S4647 The Bleeding Duodenal Varix Dilemma: An Atypical Endoscopic Presentation of Duodenal Variceal Bleed

Introduction: Cirrhosis is a major risk factor for gastrointestinal bleeding (GIB), typically from esophageal (∼70%) or gastric (10–30%) varices. Duodenal varices are rare (∼0.4%) but carry high mortality (up to 40%), necessitating prompt recognition and management. Case Description/Methods: A 66-year-old obese woman (body mass index 54.8) with newly diagnosed MASH cirrhosis was transferred with hematemesis, melena, and hypotension. Her history included type 2 diabetes, hypertension, and ovarian cancer (post-surgery/chemotherapy). She received blood products at the outside hospital but remained hypotensive and tachycardic. She denied alcohol or anticoagulant use but reported chronic nonsteroidal anti-inflammatory drug use. She was admitted to the intensive care unit and underwent intubation, resuscitation, and initiation of IV pantoprazole, octreotide, and ceftriaxone for SBP prophylaxis. Labs showed lactate 10, hemoglobin 8.8, platelets 96, AST 78, ALT 48, total bilirubin 3.1, albumin 2.9, total protein 5.6, and creatinine 0.79. Model for end-stage liver disease was 15. Esophagogastroduodenoscopy showed no esophageal or gastric luminal stigmata of liver disease. An actively bleeding lesion was found in the second part of the duodenum: 4 mm submucosal bulge with central umbilication and clot, initially suspected to be a Dieulafoy’s lesion. Epinephrine injection worsened bleeding despite multiple aliquots. Two metallic hemoclips were ineffective; 3 additional clips were placed, achieving partial hemostasis, and complete hemostasis was then achieved after Hemostatic powder was applied. Post-procedure computed tomography A/P showed cirrhosis and a small non-bleeding duodenal varix with inflow from a duodenal branch of the superior mesenteric vein and outflow to the inferior vena cava near the right gonadal vein. She recovered with durable hemostasis, was extubated, and discharged in stable condition. Discussion: This case underscores challenges in managing ectopic duodenal variceal bleeding. Duodenal varices can mimic Dieulafoy’s lesions, leading to misdiagnosis and inadequate interventions. In this case, misclassification of the lesion as a Dieulafoy’s prompted standard hemostatic techniques epinephrine injection and hemoclips which not only failed but exacerbated the bleeding.