A rare solitary varix in the descending part of the duodenum secondary to superior mesenteric vein stenosis: A case report

Introduction

The risk of bleeding from duodenal varices (DV) is reportedly four times higher than that from gastroesophageal varices,^1,2 with a mortality rate as high as 40%.^3–5

This report presents a rare case of a patient who, following an exploratory laparotomy after a car accident, developed stenosis of the superior mesenteric vein. This complication led to the formation and subsequent rupture of an isolated varix in the descending part of the duodenum. Endoscopic injection therapy using tissue adhesive was performed, which significantly controlled the variceal bleeding.

The majority of previously published case reports on DV are associated with liver cirrhosis and portal hypertension. By contrast, the case presented here is exceptionally rare, as it occurred in the absence of both cirrhosis and portal hypertension and was instead trauma-induced. Through a systematic search on PubMed, we identified and summarized case reports on DV published between 2016 and 2025. As shown in Table 1, most documented cases were managed using either surgical or interventional procedures. However, the treatment course in our patient demonstrates that endoscopic tissue adhesive injection can also serve as an effective therapeutic approach.

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Table 1.

A comprehensive summary of case report papers on duodenal varices published between 2016 and 2025.

Author	Year	The causes of duodenal varices	Treatment strategies	Follow-up
Go Anegawa 6	2016	Hepatitis C-related liver cirrhosis	Direct injection of ethanolamine oleate into the afferent collateral vessel under laparotomy	3 Months
Vincent Khor 7	2018	Liver cirrhosis	Duodenectomy	No
Bu-Shan Xie 8	2018	IPH	TIPS plus embolization	2 Months
Ajit Yadav 9	2018	Locally infiltrating pancreatic neuroendocrine tumor	Coil embolization of varices and SMV stenting of the occluded venous segment after failure of endoscopic glue injection	6 Months
Rohit Anand 10	2019	Hepatitis C and alcoholic liver cirrhosis	After the failure of treatment with tissue glue, portal vein thrombectomy, and TIPS shunt balloon angioplasty were conducted, followed by portosystemic embolization	No
Yanying Gao 11	2020	Liver cirrhosis	TIPS	2 Years
Mengying Liu 12	2020	Primary biliary cholangitis	TIPS	2 Years
Hyun Woo Kim 13	2020	Alcoholic cirrhosis	PTVO	3 Months
Se Jin Park 14	2020	Liver cirrhosis	Coil-assisted retrograde transvenous obliteration	No
Susmit Roy 15	2022	Portal vein occlusion	Portal vein stenting	Several months
Aya Kato 16	2022	Peripancreatic tuberculous lymphadenopathy	Portal vein stenting	No
Kyung Kyu Lee 17	2023	Alcoholic cirrhosis	PARTO	11 Weeks

IPH: idiopathic portal hypertension; PARTO: plug-assisted retrograde transvenous obliteration; PTVO: percutaneous trans-splenic variceal obliteration; SMV: Superior Mesenteric Vein; TIPS: transjugular intrahepatic portosystemic shunt.

