obliteration
- PTO:
-
Percutaneous transhepatic obliteration
- GI:
-
Gastrointestinal
References
Alberti W. Uberden roentgenologischen nachweis von varizen in buolbus duodeni. Fortschro Geb Koentgenstr. 1931;43:60–5.
Kunisaki T, Someya N, Shimokawa Y, et al. Varices in the distal duodenum seen with a fiberduodenoscope. Endoscopy. 1973;5:101–4.
Bhagani S, Winters C, Moreea S, et al. Duodenal variceal bleed: an unusual cause of upper gastrointestinal bleed and a difficult diagnosis to make. BMJ Case Rep. 2017;2017:bcr2016218669.
Boregowda U, Umapathy C, Halim N, et al. Update on the management of gastrointestinal varices. World J Gastrointest Pharmacol Ther. 2019;10:1–21.
Norton ID, Andrews JC, Kamath PS, et al. Management of ectopic varices. Hepatology. 1998;28:1154–8.
Sato T. Treatment of ectopic varices with portal hypertension. World J Hepatol. 2015;7:1601–5.
Shan H, **ao XS, Huang MS, et al. Portal venous stent placement for treatment of portal hypertension caused by benign main portal vein stenosis. World J Gastroenterol. 2005;11:3315–8.
Zhou ZQ, Lee JH, Song KB, et al. Clinical usefulness of portal venous stent in hepatobiliary pancreatic cancers. ANZ J Surg. 2014;84:346–52.
Rana SS, Bhasin DK, Sharma V, et al. Clinical, endoscopic and endoscopic ultrasound features of duodenal varices: a report of 10 cases. Endosc Ultrasound. 2014;3:54–7.
Cornman-Homonoff J, Bassik N, Madoff DC, et al. Transhepatic portal stent placement and jejunal varix embolization for management of treatment-limiting gastrointestinal bleeding in a patient with unresectable recurrent intrahepatic cholangiocarcinoma. Clin Imaging. 2020;59:188–91.
Kato A, Shimizu H, Ohtsuka M, et al. Portal vein stent placement for the treatment of postoperative portal vein stenosis: long-term success and factor associated with stent failure. BMC Surg. 2017;17:11.
Sasaki T, Kanata R, Yamada I, et al. Improvement of treatment outcomes for metastatic pancreatic cancer: a real-world data analysis. In Vivo. 2019;33:271–6.
Wakabayashi M, Kohno S, Hokari T, et al. Case reports of expandable metallic stent treatment for gastrointestinal bleeding caused by portal vein stenosis after pancreatoduodenectomy. Nihon Rinsho Geka Gakkai Zasshi. 2014;75:2008–133.
Ohno Y, Kamati H, Turuga Y, et al. Case report of portal vein stent placement for portal vein stenosis due to recurrence of hilar cholangiocarcinoma. Nihon Rinsho Geka Gakkai Zasshi. 2013;74:2879–84.
Yamakado K, Nakatsuka A, Tanaka N, et al. Malignant portal venous obstructions treated by stent placement: significant factors affecting patency. J Vasc Interv Radiol. 2001;12:1407–15.
Park JH, Yeo JH, Kim YS, et al. Portal vein stent for symptomatic malignant portal vein stenosis: a single-center experience. Curr Probl Cancer. 2020;44:100476.
Kim KR, Ko G, Sung K, et al. Percutaneous transhepatic stent placement in the management of portal venous stenosis after curative surgery for pancreatic and biliary neoplasms. AJR Am J Roentgenol. 2011;196:446–50.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare no conflict of interest.
Human/animal rights
All procedures were performed in accordance with the Declaration of Helsinki.
Informed consent
Informed consent was obtained from the patient.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Fukuda, K., Sasaki, T., Hirasawa, T. et al. A case of percutaneous transhepatic portal vein stent placement and endoscopic injection sclerotherapy for duodenal variceal rupture occurring during chemotherapy for unresectable perihilar cholangiocarcinoma. Clin J Gastroenterol 13, 1150–1156 (2020). https://doi.org/10.1007/s12328-020-01213-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12328-020-01213-5