Endoscopic management of duodenal diverticular bleeding

BACKGROUND: Although the presence of a duodenal diverticulum is usually asymptomatic, bleeding in this tissue is sometimes difficult to diagnose and treat. OBJECTIVE: To investigate the strategy for treatment, we reviewed the clinical data of patients diagnosed and treated for duodenal diverticular bleeding. DESIGN: Retrospective case series. SETTING: Single tertiary-referral center. PATIENTS: Seven consecutive patients with bleeding from a duodenal diverticulum (mean age, 73.7 +/- 3.4 years old). INTERVENTIONS: The clinical characteristics, endoscopic findings, and treatment strategy for duodenal diverticular bleeding. MAIN OUTCOME MEASUREMENTS: All 7 patients achieved hemostasis. Six of 7 patients were treated endoscopically. There were no complications with endoscopic treatment. RESULTS: Three patients bled from diverticula located at the second portion of the duodenum, and 4 patients bled from that located at the third portion. In 6 of 7 patients, lesions were identified and treated endoscopically with hemoclips, hypertonic saline solution and epinephrine (HSE), and/or 1% polidocanol injection. In 1 case, the lesion could not be detected during the first endoscopic examination, and the patient, therefore, was treated with transarterial embolization followed by surgical resection. LIMITATIONS: This preliminary case series described the feasibility of the endoscopic treatment. However, optimal management, including angiography and/or surgery, should be individualized to the patients, location, and type of hemorrhage. CONCLUSIONS: Bleeding from a duodenal diverticulum should be considered in the case of upper-GI bleeding of unknown origin. An endoscopy may be an effective alternative to surgery in the management of a bleeding duodenal diverticulum.     

A case of endoscopic injection sclerotherapy for a bleeding duodenal varix

A case of bleeding duodenal varix which was treated successfully with endoscopic injection sclerotherapy (EIS) is reported. The patient developed a hemorrhage from a varix in the descending portion of the duodenum two months after EIS for esophageal varices, and hemostasis was achieved using EIS with an intravericeal injection of 1% polidocanol. The duodenal varix decreased in size after EIS. Two months after EIS, a splenectomy was performed. During a 14-month follow up period after the EIS for the duodenal varix, there was no recurrent bleeding.     

Endoscopic injection sclerotherapy of bleeding duodenal varices

Bleeding from duodenal varices is a rare finding in patients with liver cirrhosis. We report a 43 year old male with alcoholic liver cirrhosis who presented with upper gastrointestinal bleeding. Panendoscopy identified prominent tortuous varices over the second portion of duodenum with spurting of blood. At first, the varices were treated successfully with sodium tetradecyl sulfate and bleeding stopped. Consequent endoscopic sclerotherapy was done 1 week later. The varices almost disappeared 2 weeks after the second endoscopic sclerotherapy and the patient was in good condition following this.     

CASE REPORT: Successful obliteration of a bleeding duodenal varix using endoscopic ligation

The occurrence of duodenal varices is rare and experience in the control of haemorrhage from duodenal varices is limited. A 69-year-old man with hepatocellular carcinoma presenting with upper gastrointestinal bleeding is reported. Emergency upper gastrointestinal endoscopy indicated one varix 1.5 cm in diameter with white nipple sign at the anterior wall of the duodenal bulb. Endosonography confirmed the diagnosis of duodenal varix. The patient was treated with endoscopic ligation and follow-up endoscopy showed complete eradication of duodenal varix 3 weeks later.     

Endoscopic treatment of ulcer bleeding

Opinion statement Upper gastrointestinal (UGI) bleeding secondary to ulcer disease occurs commonly and results in significant patient morbidity and medical expense. After initial resuscitation, carefully performed endoscopy provides an accurate diagnosis of the source of the UGI hemorrhage and can reliably identify those high-risk subgroups that may benefit most from endoscopic hemostasis. Large-channel therapeutic endoscopes are recommended. Endoscopists should be very experienced in management of patients with UGI hemorrhage, including the use of various hemostatic devices. For patients with major stigmata of ulcer hemorrhage—active arterial bleeding, nonbleeding visible vessel, and adherent clot—combination therapy with epinephrine injection and either thermal coaptive coagulation (with multipolar or heater probe) or endoclips is recommended. High-dose intravenous proton-pump inhibitors are recommended as concomitant therapy with endoscopic hemostasis of major stigmata. Patients with minor stigmata or clean-based ulcers will not benefit from endoscopic therapy and should be triaged to less intensive care and be considered for early discharge. Effective endoscopic hemostasis of ulcer bleeding can significantly improve outcomes by reducing rebleeding, transfusion requirement, and need for surgery, as well as reduce cost of medical care.     

