Rarely Seen Duodenal Varices Merit Vigilant Endoscopy

Case report: We present a 30-year-old female who was diagnosed recently to be suffering from cryptogenic related compensated chronic liver disease. She had no history of ascites, pedal edema, upper or lower gastrointestinal bleed or Porto systemic encephalopathy. On evaluation her complete hemogram revealed mild anemia and thrombocytopenia, liver function were mildly deranged with slight increase in serum bilirubin, transaminases, and mild coagulopathy as evidenced by international normalized ratio (INR) level of 1.3. The renal function test, thyroid profile, blood sugar, serum electrolytes, autoimmune, and Wilson profile were normal and viral screen was negative. The ultrasonogram abdomen revealed coarse and shrunken liver with altered echotexture and splenomegaly. The serum IgA TTG (tissue transglutaminase) antibody test was positive (28.5 IU/mL). The patient was subjected to upper gastrointestinal endoscopy for screening of varices as well as duodenal biopsies for confirming associated celiac disease. The endoscopy revealed low grade esophageal varices but three prominent duodenal varices located in second part. Normally, duodenal biopsies for confirming celiac disease are also taken from second part of duodenum. In this case a great caution was taken while taking biopsy, so as to avoid trauma to duodenal varices. In such cases even biopsies from first part of duodenum can also be taken.

Conclusion: A beginner can confuse duodenal varix with mucosal folds or sub-mucosal lesion and can attempt unwarranted biopsy that can be life-threatening and will require urgent banding or glue injection.

Table 1 Type wise distribution of duodenal nodules related to biopsy findings

Types of nodules	Nonspecific duodenitis	Duodenitis[a]	Celiac disease	Giardiasis	Eosinophilic duodenitis	Adenocarcinoma	NET	Strongyloides stercoralis	Lipoma	Total
Type 1	20 (43.47%)	14 (30.43%)	4 (8.69%)	5 (one diagnosed to be CVID) (10.86%)	2 (4.34%)	0	0	1 (2.17%)	0	46 (65.7%)
Type 2	8 (42.10%)	3 (15.78%)	5 (26.31%)	0	1 (5.26%)	1 (5.26%)	1 (5.26%)	0	0	19 (27.2%)
Type 3	0	1 (20%)	0	0	0	2 (40%)	1 (20%)	0	1 (20%)	5 (7.1%)
Total	28 (40%)	18 (25.71%)	9 (12.85%)	5 (7.14%)	3 (4.28%)	3 (4.28%)	2 (2.84%)	1 (1.42%)	1 (1.42%)	70

^a Duodenitis includes: active, chronic, peptic, H. Pylori duodenitis.

Fig. 1 Endoscopy Showing Duodenal Varices Becoming More Prominent in Inhalation

Fig. 2 Endoscopy showing duodenal varices becoming less prominent in exhalation.

Publication History

Article published online:
22 April 2024