An Uncommon and Challenging Case of Duodenal Variceal Bleeding

A 59-year-old man with a history of alcohol-induced cirrhosis presented to an outside institution with complaints of hematochezia and hematemesis. Notable laboratory results included hemoglobin 2.8 g/dL, international normalized ratio 1.39, albumin 1.7 g/dL, and total bilirubin 2.2 mg/dL. Esophagogastroduodenoscopy at the outside hospital did not reveal a source of the bleed. He was transferred to our institution for further management. Esophagogastroduodenoscopy was repeated, which showed blood oozing from large duodenal varices in the second part of the duodenum (Figure 1). Abdominal computed tomography showed large periduodenal varices during the arterial phase imaging (Figure 2). Patient emergently underwent transjugular intrahepatic portosystemic shunt (TIPS) placement. The appearance of the periduodenal varices before and after TIPS placement is shown in Figure 3. Patient improved over the next few days with resolution of his acute gastrointestinal bleed