Case report: rapid development and progression of duodenal varices without significant change in existing esophagogastric varices

Background: Duodenal varices (DV) are a rare complication of portal hypertension, leaving the topic relatively unexplored. There are some reports describing the presence of and potential treatments for DV, but little is known about their progression. Below we present an interesting case of a patient with portal hypertension who developed and had rapid progression of DV without any progression of her existing esophageal varices (EV). Case Information: The patient had an esophagogastroduodenoscopy (EGD) which showed non bleeding grade 1 esophageal varices and no other abnormal findings.2 years later, the patient underwent an EGD which showed non bleeding grade 1 varices found in the lower third of the esophagus. Further inspection revealed large non bleeding varices in the second portion of her duodenum. Conclusions: Although rarer than EV, bleeding from DV is often difficult to diagnose and even harder to control, leading to mortality rates up to 40% for initial bleeding. Otherwise, there is little data comparing the pathophysiology and outcomes of EV and DV. We hypothesize that the rapid development and progression of DV without any significant change in EV may be related to 1) increased flow toward the duodenum and away from the esophagus, 2) increased propensity for duodenal anastomoses to dilate, or 3) anatomical variants not previously identified or studied. As our understanding of DV grows, diagnostic and therapeutic algorithms may need to be adjusted to account for ectopic varices other than EV and to more effectively allocate beta blocker prophylaxis in patients with portal hypertension.