S4809 Thrombin Injection for Duodenal Variceal Bleeding: A Lifesaving Endoscopic Salvage in Complex Anatomy

Introduction: Duodenal variceal bleeding is a rare but life-threatening complication of portal hypertension. Management becomes even more challenging in patients with complex post-surgical and vascular anatomy. We present the case of a young woman with prior pancreatic and biliary interventions who developed refractory duodenal variceal hemorrhage. Case Description/Methods: A 29-year-old woman presented with profound hematemesis and melena. Her history included solid pseudopapillary pancreatic neoplasm resection with superior mesenteric vein (SMV) resection complicated by chronic SMV thrombosis, duodenal fistula, and subsequent scarring with complete distal bile duct stricture requiring metal stent placement and a percutaneous transhepatic choledochoduodenostomy. Esophagogastroduodenoscopy (EGD) revealed blood pooling in the duodenal bulb; visualization was limited due to active bleeding. Empiric embolization of the gastroduodenal artery was performed without success. computed tomography angiography showed proximal SMV thrombosis with extensive collaterals draining into the splenic and portal veins. Continued hematemesis, hemoglobin decrease, and transfusion need prompted repeat EGD, which showed clots near the biliary stent. The stent was removed, and thrombin was injected into the stent tract for possible sphincterotomy site bleeding. Multiple large varices were identified in the 2nd and 3rd portions of the duodenum, 1 with a white nipple sign. Due to complete SMV occlusion precluding potential transhepatic embolization, the ectopic varices were injected with thrombin, achieving hemostasis. No rebleeding occurred over 2 years of follow-up. Discussion: Ectopic varices are difficult to manage due to the absence of standardized treatment protocols. Management is often guided by local expertise, vascular anatomy, and the availability of endoscopic or radiologic interventions. First-line options typically include endoscopic cyanoacrylate injection, transjugular intrahepatic portosystemic shunt (TIPS), or endovascular embolization, but these may be limited by technical or anatomic constraints. This case highlights the importance of a multidisciplinary approach and demonstrates that endoscopic thrombin injection can serve as an effective salvage therapy for refractory duodenal variceal bleeding. Sustained hemostasis achieved over 2 years is notable given the high risk of rebleeding in ectopic varices and suggests thrombin injection may offer durable benefits in anatomically complex cases of non-cirrhotic portal hypertension.