Duodenal varices: a novel treatment and literature review

Hemorrhage associated with duodenal varices is an uncommon but often fatal manifestation of portal hypertension. We report a case of duodenal varices, review the literature, and present a new treatment modality. A 63-year-old man presented with hematemesis and hematochezia. An upper gastrointestinal endoscopy revealed hemorrhage from the duodenal varices that was initially controlled with injections of epinephrine. However, this was only partially successful, as the patient had repeated episodes of bleeding that was not amenable to injection sclerotherapy. The patient was taken emergently to the operating room after endoscopy failed to control the hemorrhage. The bleeding was controlled with simple oversewing of the duodenal varices through a duodenotomy. Three years later the patient remains symptom free. We propose that simple oversewing of duodenal variceal veins combined with a beta-blocker is an effective treatment for duodenal variceal hemorrhage.     

Duodenal varices as a cause of massive upper gastrointestinal bleeding

Duodenal varices are an uncommon but serious manifestation of portal hypertension. Our management of three patients with massive bleeding due to duodenal varices stimulated a review of this subject. Thirteen cases of this condition were previously reported. Endoscopic examination of the entire duodenal mucosa is essential to document bleeding from duodenal varices. Medical therapies, including vasopressin and endoscopic sclerotherapy, have had limited success in controlling active duodenal variceal bleeding. Duodenal varix suture ligation or resection also resulted in a high rate of rebleeding. End-to-side portocaval shunt was the most effective procedure in stopping acute and subsequent bleeding in patients with duodenal varices. Despite therapy with or without portosystemic shunt, mortality risk is high in Child's class C patients and in patients with emergency duodenal variceal bleeding.     

Duodenal dearterialization and stapling for severe hemorrhage from duodenal varices with portal vein thrombosis

BACKGROUND: Hemorrhage from duodenal varices is a rare but frequently fatal cause of gastrointestinal bleeding. Portal vein thrombosis may worsen the bleeding and prevent access for reduction of variceal pressure. METHODS: A technique to control bleeding and reduce inflow pressure to the varices is described. It includes ligation of the gastroduodenal and splenic arteries, splenectomy, stapling of the duodenum, and gastroenterostomy. RESULTS: Three patients, hemodynamically unstable from duodenal hemorrhage, underwent the procedure. No further bleeding was encountered. One patient died of fungal sepsis and liver failure, but 2 are alive without further problems 21 and 24 months later. CONCLUSIONS: Reduction in arterial inflow, direct variceal ligation, reversal of hypersplenism, and food stream diversion are elements of this procedure that may have contributed the control of severe hemorrhage from duodenal varices associated with portal vein thrombosis.     

Bleeding oesophageal varices.

At the Royal Prince Alfred Hospital, most patients with bleeding varices have been poor-risk alcoholics. A high proportion were receiving a State pension. The early mortality due to bleeding varices was 53%. This figure comprised a 60% mortality following conservative management and 40% after urgent shunt. All patients having urgent operations which were not portal decompression died. No patient who had an elective shunt died. In a mean follow-up period of 15.4 months, a further 14% of survivors died. No form of conservative management appeared to have much effect on the natural history of the bleeding. A blood replacement of more than five litres indicated that spontaneous cessation of haemorrhage was unlikely. Shunt operations usually controlled haemorrhage, but hepatorenal failure was common after the urgent shunts. The cost of operation was greater than that of conservative management, but in neither case was it considered excessive.     

Spinal epidural varices.

A 16-year-old male experienced a sudden attack of back pain while walking through the corridor of school which required emergent hospitalization. Except for the back pain, no neurological symptoms were noted. Magnetic resonance (MR) imaging indicated an angiopathy-like flow void in the epidural region at Th 3-5 which seemed to explain the patient's back pain. Thoracic laminectomy at Th 3-5 and resection of the affected site were performed. Pathologically, the resected lesion only had a dilated normal vein and no findings indicating vascular deformity. The patient's outcome was good and no relapse of pain has occurred for about 2 years since the operation. Although some authors have reported vascular deformity with spinal epidural hemorrhage or varices with lumbar hernia of the intervertebral disc, there is no report concerning spinal epidural varices with pain only. The present case seemed to be a rare event and is reported here.     

