Convoluted tumorous lesions at second portion of duodenum in a cirrhotic patient with massive upper gastrointestinal bleeding and shock

This 49-year-old male, a victim of chronic hepatitis B-related liver cirrhosis, visited our emergency department due to hematemesis and tarry stool passage. Hypovolemic shock severe anemia (Hb 4.8 mg/dL) were noted on arrival. After fluid resuscitation blood transfusion, urgent esophagogastroduodenoscopy revealed no varices in the esophagus cardiac portion stomach; however, some was retained at proximal duodenum. scope pushed down distal 2nd duodenum, convoluted tumorous lesions (Figure 1) with an erosion noticed ampulla vater. First, what is your diagnosis? Second, will be next step? Ectopic duodenal second diagnosed by endoscopy. It confirmed computed tomography 2), which enhanced engorged vessels wall The bleeding episode successfully controlled endoscopic injection sclerotherapy histoacryl glue somatostatin intravenous infusion. are defined as dilated portosystemic collateral veins located unusual sites other than gastroesophageal region constitute 1% 5% all variceal bleeds.1 These could locate different sites, including small bowel, rectum, anastomotic site, stoma high interobserver variability their distribution.2 In large study 173 patients from Japan, Watanabe et al.3 mentioned that duodenum (32.9%) most common 82.5% them descending part. Currently, there clear guidelines management ectopic varices. Endoscopic treatment, ligation, frequent modality for acute bleeding, interventional radiology therapy such transjugular intrahepatic shunt or surgery used rescue therapy. successful rate treatment alone 73.3%. However, 53.3% experience rebleeding within 1 year.4 Each author contributed manuscript. Wei-Chih Su: Conceptualization, Writing—original draft. Chia-Chi Wang: Writing—review & editing, Jiann-Hwa Chen: Supervision, editing. authors declare conflicts interest. case report approved Institutional Review Board (11-CR-105) Taipei Tzu Chi Hospital, Buddhist Medical Foundation.