Background: Bleeding from duodenal varices are often severe (mortality as high as 40%), and more difficult to sclerose than esophageal varices. We report a patient with a bleeding duodenal varix, refractory to sclerotherapy, successfully treated by the association of portosystemic shunt placement and varix embolization, via the same transjugular intrahepatic route. Methods: A 40-year-old Black male underwent emergency TIPS and duodenal varix embolization after failure of endoscopic sclerotherapy. The portosystemic pressure gradient droped from 16 to 9 mm Hg following TIPS. At 5 months from TIPS, the patient is well, with a patent shunt at Doppler ultrasound. Conclusion: The present report of successful control of duodenal varix, actively bleeding and refractory to sclerotherapy, by means of combined TIPS and embolization, supports the role of TIPS and suggests that its association to embolization can be valuably considered in the difficult setting of portal hypertension with bleeding duodenal varices.

Keywords:
Portal hypertension, Ectopic varices, Embolization, Transjugular portosystemic shunt
1.
Rikkers LF: The changing spectrum of treatment for variceal bleeding. Ann Surg 1998;228:536–546.
2.
Banares R, Casado M, Rodriguez-Laiz J, et al: Urgent transjugular intrahepatic portosystemic shunt for control of acute variceal bleeding. Am J Gastroenterol 1998;93:75–79.
3.
Kinkhabwala M, Mousavi A, Iyer S, Adamsons R: Bleeding ileal varicosity demonstrated by transhepatic portography. Am J Roentgenol 1977;129:514–516.
4.
Khouqeer F, Morrow C, Jordan P: Duodenal varices as a cause of massive upper gastrointestinal bleeding. Surgery 1987;102:548–552.
5.
Sanyal AJ, Freedman AM, Luketic VA, et al: Transjugular intrahepatic portosystemic shunts for patients with active variceal hemorrhage unresponsive to sclerotherapy. Gastroenterology 1996;111:138–146.
6.
Sauer P, Theilmann L, Stremmel W, Banz C, Richter GM, Stiehl A: Transjugular intrahepatic portosystemic shunt versus sclerotherapy plus propanolol for variceal rebleeding. Gastroenterology 1997;113:1623–1631.
7.
Azoulay D, Castaing D, Ichai Ph, Saliba F, Bismuth H: Shunt intrahépatique porto-sushépatique de sauvetage pour hémorragie par rupture de varices eosophagiennes non contrôlée chez le cirrhotique. Presse Méd 1996;25:842–846.
8.
Jonnalagadda SS, Quiason S, Smith OJ: Successful therapy of bleeding duodenal varices by TIPS after failure of sclerotherapy. Am J Gastroenterol 1998;93:272–274.
9.
Norton ID, Andrews JC, Kamath PS: Management of ectopic varices. Hepatology 1998;28:1154–1158.
10.
Ota K, Shirai Z, Masuzaki T, et al: Endoscopic injection sclerotherapy with n-butyl-2-cyanoacrylate for ruptured duodenal varices. J Gastroenterol 1998;33:550–555.
11.
Yeh YY, Hou MC, Lin HC, Chang FY, Lee SD: Case report: Successful obliteration of a bleeding duodenal varix using endoscopic ligation. J Gastroenterol Hepatol 1998;13:591–593.
12.
Omata F, Itoh T, Shibayama Y, et al: Duodenal variceal bleeding treated with a combination of endoscopic ligation and sclerotherapy. Endoscopy 1998;30:S62–S63.
13.
Wong RC, Berg CL: Portal hypertensive stomopathy: A newly described entity and its successful treatment by placement of a transjugular intrahepatic portosystemic shunt. Am J Gastroenterol 1997;92:1056–1057.
14.
Haskal ZJ, Scott M, Rubin RA, Cope C: Intestinal varices: Treatment with the transjugular intrahepatic portosystemic shunt. Radiology 1994;191:183–187.
15.
Sort P, Elizalde I, Llach I, et al: Duodenal variceal bleeding treated with a transjugular intrahepatic portosystemic shunt. Endoscopy 1995;27:626–627.
16.
Born P, Huber W, Neuhaus H, Classen M: Hemorrhage cause by duodenal varices. Dtsch Med Wochenschr 1995;120:1241–1247.
17.
Ponec RJ, Kowdley KV: Paradoxical cerebral emboli after transjugular intrahepatic portosystemic shunt and coil embolization for treatment of duodenal varices. Am J Gastroenterol 1997;92:1372–1373.
18.
Vuillemin E, Aube C, Rifflet H, et al: Recurrent stomal hemorrhage treated by transjugular intrahepatic portosystemic anastomosis and embolization of stomal varices. J Radiol 1998;79:690–692.
19.
Buhler L, Tamigneaux I, Giostra E, et al: Ectopic varices, a rare cause of digestive hemorrhage. Schweiz Med Wochenschr 1996;79(suppl):70S–72S.
20.
Tsokos M, Bartel A, Schoel R, Rabenhorst G, Schwerk WM: Fatal pulmonary embolism after endoscopic embolization of downhill esophageal varix. Dtsch Med Wochenschr 1998;123:691–695.
© 2000 S. Karger AG, Basel
2000
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.