Endoscopic treatment of a bleeding duodenal ulcer & an incidental duodenal varix

A 62 y/o male patient presented with acute upper GI bleed.  Prior to this event, he was being managed for HCV (hepatitis-C virus) positive decompensated hepatic cirrhosis.  Vital signs were normal on examination.  Patient was alert, afebrile and anicteric.  He had moderate ascites and a non-tender abdomen.  Laboratory values included Hb% 10.1, HCT 42, PLT 91,000/cu.mm, PT > 10 sec, serum albumin 3.2 g/dl., and a normal basic metabolic panel.  After initiating IV fluid resuscitation, patient was taken  for an upper GI endoscopy.  A single channel, 9.2 mm Pentax gastroscope was introduced under conscious sedation.  The esophagus showed four columns of moderate size non-bleeding varices.  There were no gastric varices.  Mild mucosal edema and congestion was consistent with portal gastropathy.  A 1 cm large ulcer was seen on the posterior wall of duodenal bulb with a visible vessel in the base.  2 cm duodenal varix was also noted adjacent to this large ulcer (fig-1).

There was no active bleeding.  A  22G sclerotherapy needle was introduced through the accessory channel of the gastroscope and 3 ml. of absolute alcohol was slowly injected around the ulcer base (fig-2). 

Post-injection view highlighting immediate pallor and reduction in size of the visible vessel is shown (Fig-3). 

Additional 3-ml. absolute alcohol was also injected  into the duodenal varix as a prophylaxis against future bleed from extension of the adjacent ulcer.

Patient tolerated the procedure well without further episodes of upper GI bleed and was discharged in stable condition.  Unusual or co-existent source of upper GI bleeding (e.g., a duodenal ulcer or an ectopic varix) should be considered during management of patients with portal hypertension.  Doudenal varices occur in 0.4% of such patients.  

Back to Case Listing