Upper gastrointestinal bleeding in cirrhosis: varix or no varix?

Abstract

Upper gastrointestinal bleeding from variceal origin is a frequent complication in the cirrhotic population. Duodenal variceal haemorrhage, however, is infrequent and the endoscopic management of such lesions is not straightforward. Non-endoscopic options include vasoactive drugs, transjugular intrahepatic portosystemic shunt (TIPS), transvenous obliteration and surgery as rescue therapy. We present a patient with Child-Pugh A hepatitis C virus-cirrhosis with acute bleeding from a duodenal varix. It was managed with elastic band ligation but late rebleeding occurred after 6 weeks. Gastroduodenoscopy revealed active bleeding from the ligation eschar. Band ligation and sclerosis were attempted but unsuccessful. Terlipressin was started and the patient referred for TIPS. Surprisingly, angiography showed a normal hepatic vein pressure gradient; therefore, TIPS was not performed. Haemorrhage ceased with medical treatment alone. The patient remained stable and was discharged after 10 days, being currently under evaluation for hepatitis C therapy.

Figure 1

Oozing varix on the second portion of the duodenum.

Figure 2

Endoscopic variceal band ligation.

Figure 3

CT scan of the abdomen (venous phase) showing an enlarged liver with slightly lobulated contour and repermeabilisation of the paraumbilical vein.

Figure 4

Oozing from the ligation eschar.

Figure 5

Bleeding after failure of endoscopic haemostasis.