Fatal rebleeding of a residual duodenal varix caused by portal hemodynamic redistribution after selective embolization

Abstract Duodenal varices are a rare form of ectopic varices that develop as a consequence of portal hypertension and may cause life-threatening gastrointestinal bleeding. Due to complex portosystemic collateral pathways, optimal treatment strategies have yet to be established. We herein report a fatal case of ruptured duodenal varices in a man in his 50s with decompensated liver cirrhosis. The patient presented with hematochezia and hemorrhagic shock. Endoscopic hemostasis was unsuccessful, and emergency transileocolic venous obliteration (TIO) was performed. Contrast-enhanced computed tomography revealed three duodenal varices located in the horizontal portion of the duodenum, supplied by the superior mesenteric vein and draining into the right testicular vein, forming a high-flow portosystemic shunt. Selective embolization of two of the bleeding varices using coils and N-butyl-2-cyanoacrylate was successfully achieved, while the third varix was intentionally preserved to avoid an excessive elevation in portal pressure. Portal vein thrombosis (PVT) subsequently developed, which may have contributed to the redistribution of portal venous flow toward the remaining untreated varix. Coil exposure and bacteremia due to Streptococcus anginosus were also observed during the clinical course. The residual varix ultimately ruptured and caused massive rebleeding. Despite additional treatment, the patient developed hepatic failure followed by multiple organ failure and died on day 47. Selective embolization of ectopic varices may change portal hemodynamics and increase pressure in residual varices, potentially leading to fatal rebleeding. This case highlights the importance of anticipating hemodynamic redistribution and considering early portal decompression strategies in the management of duodenal varices.