Massive duodenal variceal bleed: endoscopic ultrasonography of ruptured varix and successful endoscopic clipping treatment.

Duodenal varices are a rare cause of upper gastrointestinal (GI) bleeding [1–5] and endoscopic management is not standardized [1, 2]. We report the case of a 50-year-old woman with alcoholic cirrhosis who was referred for severe digestive tract bleeding with hematemesis and hemodynamic instability. After medical management, emergency endoscopy (GIF 190, 2.8-mm operating channel; Olympus, Tokyo, Japan) showed a transverse varix in the second part of the duodenum, with two ulcerations one of which had a blood clot (●" Fig.1a, ●" Fig.1b). This finding was highly suggestive of a variceal rupture site. We immediately performed an endoscopic ultrasound (EUS) exploration (2.5-mm miniprobe, Olympus) to confirm and delineate the varix and its feeding vessel (●" Fig.2a,●" Fig.2b). The varix was 8mm large and connected at its anterior part (left) to a transmural perforating vein. A first clip (Instinct; Cook Medical, Bloomington, Indiana, USA) was deployed on the left part of the varix (●" Fig.3a,●" Fig.3b) andwas immediately effective in reducing the blood flow as shown by EUS (●" Fig.3c, ●" Fig.3d, ●" Fig.3e). A second clip was applied close to the first one to grasp a larger piece of tissue. We achieved hemostasis by placing two additional hemoclips on the posterior (right) part of the varix and then two on the bleeding point (●" Fig.4a). We confirmed the disappearance of the vessel by a third EUS miniprobe examination (●" Fig.4b). Clinical outcomeswere positive for the patient with no bleeding recurrence in the following days. To summarize, in rare cases duodenal varices are responsible for GI bleeding. Previous reports describe treatment of such varices with sclerotherapy [5], glue injection, or with a transhepatic portosystemic shunt (TIPS) combined with clipping [4]. However we have previously encountered lung embolization during treatment of duodenal varices by glue injection, and duodenal necrosis as a result of band ligation since the entire duodenal wall can be suctioned into the band. Thus, we usually use clipping for duodenal varices as it is precise and safe. Use of the EUS miniprobe allows assessment of the effectiveness of the hemostatic treatment by showing the vessel’s disappearance or reduction in size.