Hemodynamics and Treatment of Ectopic Varices

  • Katsutoshi ObaraEmail author


Formerly, the presence of ectopic varices was difficult to discover, and mortality rates tended to be high when they began to bleed. Nowadays, advances in diagnostic modalities have enabled ectopic varices to be discovered more frequently. However, few randomized controlled trials of large case series have been conducted on ectopic varices, and no evidence-based guidelines have been published concerning their management. According to a nationwide questionnaire survey carried out in 1990 in Japan, ectopic varices were observed in 129 (0.7%) out of a total of 18,540 patients with a history of receiving endoscopic injection sclerotherapy for esophageal varices, representing a low prevalence; however, the prevalence increased substantially to 3.8% in our data reviewed in 2013. On the other hand, the percentages of bleeding cases were 57.4% in 1990 and 45.1% in 2010, which were not significantly different. In Japan, the majority of ectopic varices develop following endoscopic treatment of esophagogastric varices, and therefore, practitioners should conduct follow-up examinations taking ectopic varices into consideration so that even bleeding ectopic varices can be treated timely and effectively. Modalities often used to detect ectopic varices in Japan include endoscopy, computed tomography, and (color Doppler) endoscopic ultrasonography, while therapeutic options range from endoscopic treatment to surgical operation as well as interventional radiology and pharmacology.


Ectopic varices Portal hypertension Endoscopic injection sclerotherapy Endoscopic variceal ligation Interventional radiology 


