Successful treatment of ruptured duodenal varices with dual balloon-occluded embolotherapy
The Human Subjects Research Review Board at our institution approved the interventional protocol; patient consent for inclusion in this retrospective study was waived.\nThis 60-year-old man suffered from chronic hepatitis due to hepatitis C virus infection since undergoing a right hepatic lobectomy for hepatocellular carcinoma 5 months earlier. Blood transfusions, because he had become anemic with melena and abdominal pain starting approximately one week earlier, failed to improve his symptoms. On the day of the procedure hematemesis developed. Laboratory examinations revealed anemia (hemoglobin 4.7 mg/dl); liver function was graded as Child-Pugh B (total bilirubin 1.8 mg/dl, albumin 2.2 g/dl, prothrombin time 52%, ascites).\nContrast-enhanced computed tomography (CT) scans obtained with a 64-row multidetector CT instrument (Brilliance-64, Philips Medical Systems, Best, The Netherlands) revealed duodenal varices fed from the posterior inferior pancreaticoduodenal vein; drainage was into the right gonadal vein. Esophagogastroduodenoscopy detected active bleeding from ruptured duodenal varices. Conservative management with fasting did not improve his progressive anemia and melena, nor did endoscopic injection sclerotherapy (Fig. ). Prior written informed consent was obtained for angiography and BRTO or dual balloon-occluded embolotherapy (DBOE) and for entry into this study.\nA 5-F guiding sheath (Flexor Tuohy-Borst Side-Arm Introducer; Cook, Bloomington, IN, USA) was inserted from the right femoral vein; to assist in placement we used a 0.035-inch diameter torque Radifocus guidewire (Terumo-Clinical Supply Co., Tokyo, Japan). A 3-F occlusion balloon catheter with an 8-mm diameter balloon (Attendant; Terumo-Clinical Supply Co., Tokyo, Japan) was wedged into the right gonadal vein to introduce a Syncro 2 guidewire (outside diameter 0.014 inch) with a free transformation tip (Boston Scientific Corp., Watertown, MA, USA). We manually injected 10 mL of iomeprol (Iopamiron 300 [300 mg I/mL]; Bayer, Osaka, Japan), inflated the balloon, and obtained right gonadal venography. No opacified duodenal varices were detected (Fig. ). Subsequently, we used the percutaneous transhepatic approach to insert a 7-F vascular sheath (Medikit Co. Ltd., Tokyo, Japan) and a 5-Fr balloon catheter (Terumo-Clinical Supply Co.) into the posterior inferior pancreaticoduodenal vein. Venography revealed well-opacified duodenal varices (Fig. ).\nWe then injected 10 mL of a 70% glucose solution into the gastric varices before injecting 5% ethanolamine oleate (EO) (Odamin; Mochida Pharmaceutical, Tokyo, Japan). The sclerosing agent was a mixture of 10% EO and the same dose of a non-ionic contrast medium (Iopamiron 300) (EOI); this yielded radio-opacity. To prevent hemolysis and subsequent renal failure () during the procedure we intravenously delivered 4000 units of human haptoglobin (Green Cross, Osaka, Japan); 1 unit binds 1 mg of hemoglobin. The sclerosing agent was injected slowly under fluoroscopic monitoring until the duodenal varices were completely filled. The injected 5% EOI remained in the varices for 1 h during balloon occlusion. During DOBE we monitored his blood pressure, pulse rate, urine volume, arterial oxygen saturation status (pulse oximeter), and obtained electrocardiograms. We terminated DOBE after 1 h; at that time, test injection of contrast medium showed clot formation in the varices. Lastly a portography was performed. As it revealed marked dilation of the coronary vein compared to pre-DOBE findings we performed microcoil-embolization of this vessel using interlocking detachable coils (Boston Scientific).\nAfter the procedure his hematemesis improved and the hemoglobin increased from 3.6 to 9.7 mg/dl. Esophagogastroduodenoscopy 1 week post-DOBE detected no active bleeding from duodenal varices. On endoscopic images there was a change in the color tone (Fig. ). Although he died from hepatic failure 2 months later, there was no hemorrhage and the hemoglobin did not decrease during that period.