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An unusual cause of upper gastrointestinal bleeding
Accepted Manuscript Title: An Unusual Cause of Upper Gastrointestinal Bleeding Authors: I-Chang Lin, Ching-Tai Lee, Yao-Chun Hsu, ChaoMing Tseng PII: DOI: Reference:
S1590-8658(17)30984-2 http://dx.doi.org/doi:10.1016/j.dld.2017.07.009 YDLD 3497
To appear in:
Digestive and Liver Disease
Please cite this article as: Lin I-Chang, Lee Ching-Tai, Hsu Yao-Chun, Tseng ChaoMing.An Unusual Cause of Upper Gastrointestinal Bleeding.Digestive and Liver Disease http://dx.doi.org/10.1016/j.dld.2017.07.009 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Image of the Month An Unusual Cause of Upper Gastrointestinal Bleeding Authors: I-Chang Lin, MD1, Ching-Tai Lee2, Yao-Chun Hsu2,3, Chao- Ming Tseng4,5 Department of Radiology1 and Internal Medicine2, E-Da Hospital, I-Shou University, Kaohsiung City; Taiwan 3School
of Medicine, Fu-Jen Catholic University, New Taipei City; Taiwan
4Department
of Internal Medicine, E-Da Cancer Hospital, I-Shou University,
Kaohsiung City; Taiwan 5Taiwan
Association for the Study of Small Intestinal Diseases
Correspondence Dr. Chao-Ming Tseng: Department of Internal Medicine, E-Da Cancer Hospital, 1, E-Da Rd, Jiau-Shu Village, Yan-Chau District, Kaohsiung 824, Taiwan, ROC e-mail: [email protected]
I-Chang Lin: drafting of the manuscript Ching-Tai Lee: interpretation of data, technical support Yao-Chun Hsu: technical support (follow-up data) Chao-Ming Tseng: critical revision of the manuscript Financial Disclosures: No funding was received in support of this work. Conflict of interest: No conflicts of interest exist. A 78-year-old man presented to our hospital with acute onset of melena. His
medical history was significant for hypertension and liver cirrhosis. Physical examination revealed tachycardia, hypotension and pale conjunctiva. After resuscitation, emergent EGD was performed and demonstrated multiple ulcers in the first and second portion of the duodenum. One visible vessel with blood clot was noted within the ulcer in the second portion (figure A). Emergent CT angiography (figure B) showed tortuous vascular structure with intra-luminal contrast extravasation in the second portion of the duodenum. Duodenal variceal bleeding was diagnosed. Band ligation was performed successfully (figure C). He was then discharged uneventfully. Follow-up EGD 1 month later showed ulcer scar formation in the previous banding site (figure D). Bleeding from ectopic varices represent only 2%-5% of all variceal bleeding but is associated with a high mortality of 40%. Duodenal varices are the most common site of bleeding within all ectopic varices1. Diagnosis can be challenging because some varices are buried deep in the submucosa1. In this case we demonstrated the particular endoscopic picture of variceal bleeding mimicking ulcer bleeding. The treatment of duodenal varices is controversial due to limited experience and management options include endoscopic band ligation and sclerotherapy, interventional radiologic treatment and surgery. Endoscopic band ligation was reported to be safe and achieve a high initial hemostasis rate2.
We declare that there is no conflict of interest. Neither conflict of interest nor relevant disclosure is declared relative to this manuscript. No funding was received in support of the work.
References 1. Saad WE, Lippert A, Saad NE, Caldwell S. Ectopic varices: anatomical classification, management.
hemodynamic Techniques
in
classification, vascular
and
and
hemodynamic-based
interventional
radiology.
2013;16(2):158-75. 2. Gunnerson AC, Diehl DL, Nguyen VN, Shellenberger MJ, Blansfield J. Endoscopic duodenal variceal ligation: a series of 4 cases and review of the literature (with video). Gastrointestinal endoscopy. 2012;76(4):900-4.
Figure [A]
Figure [B]
Figure [C]
Figure [D]
S1590-8658(17)30984-2 http://dx.doi.org/doi:10.1016/j.dld.2017.07.009 YDLD 3497
To appear in:
Digestive and Liver Disease
Please cite this article as: Lin I-Chang, Lee Ching-Tai, Hsu Yao-Chun, Tseng ChaoMing.An Unusual Cause of Upper Gastrointestinal Bleeding.Digestive and Liver Disease http://dx.doi.org/10.1016/j.dld.2017.07.009 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Image of the Month An Unusual Cause of Upper Gastrointestinal Bleeding Authors: I-Chang Lin, MD1, Ching-Tai Lee2, Yao-Chun Hsu2,3, Chao- Ming Tseng4,5 Department of Radiology1 and Internal Medicine2, E-Da Hospital, I-Shou University, Kaohsiung City; Taiwan 3School
of Medicine, Fu-Jen Catholic University, New Taipei City; Taiwan
4Department
of Internal Medicine, E-Da Cancer Hospital, I-Shou University,
Kaohsiung City; Taiwan 5Taiwan
Association for the Study of Small Intestinal Diseases
Correspondence Dr. Chao-Ming Tseng: Department of Internal Medicine, E-Da Cancer Hospital, 1, E-Da Rd, Jiau-Shu Village, Yan-Chau District, Kaohsiung 824, Taiwan, ROC e-mail: [email protected]
I-Chang Lin: drafting of the manuscript Ching-Tai Lee: interpretation of data, technical support Yao-Chun Hsu: technical support (follow-up data) Chao-Ming Tseng: critical revision of the manuscript Financial Disclosures: No funding was received in support of this work. Conflict of interest: No conflicts of interest exist. A 78-year-old man presented to our hospital with acute onset of melena. His
medical history was significant for hypertension and liver cirrhosis. Physical examination revealed tachycardia, hypotension and pale conjunctiva. After resuscitation, emergent EGD was performed and demonstrated multiple ulcers in the first and second portion of the duodenum. One visible vessel with blood clot was noted within the ulcer in the second portion (figure A). Emergent CT angiography (figure B) showed tortuous vascular structure with intra-luminal contrast extravasation in the second portion of the duodenum. Duodenal variceal bleeding was diagnosed. Band ligation was performed successfully (figure C). He was then discharged uneventfully. Follow-up EGD 1 month later showed ulcer scar formation in the previous banding site (figure D). Bleeding from ectopic varices represent only 2%-5% of all variceal bleeding but is associated with a high mortality of 40%. Duodenal varices are the most common site of bleeding within all ectopic varices1. Diagnosis can be challenging because some varices are buried deep in the submucosa1. In this case we demonstrated the particular endoscopic picture of variceal bleeding mimicking ulcer bleeding. The treatment of duodenal varices is controversial due to limited experience and management options include endoscopic band ligation and sclerotherapy, interventional radiologic treatment and surgery. Endoscopic band ligation was reported to be safe and achieve a high initial hemostasis rate2.
We declare that there is no conflict of interest. Neither conflict of interest nor relevant disclosure is declared relative to this manuscript. No funding was received in support of the work.
References 1. Saad WE, Lippert A, Saad NE, Caldwell S. Ectopic varices: anatomical classification, management.
hemodynamic Techniques
in
classification, vascular
and
and
hemodynamic-based
interventional
radiology.
2013;16(2):158-75. 2. Gunnerson AC, Diehl DL, Nguyen VN, Shellenberger MJ, Blansfield J. Endoscopic duodenal variceal ligation: a series of 4 cases and review of the literature (with video). Gastrointestinal endoscopy. 2012;76(4):900-4.
Figure [A]
Figure [B]
Figure [C]
Figure [D]