Case presentation

A 50-year-old male was admitted to our hospital with a chief complaint of “intermittent hematemesis and melena for 12 years, recurrence within 24 h.” Tracing the patient’s history, the origin of this condition dates back 20 years to a motor vehicle accident involving abdominal impact and a subsequent laparotomy. This surgery resulted in superior mesenteric vein stenosis and led to the development of extremely rare, isolated ectopic varices in the horizontal part of the duodenum. For the past 12 years, the patient has experienced recurrent gastrointestinal bleeding. Initial gastroscopy findings were unremarkable; however, a follow-up gastroscopy and abdominal computed tomography (CT) angiography later confirmed the presence of varices in the descending part of the duodenum. In an attempt to reduce portal venous pressure, the patient underwent a splenectomy, splenorenal shunt, and a superior mesenteric vein-to-right gastroepiploic vein bypass. Despite these surgical interventions, subsequent bleeding episodes were not prevented. It is noteworthy that the patient had no history of liver cirrhosis, portal hypertension, or coagulopathy. To address the recurrent gastrointestinal bleeding, the patient underwent gastroscopy at our hospital 5 years ago. The examination revealed tortuous, beaded, and nodular varices in the descending part of the duodenum, accompanied by red signs and mucosal erosion (Figure 1(a)). This, combined with a previous abdominal CT (Figure 2(a)) showing tortuous and dilated veins in the pancreatic head and duodenal region, confirmed the diagnosis of hemorrhage from varices in the descending part of the duodenum. An endoscopic treatment strategy was employed, and the patient subsequently underwent endoscopic sclerotherapy combined with tissue adhesive injection for the DV (Figure 1(b)). Close endoscopic follow-up was conducted: gastroscopy 1 week post-procedure showed postoperative changes at the treatment site (Figure 1(c)); at 4 months post-procedure, extrusion of the tissue adhesive was observed in the descending part of the duodenum (Figure 1(d)); and by 24 months post-procedure, significant improvement was noted, characterized by adhesive extrusion and collapse of the originally treated varix (Figure 1(e)). The patient remained clinically stable during a long-term regular follow-up period of 46 months. However, in the 47th month (prior to this current admission), gastrointestinal bleeding recurred. Upon this current admission, the patient’s vital signs were stable. Physical examination revealed a flat abdomen without visible abdominal wall collateral veins, no tenderness, rebound tenderness, guarding, or palpable masses. The liver was not palpable below the costal margin, and there was no edema in the lower extremities. Laboratory tests indicated anemia (hemoglobin, 72 g/L) with a negative infectious disease panel. Gastroscopy performed after this admission revealed recurrent, bluish, beaded varices with red signs, and erosive bleeding around the previous treatment site in the descending part of the duodenum (Figure 1(f)). Subsequently, a repeat session of endoscopic sclerotherapy combined with tissue adhesive injection was performed (Figure 1(g)), successfully achieving hemostasis.

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Figure 1.

Endoscopic examination and treatment of varices in the descending part of the duodenum. (a) Gastroscopy 5 years ago showed tortuous, beaded, and nodular varices with red signs and superficial erosion. (b) Immediate post-injection appearance of sclerosant and tissue adhesive. (c) Follow-up gastroscopy 1 week later demonstrated edema at the injection site, consistent with the expected post-glue edema phase. (d) Follow-up gastroscopy 4 months later showed adhesive exudation and localized swelling. (e) Follow-up gastroscopy 24 months later showed the treatment site exhibited vein collapse and scar formation (scar phase). (f) Follow-up gastroscopy 47 months later showed recurrent bluish bead-like varices were observed near the prior treatment site, with red signs and active bleeding. (g) At 47 months post-operation, endoscopic sclerosing agent and tissue glue injection were performed again, successfully achieving hemostasis. The “arrows” in the images point to the locations of the ectopic varices.

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Figure 2.

Abdominal CT imaging before and after endoscopic treatment. (a) Pre-treatment CT scan demonstrating significant dilation and tortuosity of peri-pancreatic and peri-duodenal veins. (b) CT image acquired shortly after initial endoscopic therapy showing reduced size and tortuosity of the varices, suggesting a positive response to treatment. (c) CT scan prior to the second endoscopic procedure (47 months after initial treatment), revealing persistent venous dilation and morphological changes around the duodenum, consistent with endoscopic findings of recurrence. The “circles” in the images point to the locations of the ectopic varices.

Discussion

Esophageal and gastric varices are common clinical findings, whereas extrahepatic varices—those occurring outside the esophagus and gastric fundus—are relatively rare, accounting for only 2%–5% of all variceal bleeding cases. ¹ Among these, DV comprises ~17%.^18,19 They most frequently occur in the duodenal bulb and descending part, with isolated varices in the descending part of the duodenum being exceedingly uncommon. DV bleeding was first described by Alberti et al. in 1931 and later observed endoscopically in 1973. ²⁰ This condition is predominantly associated with liver cirrhosis, portal hypertension, and a history of abdominal surgery.

This case is highly uncommon. While the majority of patients with DV have underlying cirrhosis, this individual presented with narrowing and degeneration of the superior mesenteric vein, leading to the development of tortuous and dilated varices in the descending part of the duodenum, in the absence of cirrhosis or portal hypertension. Following stenosis of the superior mesenteric vein, blood flow within the portomesenteric circulation becomes obstructed, resulting in elevated regional venous pressure—a condition known as regional portal hypertension. Under such hemodynamic conditions, collateral veins, such as the pancreaticoduodenal vein, gradually dilate and become tortuous, ultimately forming varices. As venous pressure continues to rise, the walls of these vessels thin and lose elasticity, eventually resulting in isolated variceal formations. ¹ DV is associated with high mortality, and its rupture can be life-threatening due to the inability of the duodenal wall to compress and achieve hemostasis. Diagnosis typically relies on endoscopic and CT imaging.