Sciatic nerve varices.

OBJECTIVE(S): To describe patients presenting with sciatic nerve varices (SNV), presenting pitfalls in diagnosis and management. DESIGN: Case series. METHODS: Patients were investigated using duplex ultrasonography pre-operatively in three cases. Treatment was undertaken both by surgery and by foam sclerotherapy. RESULTS: Clinically, SNV appeared just below the popliteal skin crease, lateral to the small saphenous vein (SSV). In two cases SNV occurred alone, in two further cases SNV occurred in conjunction with varices from other sources. Symptoms of 'sciatic' pain were present in all. Foam sclerotherapy (1% Polidocanol) was undertaken in one case with a varix. Complete obliteration of the vein and resolution of all symptoms was achieved at the 1-month follow-up examination. Surgical management was used in the other cases. CONCLUSION: The sciatic nerve vein follows the fibular saphenous nerve (lying superficial to the fascia in the leg). This nerve arises from the common peroneal nerve (in the popliteal fossa), and is a major branch of the sciatic nerve. Varices of the associated vein appear to be the result of a dysplasia. This condition may be more common than is currently recognised.     

Reflux oesophagitis resembling varices.

Three cases of established reflux oesophagitis resembling varices are presented. Although the condition is rare, the importance of distinguishing oesophagitis from varices is pointed out in order to avoid unnecessary arteriography and surgery.     

Duodenal cancer. A clinical-pathological study

Seven primary carcinomas of the duodenum were observed from 1973 to 1976 at the University Hospital Hamburg; four in females and three in males with an age between 32 and 69 years of age. The interval between the first symptoms (epigastric pain, jaundice, pruritus, diarrhea, and loss of weight) and surgical therapy (duodeno-pancreatectomy) averaged four months. All carcinomas were resected radically from the macroscopic (intraoperative) aspect as well as from the histological findings. Local tumour recurrences which proved fatal occurred in five patients within nine to twenty-one months. One patient died of peritonitis and another of pancreatitis. The diagnostic mode has been changed since the introduction of endoscopy and retrograde cholangio-pancreaticography (ERCP). The consistent inclusion of the duodenum in routine gastroscopy leads to the hope that more carcinomas of the duodenum can be detected early.     

Injection sclerotherapy for esophageal varices.

Thirty-five consecutive patients with bleeding esophageal varices were treated by repeated endoscopic injection sclerotherapy. During each session the varices were injected with 14 +/- 4.2 ml (mean +/- SD) of 5% ethanolamine oleate submucosally or intravariceally. The varices were obliterated in 31 (89%) patients. On average 3.3 +/- 2.4 sclerotherapy sessions were required for eradication of the varices. Mild fever was noticed almost in every patient after sclerotherapy. Mediastinitis was a complication in one (2.8%) patient. Esophageal stricture ensued in two (5.7%) patients which did not require treatment. The cumulative survival rates at 1, 2, 3, 4 and 5 years were 83%; 65%; 52%; 52% and 47% respectively. The corresponding 95% confidence intervals were (0.7, 0.96); (0.48, 0.8); (0.34, 0.7); (0.3, 0.74) and (0.22, 0.7). Sclerotherapy is an effective and safe method to treat bleeding esophageal varices.     

Duodenal perforation in blunt abdominal trauma.

Ten patients with duodenal perforation secondary to blunt abdominal trauma are reviewed. All 10 patients survived. Most of the injuries were related to motor vehicle accidents. Early recognition requires a high index of suspicion because preoperative signs and symptoms tend to be nonspecific and x-rays are usually not helpful. A careful exploration of the duodenum at laparotomy including both the Kocher maneuver and the Cattell-Braasch exposure is essential. Suitable methods of surgical repair are numerous, but those providing for restoration of normal gastrointestinal tract continuity are preferred.