Successful Treatment of Duodenal Variceal Bleeding by Endoscopic Clipping
A 49-year-old male patient presented with hematemesis and hematochezia. He had been diagnosed with alcoholic liver cirrhosis 14 years ago, and had hyperthyroidism and diabetes.\nAt the time of admission the patient's blood pressure was 60/30 mm Hg, pulse rate was 122 per minute, and respiratory rate was 20 per minute. Basal body temperature was 36℃ and blood glucose level was 257 mmol/L. Physical examination showed acutely ill appearance with mild confusion. The patient had conjunctival pallor, no scleral icterus and no abnormalities on chest auscultation. The abdomen was soft to palpation but was distended, and there was tenderness to palpation at the epigastrium without rebound tenderness.\nLaboratory findings showed hemoglobin concentration of 7.9 g/dL, leukocytes 12,060/mm3 (neutrophils 86.7%), and platelets 101,000/mm3. Serum biochemistry showed the total protein concentration to be 4.9 g/dL, albumin concentration 2.0 g/dL, total bilirubin 0.52 mg/dL, blood urea nitrogen 15.4 mg/dL, creatinine 0.9 mg/dL, aspartate aminotransferase/alanine aminotransferase 31/51, alkaline phosphatase 93 IU/L, prothrombin time 14.4 seconds (international normalised ratio, 1.21), while all of hepatitis B surface antigen, hepatitis B surface antibody, and antihepatitis C virus were negative.\nAn emergency upper gastrointestinal endoscopy was performed on the day of the patient's admission. It showed a varix (F3, Lm, Cb, RC-) without red color sign from all along the mid to lower esophagus. Apart from signs of congestive gastropathy, there were no other lesions suggestive of bleeding. Along the entire wall of the duodenal bulb was a pulsating blue dumbbell-shaped varix and stigma on the surface of this varix (). This was considered to be a bleeding focus, so the efferent vein and afferent vein were ligated using hemoclips, and hemostasis was achieved following hemoclips placement directly on the visible vessel ().\nThree dimensional (3D) computed tomographic (CT) angiography was performed to verify the duodenal varix and the collateral pathways which showed a broad collateral varix around the duodenum and the head of the pancreas due to thrombosis of the main portal vein and the splenic vein (). Following 3D CT angiography, somatostatin intravenous injection and blood transfusion were given along with other conservative management. Although the patient had large amounts of melena, his vital signs were stabilized. A follow-up endoscopy 3 days after he procedure showed no signs of bleeding and two hemoclips were fixed on the varix (). The vital signs were stable, without any more melena, and the patient was discharged from the hospital 14 days after his first admission. Repeat endoscopy 3 months later revealed persistent duodenal varix but of a reduced size and absence of the stigmata of recent bleeding (). Since then, the patient has not had any rebleeding episodes and is being followed up on an outpatient basis.