The patient described in this case report presented with recurrent gastrointestinal bleeding. In such clinical scenarios, it is essential to promptly perform gastroscopy, colonoscopy, and abdominal CT imaging to identify the source and etiology of bleeding. Based on these findings, an individualized treatment strategy should be formulated. Differential diagnoses include rupture of esophageal or gastric varices, peptic ulcer bleeding, gastrointestinal malignancy, Dieulafoy’s lesion, hemobilia, and aortoenteric fistula. The main goals of treatment are to prevent initial bleeding, control active hemorrhage, and prevent rebleeding. ¹ Current therapeutic options include pharmacotherapy, surgical intervention, and endoscopic techniques—such as endoscopic variceal band ligation, endoscopic cyanoacrylate injection, and endoscopic sclerotherapy—as well as endovascular embolization.^2,21,22 Surgical management may also be considered. In this case, the patient initially underwent splenectomy, splenorenal shunt, and superior mesenteric vein to right gastroepiploic vein bypass surgery under the assumption that surgical decompression would alleviate portal hypertension. Unfortunately, the outcome was unsatisfactory, with the patient continuing to experience intermittent hematemesis and melena. Interventional therapy exhibits limited efficacy in regional portal hypertension, requires advanced technical expertise, and carries a substantial risk of complications. It is more suitable for patients with cirrhosis-related portal hypertension. In non-cirrhotic cases, a careful risk–benefit assessment is essential before considering interventional procedures. Given these considerations, we opted for endoscopic therapy due to its minimal invasiveness and ability to achieve immediate hemostasis.

In recent years, advancements in endoscopic technology have contributed to the growing adoption of endoscopic tissue adhesive injection therapy, particularly using cyanoacrylate.^23–25 Upon contact with blood, cyanoacrylate rapidly polymerizes, promoting thrombosis within the varix. Notably, n-butyl-2-cyanoacrylate is associated with reduced tissue toxicity compared to other sclerosing agents. ²⁶ With the evolution of endoscopic ultrasound, this modality now enables more precise assessment of the degree of vascular shrinkage or resolution following variceal treatment.

In the patient reported here, the therapeutic effect lasted for 46 months, but gastrointestinal bleeding recurred in the 47th month. The absence of bleeding over 46 months suggests that endoscopic therapy remained effective for an extended duration. Rebleeding is likely attributable to persistent portal hypertension.

In patients presenting with gastrointestinal bleeding, if no varices, ulcers, or other lesions are detected in the esophagus, stomach, or other conventional segments, a high suspicion of DV should be maintained, and the endoscope should be advanced to the descending part of the duodenum for thorough examination. For patients diagnosed with DV, primary prevention measures should be instituted during stable periods, and underlying conditions should be actively managed. In this case, endoscopic injection of tissue adhesive effectively controlled the bleeding, and no recurrence was observed during the 46-month follow-up period. The patient expressed satisfaction with the treatment outcome. However, given the relatively thin wall of the duodenum, procedures carry risks of ulceration and bleeding.^26,27 as well as complications, such as perforation, ectopic embolism, ²⁸ and intestinal stenosis.^29,30 Therefore, meticulous technique and controlled injection volume are essential. By summarizing the experience from this case, we can improve the recognition and diagnostic accuracy of isolated DV, refine endoscopic techniques, develop individualized treatment plans, integrate portal hypertension management within a multidisciplinary framework, and strengthen long-term follow-up and monitoring—ultimately reducing the risk of rebleeding and other complications. Moving forward, endoscopic treatment strategies are likely to evolve toward greater precision, safety, and efficacy, leading to improved patient outcomes.

Conclusion

Isolated DV bleeding can be effectively managed via endoscopic injection of tissue adhesive. Long-term follow-up following endoscopic therapy is essential. In addition, multidisciplinary collaboration is recommended when necessary to develop individualized treatment plans and improve prognosis.

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