Singapore Med J 2005; 46(12) : 723 ABSTRACT Endoscopic treatment of bleeding duodenal varices is less invasive than the usual surgical options. However, there is limited experience with endoscopic treatment of bleeding duodenal varices, especially with that of endoscopic ligation. W e report a 55-year-old man with a bleeding duodenal varix that was successfully ligated endoscopically. He has been followed up for nine months with no recurrence of bleeding. Endoscopic ligation may offer a new and effective treatment modality for bleeding duodenal varix. Keywords: duodenal varix, endoscopic banding, endoscopy, gastrointestinal bleeding Singapore M ed J 2 0 0 5 ; 4 6 (1 2 ):7 2 3 -7 2 5 INTRODUCTION Haematemesis and melaena are common presentations among patients in the surgical department. Common causes include gastritis, peptic ulcer disease, oesophageal varices, Mallory-Weiss disease and gastric tumours. However, bleeding from a duodenal varix is rarely encountered and there is limited experience in treating it endoscopically. Endoscopic band ligation offers a fast and effective way to secure haemostasis and can be the treatment of choice in the future for bleeding duodenal varices. CASE REPO RT A 55-year-old Malay man had a known history of Child’s A liver cirrhosis secondary to chronic hepatitis B infection and alcoholism since the age of 16 years. Subsequently, he suffered from multiple episodes of gastrointestinal bleeding from his oesophageal varices and underwent a portal shunt and splenectomy in 1965. Post-surgery, his bleeding oesophageal varices recurred in 1999 and he underwent multiple episodes of band ligation and sclerotherapy. On this admission, he presented initially at the emergency department with melaena for the past three days, together with haematemesis on two separate occasions. He was hypotensive (blood pressure 76/54 mmHg) and tachycardic (pulse rate of 117 beats/minute) at the emergency room. His haemoglobin level had dropped from 14.8g% two weeks ago to 11.2g%. Fluid resuscitation, which included 2.0 L of crystalloids, 0.5 L of colloids and 1.0 L of blood, was quickly administered to stabilise the patient haemodynamically. An immediate gastroscopy was performed. At gastroscopy, no bleeding oesophageal varices were seen. However, a spurting duodenal varix, approximately 1.5 cm in diameter, was found (Fig. 1). This bleeding duodenal varix was successfully band-ligated (Figs. 2 & 3). Technically, there was no difficulty in banding the duodenal varix after the blood clots were flushed away, though the varix was still spurting away. The transparent cap from the ligation device which was attached to the gastroscope (Fig. 2) prevented blood and mucosa from obscuring the operator’s view. Continuous insufflation of air into the duodenal lumen also gave ample space to ligate the varix easily. Intravenous somatostatin was started from admission for a duration of five days but oral propanolol (ß-blocker) was only commenced three days after the gastroscopy, when the patient started feeding. Subsequently, the patient remained haemodynamically stable and no repeat gastroscopy and banding was needed. He was finally discharged one week later with a stable haemogloblin level of about 10g%. The patient has been followed-up for the last one year with no signs and symptoms to suggest any recurrence of bleeding. However, no repeat gastroscopy was done due to patient’s refusal until only recently (one year post-banding). The previous duodenal varix has totally regressed and only a duodenal scar was seen (Fig. 4). DISCUSSION Duodenal varices are rare, compared to oesophageal or gastric varices. Portal hypertension due to liver cirrhosis remains the most common cause, as in this patient. Duodenal varices resulting from retroperitoneal porto-systemic shunts are caused by increased Department of Surgery Changi General Hospital 2 Simei Street 3 Singapore 529889 N C Tan, MBBS, MMed, MRCSE Registrar S Ibrahim, MBBS, FRCS, FAMS Consultant K H Tay, FRCSE, FRCS, FAMS Senior Consultant and Chief Correspondence to: Dr Tan Ngian Chye Tel: (65) 6850 3551 Fax: (65) 6260 1709 Email: ngian79@ singnet.com.sg Successful management of a bleeding duodenal varix by endoscopic banding N C Tan, S Ibrahim, K H Tay Case Report