Endoscopic treatment of ERCP-related duodenal perforation

Duodenal perforation following ERCP is an unusual but severe adverse event. Prompt recognition improves clinical outcomes including mortality, thus endoscopists should have a low threshold to consider perforation in those with abdominal pain, hemodynamic perturbation, and atypical fluoroscopy findings. Classification of perforations as retroperitoneal/periampullary vs free/remote from the papilla is important as the former can be managed nonoperatively in most cases. Nonsurgical therapy typically includes medical therapy supplemented by placement of fully covered self-expandable stents in the bile duct and through-the-scope endoscopic clips over the defect. New endoscopic technology including full thickness suturing devices, over-the-scope clips, fibrin injection, and vacuum therapy may increase the proportion of patients with duodenal perforation who may be amenable to minimally invasive treatment.     

Endoscopic management of upper gastrointestinal bleeding from a duodenal diverticulum

Hemorrhage from duodenal diverticulum is a rare cause of upper gastrointestinal hemorrhage. The side-viewing endoscope was used for almost all cases of diagnosis and endoscopic hemostasis. However, a forward-viewing endoscope is used in emergent endoscopic study for upper gastrointestinal hemorrhage. We report a case in which the endoscopic hemostasis of bleeding duodenal diverticulum was performed during emergent forward-viewing endoscopic study.     

十二指肠黏膜下肿瘤的内镜治疗

目的 总结内镜治疗十二指肠黏膜下肿瘤( SMT)的经验,探讨其临床价值.方法 回顾分析2006年5月至2011年5月复旦大学附属中山医院内镜中心行内镜治疗的十二指肠SMT患者资料,了解病变特点、手术过程、术后并发症及复发情况.结果 共67例患者接受了69例次内镜治疗,其中男性36例,女性31例,中位年龄55岁,病变平均最大径(1.34±0.50) cm.69例病变中,位于球部38例、球降交界部12例、降部19例.均成功完成内镜治疗,其中电切治疗11例,内镜黏膜切除术(EMR) 12例,内镜黏膜下剥离术(ESD) 45例,尼龙绳结扎1例.并发症发生率14.5％(10/69),其中术中发生活动性大出血1例,穿孔2例,延迟性出血3例,一过性淀粉酶水平增高3例,迟发性穿孔1例.67例获病理诊断,其中最常见的是Brunner腺瘤(36例).60例患者术后随访,中位随访时间为13个月.1例类癌患者ESD术后病理诊断提示脉管内有肿瘤细胞,再行择期扩大切除术.1例Brunner腺瘤患者EMR术后1年复发,再行ESD治疗后好转.结论 内镜治疗安全、微创、有效,可成为部分十二指肠SMT的治疗方案之一.     

Endoscopic treatment of duodenal bleeding caused by direct hepatocellular carcinoma invasion with an ethanol injection

We report a case of a man who developed duodenal bleeding caused by direct hepatocellular carcinoma (HCC) invasion, which was successfully treated with endoscopic ethanol injection. A 57-year-old man with known HCC was admitted for melena and exertional dyspnea. He had been diagnosed with inoperable HCC a year ago. Urgent esophagogastroduodenoscopy (EGD) showed two widely eroded mucosal lesions with irregularly shaped luminal protruding hard mass on the duodenal bulb. Argon plasma coagulation and Epinephrine injection failed to control bleeding. We injected ethanol via endoscopy to control bleeding two times with 14 cc and 15 cc separately without complication. Follow-up EGD catched a large ulcer with necrotic and sclerotic base but no bleeding evidence was present. He was discharged and he did relatively well during the following periods. In conclusion, Endoscopic ethanol injection can be used as a significantly effective and safe therapeutic tool in gastrointestinal tract bleeding caused by HCC invasion.