Successful endoscopic banding after cyanoacrylate failure for active bleeding duodenal varix.

which there is little agreement on the best therapeutic option (1-5). A 47-years-old male, with alcoholic liver cirrhosis (Child-Pugh class C; MELD 29) and previous oesophageal varices bleeding, was admitted for profuse hematochezia. He was tachycardic, hypotensive and had haemoglobin 2,7 g/dl. Fluid and blood resuscitation, intravenous octreotide, ciprofloxacin and PPI were promptly started. Emergent upper gastrointestinal endoscopy (UGIE) revealed scarce fresh blood in the stomach and grade II oesophageal varices with red signs, which were thought to be the source of bleeding and treated with endoscopic banding. As hemodynamic instability and hematochezia persisted, UGIE was repeated with similar findings and no bleeding was identified on angiography. At 48 h from admission massive rebleeding occurred and a 3rd UGIE showed a fresh clot-over-varix located at 2nd to 3rd portions of duodenum (Fig. 1). Injection of the varix with 1 cc of lipiodol and cyanoacrylate 1:1 mixture was performed (Fig. 2), but spurting began soon after the procedure. Given the high surgical risk, yet another endoscopic approach was decided and successful 1ring banding was accomplished (Fig. 3). A 3rd-day UGIE showed a clean, shallow ulcer at the site of the varix (Fig. 4). No rebleeding episodes occurred. Several authors reported endoscopic banding for bleeding duodenal varices (1-4), sometimes followed by other therapies for rebleeding (3,4). Others used cyanoacrylate for emergent treatment of this condition (5), including after banding failure (3). This is, to our knowledge, the first report in which banding was apSuccessful endoscopic banding after cyanoacrylate failure for active bleeding duodenal varix