Successful management of a bleeding duodenal varix by sclerotherapy withn-Butyl-2-CyanoAcrylate

UCIGEH, Servico de Gastrenterologia, Hospital de Santa Maria, Lisboa, Portugal. Duodenal varices are a rare complication of portal hypertension and experience in the control of haemorrhage is limited. Endoscopic approach, using sclerotherapy with N-butyl-2-cyanoacrylate (1,2) or band ligation (3,4), appears to be a safe and efficient first-choice therapy. Other strategies, such as TIPS (5), are mainly reserved when there is failure to control bleeding. We report the case of a 62-year-old man, with previously diagnosed alcoholic cirrhosis, presenting, for the first time, with melena without hematemesis. An upper gastrointestinal endoscopy showed large esophageal varices, with red spots, without active bleeding, which were submitted to endoscopic band ligation. The patient persisted with melena, needing frequent red blood transfusions to maintain haemodinamic stability. A colonoscopy was undertaken showing diverticula of the left and right colon, without stigmata of recent bleeding. An enhanced contrast CT scan and also a capsule enteroscopy were done and no significant lesions were found. One week after admission, the patient had, for the first time, hematemesis. An upper endoscopy was repeated, revealing recent blood in the duodenum and, in its third portion, a nodular varix with a central depression, without active bleeding (Figure 1). Using a duodenoscope, it was succesfully obliterated with injection of N-butyl-2cyanoacrylate (diluted with lipiodol 1:1), with a total of 3cc of the mixture (Figure 2). The radioscopic control showed no evidence of pulmonar embolisation. He has now a 6-month period of follow-up free from recurrence of bleeding. This paper supports that endoscopic injection sclerotherapy with N-butyl-2-cyanoacrylate is effective in achieving immediate cessation of bleeding in duodenal varices and that long-term hemostasis can be expected.