EUS-assisted thrombin injection for ectopic bleeding varices--a case report and review of the literature.
Ectopic varices (EV) represent dilated porto-systemic collaterals located at sites other than the gastro-oesophageal junction. They mainly develop in cirrhotic patients following oesophageal variceal band ligation and more rarely secondary to abdominal surgical procedures or to abdominal venous thrombosis secondary to inflammation.1 Bleeding from EV is unusual and represents <5% of all variceal bleeds. Norton et al .2 reviewed 169 cases of bleeding from EV; 26% were from ileostomy varices in primary sclerosing cholangitis patients, 17% in the duodenum, 17% in the jejunum or ileum, 14% in the colon, 8% in the rectum, 9% in the peritoneum. Duodenal varices most commonly complicate portal or splenic vein thrombosis.2

A 49-year-old male was diagnosed with coeliac disease 3 years prior to presentation. He was receiving iron supplements for severe iron deficiency anaemia; however, several investigations including, repeated upper and lower gastrointestinal (GI) endoscopies failed to identify a cause.

Prior to transfer to our Unit, he was admitted to his regional hospital with melaena and a Hb of 66 g/l. An upper gastrointestinal endoscopy (UGIE) identified a polypoid mass in the second part of the duodenum (D2). Biopsies were taken but resulted in profuse bleeding requiring 6 U of red cell concentrate (RCC).

A repeat endoscopy in our hospital showed a ‘C shaped’ non-bleeding polypoid lesion at the junction of D2/3 which was characterized further by endoscopic ultrasound (EUS); this was a vascular lesion at D2/3; the splenic vein was dilated and tortuous …