Post written by Abbinaya Elangovan, MD, from the University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA.

We report on a patient with pancreatic adenocarcinoma who presented with recurrent GI bleeding. He underwent multiple investigations that did not reveal the etiology of bleeding. A bulging was noted in the duodenum in upper endoscopy that was thought to be extrinsic compression from the pancreatic head tumor.

During a repeat endoscopy, a bluish hue was noted in the duodenum that led to further evaluation with EUS, which demonstrated a positive Doppler signal consistent with duodenal varix. 

In this video, we demonstrate a stepwise approach to inject glue using a non-EUS, freehand technique under Doppler guidance. Through-the-scope Doppler is a useful tool that detects varix as a continuous low-pitched hum. Doppler also is used after glue injection to determine if additional therapy is necessary.

In our case, 2 large varices were detected using Doppler. Prior to glue injection, the working channel was injected with olive oil to prevent glue adherence to the endoscope. In addition, it is important to prevent inadvertent contact of air or fluids with glue.

Therefore, after the insertion of the needle, the channel was flushed with 10 cc of air to dry the needle completely. Then, undiluted glue was injected as a single rapid bolus. Undiluted glue was used, as it preserves the speed of polymerization upon contact with blood. The volume required was determined based on the size of the varix.

For the 2 large varices in our case, 3 mL was drawn for each varix (2 mL for the large varix and an additional 1 mL to account for the dead space of the needle). To minimize the risk of embolism, the total amount of glue injected per varix per session typically should not exceed 3 mL. The injected varix was reexamined, and no audible Doppler signal was noted. The patient did not have any procedure-related adverse events or recurrent bleeding at his 3-month follow-up. 

In conclusion, duodenal variceal bleeding is rare, challenging to diagnose, and may require extensive evaluation. Doppler-guided cyanoacrylate injection is an effective treatment for immediate hemostasis of duodenal variceal bleeding.

A, EUS showing positive Doppler signal. B, EGD showing large blebs with blue hue in duodenal bulb.

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