  1. 1.
    Watanabe N, Toyonaga A, Kojima S, Takashimizu S, Oho K, Kokubu S, Nakamura K, et al. Current status of ectopic varices in Japan: results of a survey by the Japan Society for Portal Hypertension. Hepatol Res. 2010;40:763–76.CrossRefGoogle Scholar
  2. 2.
    Alberti W. Uber den Rontgenologischen Nachweis von Varizen im Bulbus duodeni. Fortschr Gep Rontgenstr. 1931;43:60–5.Google Scholar
  3. 3.
    Nishioka K, Kanetake Y, Matsui E, Imaeda T. Suspected case of varicose veins of the duodenum. Rinsho Hoshasen. 1968;13:305–12. [In Japanese].Google Scholar
  4. 4.
    Cabot RC, Castleman B, Towne VW. Case 40102. N Engl J Med. 1954;250:434–8. Scholar
  5. 5.
    Kumagai Y, Omori Y, Takeda Y, Makuuchi H. Rare gastrointestinal varices. In: Makuuchi Y, Yoshida M, editors. EIS for esophagogastric varices. Tokyo: Bunkodo; 1992. p. 311–6. [In Japanese].Google Scholar
  6. 6.
    Kumagai Y, Makuuchi H, Omori Y. Rare gastrointestinal varices. In: Idezuki Y, editor. Supervised. Tokyo: Tokyo Igakusha;1995. p. 9–133. [In Japanese].Google Scholar
  7. 7.
    Sato T, Akaike J, Toyota J, Karino Y, Ohmura T. Clinicopathological features and treatment of ectopic varices with portal hypertension. Int J Hepatol. 2011;2011:960720. Scholar
  8. 8.
    Obara K. Treatment for ectopic varices. Endosc Dig. 2013;25:1411–6. [In Japanese].Google Scholar
  9. 9.
    Obara K. Gastroenterological varices: management of ectopic varices. Clin Gastroenterol. 2003;6:507–15. [In Japanese].Google Scholar
  10. 10.
    Portosystemic collaterals in location other than esophagogastric region. In: Takase Y. Supervised. Portosystemic vascular atlas for the treatment of varices. Tokyo: Igaku-Shoin Ltd;1999. p. 27. [In Japasnese].Google Scholar
  11. 11.
    Matsui S, Kudo M, Ichikawa T, Okada M, MIyabe Y. The clinical characteristics, endoscopic treatment, and prognosis for patients presenting with duodenal varices. Hepato-Gastroenterology. 2008;55:959–62.PubMedGoogle Scholar
  12. 12.
    Shudo R, Yazaki Y, Sakurai S, et al. Clinical study comparing bleeding and nonbleeding rectal varices. Endoscopy. 2002;34:189–94.PubMedCrossRefGoogle Scholar
  13. 13.
    Barbish AW, Ehrinpreis M. Successful endoscopic injection sclerotherapy of a bleeding duodenal varix. Am J Gastroenterol. 1993;88:90–2.PubMedGoogle Scholar
  14. 14.
    Sato H, Fujishiro H, Rumi MA, Kinoshita Y, NIigaki M, Kohge N, et al. Successful endoscopic injection sclerotherapy for duodenal varices. J Gastroenterol. 2002;37:143–4.PubMedCrossRefGoogle Scholar
  15. 15.
    Seo YS, Kwon YD, Prk S, Keum B, Prk BJ, Kim YS, et al. Complete eradication of duodenal varices after endoscopic injection sclerotherapy with ethanolamine oleate: a case report. Gastrointest Endosc. 2008;67:759–62.PubMedCrossRefGoogle Scholar
  16. 16.
    Shirai M, Hiroyasu S, HIga T, Oshiro S, Muto Y. Successful management of ruptured duodenal varices by means of endoscopic variceal ligation: report of a case. Gastrointest Endosc. 1999;49:255–7.CrossRefGoogle Scholar
  17. 17.
    Tazawa J, Saki Y, Koizumi K, et al. Endoscopic ligation for ruptured duodenal varices. Am J Gastroenterol. 1995;9:677–8.Google Scholar
  18. 18.
    Kawakami Y, Takahashi H, Kato S, Uchiyama T, Mawatari H, Iida H, et al. Effective treatment for duodenal variceal bleeding using endoscopic ligation. Hepato-Gastroenterology. 2011;58:2024–5.PubMedGoogle Scholar
  19. 19.
    Suzuki R, Irisawa A, HIkichi T, Shibukawa G, Takagi T, Wakatsuki T, et al. Hemorrhagic duodenal varices treated successfully with endoscopic injection sclerotherapy using cyanoacrylate and ethanolamine-oleate: a case report. Surg Laparosc Endosc Percutan Tech. 2009;19:e233–6. Scholar
  20. 20.
    Ota K, Shirai Z, Matsuzaki T, Tanaka K, Higashihara H, Okazaki M, et al. Endoscopic injection sclerotherapy with N-butyl-2-cyanoacrylate for ruptured duodenal varices. J Gastroenterol. 1998;33:550–5.PubMedCrossRefGoogle Scholar
  21. 21.
    Yoshida Y, Imai Y, Nishikawa M, Kurokawa M, Shibata K, et al. Successful endoscopic injection sclerotherapy with N-butyl-2-cyanoacrylate following the recurrence of bleeding soon after endoscopic ligation for ruptured duodenal varices. Am J Gastroenterol. 1997;92:1227–9.PubMedGoogle Scholar
  22. 22.
    Chikamori F, Shibuya S, Takase Y. Percutaneous transhepatic obliteration for esophagojejunal varices after total gastrectomy. Abdom Imaging. 1998;23:560–2.PubMedCrossRefGoogle Scholar
  23. 23.
    Sato T, Yamazaki K, Toyota J, Karino Y, Ohmura T, Akaike J, et al. Efficacy of color Doppler ultrasonography for the diagnosis of duodenal varices successfully treated with percutaneous transhepatic obliteration. J Med Ultrason. 2007;34:59–63.CrossRefGoogle Scholar
