CASE REPORT Variceal hemorrhage is a common etiology of gastroduodenal bleeding in portal hypertension and may also develop in noncirrhotic portal hypertension, such as portal venous thrombosis. Approximately 1%–5% of varices are ectopic, lying outside the gastroesophageal area. 1 Duodenal varices are uncommon and carry high mortality risk (>40%) when bleeding. Endoscopic cyanoacrylate injection remains first-line intervention, achieving initial hemostasis rates of 89%–95%. 2 Other therapies include Endoscopic ultrasound guided coiling, sclerotherapy, and band ligation. 2, 3 A 71-year-old male patient with portal hypertension secondary to myelofibrosis-related portal vein thrombosis presented with melena, hemodynamic instability, and hemoglobin 5 g/dL. Computed tomography angiography showed no active bleeding, but tagged red blood cell scan localized duodenal bleeding. After an unsuccessful interventional radiology embolization, emergent bedside endoscopy revealed active bleeding from a large (>5 mm) duodenal bulb varix (Figure 1), and nonbleeding gastroesophageal varices type 2. Initial direct injection of 2 cc cyanoacrylate via 23 G needle failed to achieve hemostasis (Figure 2). Topical self-assembling peptide hydrogel applied with a cap provided temporary control. Subsequently, 2 cc n-butyl-cyanoacrylate mixed with 0. 5 cc ethiodized oil was injected, followed by nontraumatic powder spray of succinic anhydrate and dextran, which formed a gel on contact with blood. This combination achieved complete hemostasis (Figure 3), with follow-up endoscopy confirming sustained bleeding control (Figure 4). Figure 1.: Esophagogastroduodenoscopy initial view of bleeding duodenal varix. Figure 2.: Failed histoacryl injection to control bleeding. Figure 3.: Succinic-Anhydride and Dextran Powder Spray application achieved complete cessation of bleeding. Figure 4.: Follow-up esophagogastroduodenoscopy showed continued healing and good control of bleeding. This case demonstrates successful triple endoscopic therapy for duodenal variceal bleed following initial cyanoacrylate injection failure. The addition of ethiodized oil to the glue compound delays polymerization, allows slow and steady glue delivery, enabling the endoscopist to fill the entire varix complex with solidified glue without inadvertent embolization. Based on published trials, glue is preferred over banding for nonesophageal varices and varices too large to be captured by band. 4, 5 Endoscopic ultrasound-guided coiling was deferred due to hemodynamic instability. This represents the first reported case of duodenal variceal bleeding managed with this specific combination approach (Video 1). "href": "Single Video Player", "role": "media-player-id", "content-type": "play-in-place", "position": "float", "orientation": "portrait", "label": "Video 1", "caption": "Duodenal variceal bleed treated with triple endoscopic hemostatic therapy. ", "object-id": {"pub-id-type": "doi", "id": "", "pub-id-type": "other", "content-type": "media-stream-id", "id": "1ₑboyu7hw", "pub-id-type": "other", "content-type": "media-source", "id": "Kaltura"} DISCLOSURES Author contributions: All authors meet ICMJE criteria for authorship: S. Hamarsheh: Contributed to the acquisition of clinical data; Drafted the manuscript; Approved the final version to be published; Accepts accountability for all aspects of the work. MU Khalid: Contributed to the conception and design of the work; Drafted the manuscript; Approved the final version to be published; Accepts accountability for all aspects of the work. H. Siddiki: Contributed to the analysis and interpretation of data; Critically reviewed the manuscript for important intellectual content; Approved the final version to be published; Accepts accountability for all aspects of the work. MU Khalid serves as the article guarantor and accepts full responsibility for the conduct of the study. Financial disclosure: None to report. Informed consent was obtained for this case report.
Hamarsheh et al. (Fri,) studied this question.