Massive Gastrointestinal Bleeding from an Ectopic Varix in a Non-Cirrhotic Patient: Angiographic Approach Following Endoscopic Treatment Failure

http://dx.doi.org/10.1016/j.jpge.2015.10.006 2341-4545/© 2015 Sociedade Portuguesa de Gastrenterologia. Published CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4 emorrhagic shock, requiring substantial transfusion suport (10 units of erythrocyte concentrate, 4 units of resh frozen plasma, 1 platelet pool and 3 g of fibrinoen), renal and respiratory failure with the need of nvasive mechanical ventilation. Urgent esophagogastrouodenoscopy, ileocolonoscopy and CT-angiography were nconclusive. Push enteroscopy identified an intermittent purting hemorrhage in the third portion of the duodenum. he underlying source of bleeding was initially misinterreted as being a Dieulafoy’s lesion. Thus, endoclips were pplied, with initial effective hemostasis, and tattooing as performed (Fig. 1A and B). However, severe rebleedng occurred 48 h after the procedure, with recurrence of emodynamic instability. A second enteroscopy identified n ectopic duodenal varix with active oozing underlying he previously applied endoclips. Cyanoacrylate injection as hampered by compromised visualization of the varix because of the previously applied endoclips and ongong bleeding), but provided hemostasis (Fig. 1C and D). o evaluate the efficacy of cyanoacrylate injection, radial ndoscopic ultrasound (EUS) was performed and showed atency (positive Doppler flow) of this large duodenal varix Fig. 2A). In a multidisciplinary team meeting, it was decided o perform angiographic therapy, after post hoc evaluation