Triple Endoscopic Hemostatic Therapy for Life Threatening Duodenal Variceal Bleed

CASE REPORT Variceal hemorrhage is a common etiology of gastroduodenal bleeding in portal hypertension and may also develop in noncirrhotic portal hypertension, such as portal venous thrombosis. Approximately 1% – 5% of varices are ectopic, lying outside the gastro-esophageal area. 1 Duodenal varices are uncommon and carry high mortality risk ( . 40%) when bleeding. Endoscopic cyanoacrylate injection remains fi rst-line intervention, achieving initial hemostasis rates of 89% – 95%. 2 Other therapies include Endoscopic ultrasound guided coiling, sclerotherapy, and band ligation. 2,3 A 71-year-old male patient with portal hypertension secondary to myelo fi brosis-related portal vein thrombosis presented with melena, hemodynamic instability, and hemoglobin 5 g/dL. Computed tomography angiography showed no active bleeding, but tagged red blood cell scan localized duodenal bleeding. After an unsuccessful interventional radiology embolization, emergent bedside endoscopy revealed active bleeding from a large ( . 5 mm) duodenal bulb varix (Figure 1), and nonbleeding gastroesophageal varices type 2. Initial direct injection of 2 cc cyanoacrylate via 23 G needle failed to achieve hemostasis (Figure 2). Topical self-assembling peptide hydrogel applied with a cap provided temporary control. Subsequently, 2 cc n-butyl-cyanoacrylate mixed with 0.5 cc ethiodized oil was injected, followed by nontraumatic powder spray of succinic anhydrate and dextran, which formed a gel on contact with blood. This combination achieved complete hemostasis (Figure 3), with follow-up endoscopy con fi rming sustained bleeding control (Figure 4). This case demonstrates