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Therapeutic Algorithm for Duodenal Varices: A Case Series

Background: Duodenal varices cause fatal bleeding and are potentially life-threatening. Treatment guidelines for duodenal varices have not yet been established due to their low incidence. We report a case series of patients with duodenal varices admitted to our hospital between April 2012 and June 2017 and share our therapeutic algorithm for duodenal varices. Case Report: This is a retrospective case series of six patients with duodenal varices. Three of the cases were emergent, two were elective, and one was prophylactic. Therapeutic options for duodenal varices can be classified into endoscopic and endovascular therapies. Using our al -gorithm, endoscopic injection sclerotherapy with n-butyl-2-cyanoacrylate, endoscopic band ligation, or balloon-occluded retrograde transvenous obliteration or both, were performed to eradicate the duodenal varices. In two of the emergent cases, rebleeding occurred after successful primary hemostasis by endoscopic band ligation. In these patients, secondary hemostasis was achieve dwith a combination of endoscopic and endovascular therapies. No recurrences of duodenal varices were reported in any patient. Conclusion: Duodenal variceal hemorrhage is fatal, and therefore, needs to be treated with an effective therapy as soon as possible. The appropriate treatment method should be chosen on a case-by-case basis considering the hemodynamics and patients’ condition. variceal bleeding (emergent cases) or duodenal varices with a prior history of bleeding (elective cases), urgent EGD and CE-CT should be performed to evaluate the bleeding focus and to assess the variceal hemodynamics. NBCA-EIS should be performed if an experienced endoscopist can access the bleeding point and the varicesaretense enough for the successful intravariceal injection of NBCA-Lip. If the conditions do not meet these requirements, band ligation or clipping can be performed to temporize the bleeding. When CE-CT after endoscopic therapy shows residual blood flow in the varices or the afferent vessel, additional treatment is needed. If the varices have portosystemic shunts accessible from efferent vessels, BRTO should be actively considered unless the patient’s condition is severe(Child-Pugh class C, uncontrolled ascites, portal vein thrombosis, or renal failure). If there is no accessible portosystemic shunt by BRTO, repeated endoscopic therapies should be attempted, depending on the situation(NBCA-EIS, EBL, and clipping).If bleeding from the varices is not controlled by repeated endoscopic therapies or BRTO, the patient can undergo other therapies such as TIPS, PTO, or surgery.In prophylactic cases, if the varices are nodular or tumorous, and if they have an accessible portosystemic shunt, BRTO should be performed. When the duodenal varices do not have an accessible portosystemic shunt, NBCA-EIS should be performed as a prophylactic treatment.