AJR 2002; 178:399-401
© American Roentgen Ray Society
Detecting Bleeding Duodenal Varices with Multislice Helical CT
Dominik Weishaupt1,
Thomas Pfammatter,
Paul R. Hilfiker,
Ursula Wolfensberger and
Borut Marincek
1
All authors: Institute of Diagnostic Radiology, University Hospital Zurich,
Raemistrasse 100, 8091 Zurich, Switzerland.
Received March 9, 2001;
accepted after revision May 23, 2001.
Address correspondence to D. Weishaupt.
Introduction
Duodenal varices have been reported in patients with intrahepatic and
extrahepatic portal hypertension
[1,2,3,4,5].
As is the case with other dilated portosystemic collateral veins, bleeding is
the most life-threatening complication of duodenal varices, with a mortality
rate of up to 40% for the initial bleeding episode
[3]. Duodenal varices are rare
and are considered ectopic varices, which account for 1-3% of all varices in
patients with liver cirrhosis
[6]. Diagnosis of duodenal
varices may be difficult, requiring careful inspection of the duodenal bulb
during endoscopy [3]. Duodenal
varices may also be revealed using angiography and transhepatic portography
[5].
We report on a patient with life-threatening bleeding from duodenal varices
detected on multislice helical CT. After endoscopic sclerotherapy failed to
stop the bleeding, we successfully treated the duodenal varices by selective
embolization and placement of a transjugular intrahepatic portosystemic shunt.
To our knowledge, ours is the first reported patient with duodenal varices
detected on CT and subsequently treated by both selective embolization and
placement of a transjugular intrahepatic portosystemic shunt. Multislice
helical CT was instrumental in our detection of the duodenal varices and
choice of treatment for the ectopic collateral pathway and portal
hypertension.
Case Report
A 59-year-old woman with a history of alcohol abuse presented to our
emergency department and was admitted to the hospital because of an episode of
hematemesis and melena. The initial upper gastrointestinal endoscopy performed
when the patient was first admitted revealed no abnormal finding other than
the presence of fresh and old blood in the duodenum. No esophageal varices or
hypertensive gastropathy were detected. The clinical examination and
sonography revealed no signs of hepatosplenomegaly nor ascites.
Twelve hours later, the patient developed a second episode of massive upper
gastrointestinal bleeding with clinical symptoms of a hypovolemic shock.
Emergency esophagastroduodenoscopy showed an active hemorrhage arising from a
duodenal varix in the second portion of the duodenum. Endoscopic sclerotherapy
was combined with IV fluid replacement and IV vasopressin infusion. Despite
this treatment, the patient continued to hemorrhage.
Other possible vascular abnormalities in the upper abdomen were
investigated using a multislice helical CT scanner (VolumeZoom; Siemens
Medical Systems, Forcheim, Germany). The abdomen was dynamically scanned
during administration of 150 mL of iodinated contrast agent (Visipaque 320;
Nycomed Imaging, Amersham, Oslo, Norway) at a flow rate of 4 mL/sec. Imaging
was performed in a single breath-hold during the portal venous phase using a 4
x 1 mm collimation. Images were reconstructed with a slice width of 1.25
mm and a reconstruction interval of 1 mm. No oral contrast agent was
administered. Axial slices showed liver cirrhosis and serpigineous vessels
within the second portion of the duodenal wall
(Fig. 1A).
Multiplanar reformation and maximum-intensity-projection images of the CT
data revealed communication of the vascular bundle with proximal branches of
the superior mesenteric vein in the left aspect of the root of the mesentery.
Venous drainage was present throughout the inferior vena cava via the right
gonadal and right renal vein (Fig.
1B). The vascular lesion was interpreted as a collateral pathway
through duodenal varices caused by liver cirrhosis. Duodenal varices were
confirmed by transjugular direct portal venography and selective
catheterization of the superior mesenteric vein
(Fig. 1C). In addition, we
detected esophageal varices and contrast-agent extravasation into the duodenum
corresponding to signs of persistent variceal hemorrhage
(Fig. 1D).
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Fig. 1B. —59-year-old woman with massive upper gastrointestinal
bleeding. Maximum-intensity-projection CT image obtained in oblique sagittal
plane reveals duodenal varices (long arrow) with efferent vessel
draining through right gonadal vein and right renal vein (short
arrow) to inferior vena cava (IVC). Afferent vessel originates in
proximal branches of superior mesenteric vein (arrowhead).
