Duodenal variceal bleeding after balloon-occluded retrograde transverse obliteration: Treatment with transjugular intrahepatic portosystemic shunt

Figure 1 Endoscopic variceal ligation was performed to control variceal bleeding. A: Tiny nodular varices with no bleeding were found at the duodenum second portion; B: Enhanced computed tomography scan showing large gastric varices (arrow); C: Balloon occluded retrograde transvenous obliteration was successfully performed.

Figure 2 An emergency endoscopic examination revealed a small, linear esophageal varices without evidence of recent bleeding. A: In the second portion of the duodenum, nodular varices expanded before balloon occluded retrograde transvenous obliteration and presented with hematocystic spots; B, C: Enhanced computed tomography scan obtained 5 mo after balloon occluded retrograde transvenous obliteration revealing complete obliteration of gastric varices (black arrow); however, duodenal varices were aggravated (white arrow).

Figure 3 Transjugular intrahepatic portosystemic shunt was created according to standard procedures. A: Portogram showing duodenal variceal flow; B: After transjugular intrahepatic portosystemic shunt and coil embolization of duodenal varices, variceal flow disappeared.

Figure 4 A follow-up computed tomography scan was obtained 21 mo after transjugular intrahepatic portosystemic shunt. A, B: Enhanced computed tomography scan shows a still patent transjugular portosystemic shunt tract and complete improvement of duodenal varices. Note the appearance of multinodular hepatocellular carcinomas in the liver.