PMC5301088_01
The following images are from a contrast-enhanced CT of the abdomen demonstrating the tortuous varix (red) protruding into the 3rd portion of the duodenum (blue outlining the duodenal border) with white arrow demonstrating lumen of the duodenum. a Sagittal image. b Coronal image at the region of varices. c Two axial CT slices at the level of the third portion of the duodenum.
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F1
The CT scan revealed a markedly cirrhotic liver, ascites, and previously undiagnosed multiple prominent varices involving the 3rd portion of the duodenum (Fig. 1). The patient was transferred from the CT scanner to the Interventional Radiology Suite and an emergent TIPS was successfully performed.
a Digital subtraction angiographic image performed during the transjugular intrahepatic portosystemic shunt (TIPS) procedure demonstrates prominent duodenal varices extending from the inferior mesenteric vein (IMV). Additionally, there is a small coronary vein noted from the main portal vein (MPV). b Focused digital subtraction image of the MPV and IMV confluence after TIPS placement (solid arrow) as well as postembolization of the duodenal varices (dashed arrow) demonstrating no further flow within the varices. a, main portal vein; b, splenic vein; c, superior mesenteric vein; d, inferior mesenteric vein; e, duodenal varices; f, coronary vein.
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F2
Owing to the size of the varix and the recurrent hematochezia, endoscopic therapy was deferred, and the patient underwent successful endovascular coil embolization of the duodenal varices (Fig. 2b).
a Endoscopic photograph of a duodenal varix involving the third portion of the duodenum (black arrows). b Endoscopic photograph of a duodenal varix involving the third portion of the duodenum (black solid arrow). Note the white spot (black dashed arrow) within an area of superficial erythema representing high-risk stigmata of bleeding.
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F3
Given the findings on CT and on angiography, the third portion of the duodenum was evaluated demonstrating a large varix (Fig. 3) with high-risk stigmata of bleeding seen as evidenced by depressed punctate white spot within an area of superficial erythema.