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Fig. 1C. —59-year-old woman with massive upper gastrointestinal
bleeding. Transjugular direct portal venogram shows duodenal varices (long
black arrow) with afferent vessel originating in superior mesenteric vein
(long white arrow) and accumulation of contrast agent (short
black arrow) in duodenal lumen caused by persistent variceal hemorrhage.
In addition, esophageal varices are visualized (short white
arrow).
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Fig. 1D. —59-year-old woman with massive upper gastrointestinal
bleeding. Direct digital subtraction venogram of superior mesenteric vein
after transjugular intrahepatic portosystemic shunt placement and percutaneous
embolization shows that duodenal varices are completely occluded.
|
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There was evidence of portal hypertension, with a portal pressure gradient
of 22 mm Hg. After a 10-mm-diameter transjugular intrahepatic portosystemic
shunt was placed, the pressure gradient dropped to 12 mm Hg. A single-curve
5-French catheter was then advanced into the mesenteric branch supplying the
duodenal varix. Subsequently, embolization of the duodenal varices was
performed using 0.035-inch steel coils (Cook, Bloomington, IN). No further
variceal hemorrhage was observed.
Discussion
Duodenal varices most frequently result from cirrhosis of the liver, portal
vein thrombosis, or obstruction of the splenic vein and inferior vena cava
[2]. Occasionally,
schistosomiasis, postoperative shunt thrombosis, and venoocclusive disease may
cause duodenal varices [2]. The
afferent vessel is usually the pancreaticoduodenal vein originating in the
portal vein trunk or superior mesenteric vein. The efferent veins drain into
the inferior vena cava [2,
3]. These communications
between intestinal or retroperitoneal tributaries of the superior and inferior
mesenteric veins with the inferior vena cava are also called veins of Retzius
[7]. Hence, duodenal varices
are considered dilated veins of Retzius located in the pancreaticoduodenal
region.
Most of the duodenal varices are located in the duodenal bulb, but they may
also occur in the second and third portions of the duodenum
[2]. Compared with esophageal
and gastric varices, duodenal varices are rare, usually occurring in
association with other dilated portosystemic collaterals, such as esophageal
and fundic varices
[1,2,3,4,5].
Conventional contrast-enhanced CT is a powerful modality for expeditiously
evaluating the overall status of portosystemic vessels in patients with portal
hypertension [6,
7]. Moreover, CT is considered
to be superior to angiography in revealing paraumbilical and retroperitoneal
varices [7]. The diagnostic
value of CT in this setting may be increased by use of multislice helical CT.
The faster scanning speeds and narrow collimation increase contrast
opacification in the mesenteric, retroperitoneal, and portal vasculature,
improving one's ability to identify and evaluate these vessels on both axial
source images and multiplanar reformations. As we saw in the case of our
patient, high-quality representations of anatomic detail may be obtained by
multislice helical CT.
Treatment of variceal hemorrhage in the upper gastrointestinal tract is
largely standardized [6,
8]. Endoscopy is of paramount
importance in the treatment of duodenal varices because it allows accurate
identification of the source of bleeding and direct therapeutic intervention
[8]. Barbish and Ephrinpreis
[4] have reported successful
therapy of duodenal varices with sclerosant injection. Surgical shunt
placement or surgical variceal ligation may be necessary to control hemorrhage
in patients in whom sclerotherapy has failed
[3]. The transjugular
intrahepatic portosystemic shunt procedure is effective in decompressing an
elevated portosystemic pressure gradient
[8]. Extensive literature
exists regarding the efficacy of percutaneous embolization techniques in the
acute setting of bleeding esophagogastric varices
[6]. However, the experience
with percutaneous embolization therapy of ectopic varices is limited
[6]. Our goal in embolization
of ectopic varices is not to occlude the bleeding site itself but to occlude
the feeding vein [6]. Because
the transjugular approach may be used for embolization of the ectopic varices
as well as for transjugular intrahepatic portosystemic shunt placement, both
treatment options may be combined in one session.
In conclusion, we believe that our experience with the reported patient
shows multislice helical CT to be effective in depicting duodenal varices as a
cause of massive upper gastrointestinal bleeding. Multislice helical CT was
also instrumental in allowing us to tailor the appropriate patient treatment
by percutaneous embolization and transjugular intrahepatic portosystemic shunt
placement after endoscopic sclerotherapy had failed.
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Introduction
Case Report