  24. 24.
    Sonomura T, Horihata K, Yamahara K, Dozaiku T, Toyonaga T, Hiroka T, et al. Ruptured duodenal varices successfully treated with balloon-occluded retrograde transvenous obliteration: usefulness of microcatheters. AJR Am J Roentgenol. 2003;181:725–7.PubMedCrossRefGoogle Scholar
  25. 25.
    Ohta M, Yasumori K, Saku M, et al. Successful treatment of bleeding duodenal varices by balloon-occluded retrograde transvenous obliteration: a transjugular venous approach. Surgery. 1999;126:581–3.PubMedCrossRefGoogle Scholar
  26. 26.
    Hotta M, Yoshida H, Mamada Y, Taniai N, Bando K, Mizuguchi Y, et al. Succeessful management of duodenal varices by balloon-occluded retrograde transvenous obliteration. J Nippon Med Sch. 2008;75:36–40.PubMedCrossRefGoogle Scholar
  27. 27.
    Hashimoto R, Sofue K, Takeuchi Y, Shibamoto K, Arai Y. Successful balloon-occluded retrograde transvenous obliteration for bleeding duodenal varices using cyanoacrylate. World J Gastroenterol. 2013;19:951–4.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Ohta K, Okazaki M, Higashihara H, Kokawa H, Shirai Z, Anan A, et al. Combination of transileocolic vein obliteration is effective for ruptured duodenal varices. J Gastroenterol. 1999;34:694–9.CrossRefGoogle Scholar
  29. 29.
    Takamura K, Miyake H, Mori H, Terashima Y, Ando T, Fuji M, et al. Balloon occluded retrograde transvenous obliteration and percutaneous transhepatic obliteration for ruptured duodenal varices after operation for rectal cancer with multiple liver metastasis: report of a case. J Med Invest. 2005;53:212–7.CrossRefGoogle Scholar
  30. 30.
    Haruta I, Isobe Y, Ueno E, et al. Balloon-occluded retrograde transvenous obliteration(BRTO), a promising nonsurgical therapy for ectopic varices: a case report of successful treatment of duodenal varices by BRTO. Am J Gastroenterol. 1996;91:2594–7.Google Scholar
  31. 31.
    Akazawa Y, Murata I, Yamao T, Yamakawa M, Kawano Y, Nomura N, et al. Successful management of bleeding duodenal varices by endoscopic variceal ligation and balloon-occluded retrograde transvenous obliteration. Gastrointest Endosc. 2003;58:794–7.PubMedCrossRefGoogle Scholar
  32. 32.
    Wang CS, Jeng LB, Chen MF. Duodenal variceal bleeding: successfully treated by mesocaval shunt after failure of sclerotherapy. Hepato-Gastroenterology. 1995;42:59–61.PubMedGoogle Scholar
  33. 33.
    Wang M, Desigan G, Dunn D. Endoscopic sclerotherapy for bleeding rectal varices: a case report. Am J Gastroenterol. 1985;80:779–80.PubMedGoogle Scholar
  34. 34.
    Sato T. Efficacy of endoscopic injection sclerotherapy for rectal varices. J Gastroenterol Hepatol Res. 2013;2:359–61.Google Scholar
  35. 35.
    Sato T. Two cases of rectal varices treated by endoscopic variceal ligation. Dig Endosc. 1999;11:66–9.CrossRefGoogle Scholar
  36. 36.
    Yoshino K, Imai Y, Nakazawa M, Chikayama T, Ando S, Sugawara K, et al. Therapeutic strategy for patients with bleeding rectal varices complicating liver cirrhosis. Heparol Res. 2014;44:1088–94.CrossRefGoogle Scholar
  37. 37.
    Sato T, Yamazaki K, Akaike J, Toyota J, Karino Y, Ohmura T. Retrospective analysis of endoscopic injection sclerotherapy for rectal varices compared with band ligation. Clin Exp Gastroenterol. 2001;3:159–63.Google Scholar
  38. 38.
    Okazaki H, Higuchi K, Shiba M, Nakamura S, Wada T, Yamamori K, et al. Successful treatment of giant rectal varices by modified percutaneous transhepatic obliteration with sclerosant: report of a case. World J Gastroenterol. 2006;12:5408–11.PubMedPubMedCentralCrossRefGoogle Scholar
  39. 39.
    Kimura T, Haruta I, Isobe Y, Ueno E, Toda J, Nemoto Y, et al. A novel therapeutic approach for rectal varices: a case report of rectal varices treated with double balloon-occluded embolotherapy. Am J Gastroterol. 1997;92:883–6.Google Scholar
  40. 40.
    Sato Y, Yokoyama N, Suzuki S, Tani T, Nomoto M, Hatakeyama K. Double selective shunting for esophagogastric and rectal varices in portal hypertension due to congenital hepatic polycystic disease. Hepato-Gastroenterology. 2002;49:1528–30.PubMedGoogle Scholar
  41. 41.
    Katakura K, Irisawa A, Obara K, Saito A, Shishido H, Shibukawa G, et al. Appearance of rectal varices in extrahepatic portal obstruction after treatment for esophago-gastric varices: a case report. Fukushima J Med Sci. 2002;48:51–6.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  1. 1.Department of Advanced Gastrointestinal EndoscopyFukushima Medical UniversityFukushimaJapan

Personalised recommendations