Year 2022 / Volume 114 / Number 12
Letter
Duodenal variceal bleeding as a presentation of hepatocellular carcinoma

749-750

DOI: 10.17235/reed.2022.8914/2022

Mafalda João, André Trigo, Marta Gravito-Soares, Elisa Gravito-Soares, Sandra Lopes, Pedro Figueiredo,

Abstract
A 79-year-old man with alcoholic liver cirrhosis without regular medical follow-up, presented at the emergency room with hematemesis. An upper endoscopy revealed a varix at the anterior wall of bulb with a red wale sign, indicating recent bleeding. An injection N-butyl-2 cyanoacrylate plus metacryloxisulfolane was successfully performed. The abdominal computed tomography angiography scan revealed a 29x26-mm nodule consistent with hepatocellular carcinoma (HCC), tumoral portal vein thrombosis (and communicating collateral from the superior mesenteric vein feeding the duodenal varix with no splenorenal shunt. After endoscopic therapy, the patient remained asymptomatic without rebleeding. Given HCC stage D (Barcelona Clinic Liver Cancer), after multidisciplinary discussion, the patient was evaluated for best supportive care. Ectopic varices are clinically challenging causes of portal hypertensive bleeding associated with significant mortality, requiring a high index of suspicion and multimodal diagnostic and therapeutic approaches. The management includes endoscopic therapy, interventional radiology techniques (TIPS with variceal embolization, balloon occluded retrograde transvenous obliteration and percutaneous transhepatic obliteration) or surgery. The best endoscopic treatment modality remains unclear because there are no studies directly comparing the different endoscopic techniques. In setting of ectopic varices, abdominal imaging is mandatory to exclude splanchnic vein thrombosis, HCC and to map portosystemic collaterals to guide further treatments.
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References
Sarin SK, Kumar CKN. Ectopic varices. Clin Liver Dis (Hoboken). 2012;1(5):167-72. Epub 2012/11/09.
López Couceiro L, Muñoz Codoceo C, Fernández I. Stomal varices: an unusual cause of bleeding in liver cirrhosis. Rev Esp Enferm Dig. 2020;112(3):241-2. Epub 2020/02/06.
Oleas R, Robles-Medranda C. Endoscopic Treatment of Gastric and Ectopic Varices. Clin Liver Dis. 2022;26(1):39-50. Epub 2021/11/23.
Mora-Soler A, Velasco-Guardado A, Acosta-Materán R, et al. Endoscopic treatment of duodenal varices with cyanoacrylate. Rev Esp Enferm Dig. 2013;105(10):629-32. Epub 2014/03/20.
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João M, Trigo A, Gravito-Soares M, Gravito-Soares E, Lopes S, Figueiredo P, et all. Duodenal variceal bleeding as a presentation of hepatocellular carcinoma . 8914/2022


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Publication history

Received: 07/05/2022

Accepted: 14/05/2022

Online First: 31/05/2022

Published: 12/12/2022

Article Online First time: 24 days

Article editing time: 219 days


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