Duodenal Varices
65 year old man with a history of chronic pancreatitis. 15 years ago he had gallstone induced pancreatitis, originally treated with cholecystectomy. Had a prolonged course, eventually developing infected pancreatic necrosis. This was treated with multiple debridements during an 8 month hospital stay. Since that time has had chronic abdominal pain and an enlarged head of pancreas. +/- malabsorptive diarrhea. No baseline liver dysfunction.
Laboratory and diagnostic studies
Now is admitted with pneumonia, when he experiences severe upper GI bleeding. Taken to ICU, resuscitated. Upper endoscopy eventually demonstrated isolated duodenal varices, actively bleeding. No gastric or esophageal varices. Unable to control this endoscopically.
Patient taken to angiography. This demonstrated patent portal vein and splenic vein with completely occluded SMV. Large paraduodenal varices noted. Hepatic vein wedge pressure 6. The angiographer (who is normally quite aggressive) feels he has nothing to offer.
The patient continues to bleed.
Treatment of Duodenal Varices
Being treated with Octreotide (somatostatin) drip at high dose.
What operative strategies to you all have in this man with a very hostile abdomen/retroperitoneum? Then I’ll let you know what we did and how it is working.
So you have a case not of potal hypertension but mesenteric venous hypertension causing these varicies. I assume that this involves only the proximal SMV, if the distal arcades were thrombosed the bowel would probably not be viable. A bypass must be done but you can’t bypass this into the renal vein because that may cause ecephalopathy. The spenic vein may be hard to find. i guess I would run a graft from some branch of the SMV to the portal vein.
Let us clarify a few issues.
1. This guy’s liver is not cirrhotic I assume.
2. His splenic vein is patent so this is not segmental portal HT (“sinistra”)
3. I do not understand the very low hepatic wedge pressure- does he has or has not portal hypertension?
I assume that his pancreas was screwed somehow during the multiple re-ops for infected pancreatic necrosis- developing stricture of the pancreatic duct and- chronic pancreatitis- resulting then -or thereafter- in SMV thrombosis.
The distorted anatomy and resulting portal HT caused the duodenal varices- which are well described.
So I assume that this guy HAS portal HT and the low wedge is false; if he would go in bleeding -hostile abdomen or not – would enter his abdomen from the right side and attempt a Sarfeh- small diameter PTFE porto-caval interposition shunt.
Let me clarify a few things about this case of bleeding duodenal varices:
There is no evidence of portal hypertension. Cirrhosis is not present. The splenic vein and portal vein are wide open by angiography. I consider a hepatic vein wedge pressure of 6 to be normal.
The SMV is completely occluded. We had been hoping for a short segment SMV occlusion that could be crossed transhepatically and opend by the interventionalist. However, no recognizable segment of the SMV proper was visualized.
Needless to say, this was veryt daunting pre- and intraoperatively.
Interesting case. Perhaps the SMV was injured/thrombosed during prior episode of pancreatitis. It sounds like the variceal hemorrhage is from the distal duodenum and that the distal SMV is patent. Assuming this, then I would do a mesocaval (from patent SMV to IVC) shunt using internal jugular vein. I can understand why GI and radiology have nothing to offer.
I ‘d like to point out that this pt has a symptomatic cronic relapsing pancreatitis.
His liver is working well and nothing has been told us that there are peripheral signs and symptoms of thrombosis of the SMV….Ascitis, collateral circulation, oedema, malabsorption of intestinal origin, etc…
Therefore,it must exist sufficient collateral splacnic irrigation that permits a normal flow of bowel’s blood flood to the porta hepatis, ICV and from there to the liver and general circulation…
No esophagogastric varices…
So,if there’s need of a surgical decission because of persistent duodenal bleeding that can’t be solved by other measures, why insist in trying to make a Drapana type shunt or other, i wonder?…
All this,limits or restricts the problem to the mesenterico-spleno-portal axe, the variceal duodenum and the cronic pancreatitis particularly of the head…
And that’s the reason why,I think that perhaps a duodenopancreatectomy of the head, with a small slice of pancreas, without touching the vessels might be a solution to this pt’s problem…
Naturally,if anatomic conditions permit such a procedure… and the pt can stand it well…
In France, chez M. Mercadier, this was the way these problems were solved.
I presume that either endoscopic variceal sclerosis was not possible or not helpful and that endoscopic variceal banding was probably technically impossible.
It is now clear that you are/were dealing with isolated SMV hypertension (angiography is definitive enough!), this is much rarer than segmental portal hypertension secondary to splenic venous obstruction. It is unfortuante that no part of SMV was patent and I presume you had already tried endoscopic measures to control the bleeding. A word of caution in resuscitating patients in portal hypertension,where the aim should be to have a systolic B.P of >100, CVP of between 0-5 cm of water and urinary output of 40mls per hour, over expansion of the circulation would cause a rebound increase in PHT and hence more bleeding. Vasoactive drugs terlipressin, somatostatin or octreotide are useful generally but not always , as you found out.
I further appreciate the difficulty of operating in such a patient with previous pancreatitis and abundant varices around the duodenum.
I would consider the following options:
a)Minimal intervention , i.e local trans-duodenal control with ligation only, achieve haemostasis and bail out
b)A pancreatico-duodenectomy- Good luck if you went down that road.
c) I cannot see how or where you could shunt the SMV considering that its occluded through and through, shunting the portal vein would be absolutely useless. I would believe the WHVPG that was reported by your radiologist.
d)I wonder if it is possible to shunt a tributary of SMV ( I am not aware of any such shunt). However , we know that smaller shunts tend to thrombose quickly.
My gut feeling is that you went for the first option and intend to use long term Beta blockade as prophylaxis against rebleeding of which he stands a very high chance.
You need to get the blood from the proximal SMV to the portal vein somehow…and it sounds like a segment of some length. I wouldn’t advise using PTFE in the venous system…every time I have seen it tried it has failed due to thrombosis in a matter of weeks. Some people do mesocaval shunts that way, but they’ll have a higher success rate in cirrhotics since there’s a pressure head to increase velocity. One option you may consider is using the left renal vein instead of the jugular…one incision, no chance to bag the RLN or the vagus, but it’s not as long. The kidney, of course, gets by on collateral drainage into the adrenal and the gonadal.
This is a tough case indeed. It seems that the problem is HTN in the SMV alone and that the liver and portal systems are normal. I think that the simplest thing is an H type mesocaval shunt. This is fast, and should be easy to do. And with normal liver, I don’t think that the patient will have significant encephalopathy.
You say injection failed, you don’t say why – if you could see the bleeder why not try again (and again) until you stop it.
Everyone’s comments on my case of bleeding duodenal varices is noted and appreciated.
We did take that patient to surgery. At surgery, the patient’s abdomen was very difficult. Everything was densely adhesed. With some trouble, were able to Kocherize the duodenum. Could also identify the ligament of Treitz. That was about it. Could not safely mobilize any small bowel. The retroperitoneum between 3rd portion of duodenum and the ligament of Treitz was a rock. Impossible to do a whipple. We did a longitudinal duodenotomy and oversewed all of the bleeding varices. Closed the duodenum, placed a lateral duodenostomy and gastrostomy and got out. Couldn’t safely get a loop of jejunum for a feeding jejunostomy.
Post operatively, kept the patient on Octreotide and started beta blockade. He is now 8 days post op. He has not bled (yet — I think his long term risk of rebleeding is 50-70%). He is extubated, without any major organ failures. That is about as good as I had hoped for.