A case of ruptured duodenal varices treated by combination therapy of endoscopic variceal ligation and balloon-occluded retrograde transvenous obliteration

57歳の男性.B型肝硬変・肝細胞癌に対して外来経過観察中,下血に対する精査加療目的で当科に緊急入院した.上部消化管内視鏡検査(EGD)で十二指腸下行脚に静脈瘤が認められたものの活動性出血および血液貯留の所見はなく,下部消化管内視鏡検査･カプセル内視鏡検査･経肛門的ダブルバルーン内視鏡検査においても回腸~結腸内に凝血塊の貯留が認められたのみで出血源の同定には至らなかった.腹部血管造影検査では十二指腸周辺に著明な門脈系-大循環系短絡路の発達が認められ,血管造影下CTで十二指腸下行脚付近に造影剤の血管外漏出が疑われた.直後の緊急EGDにより十二指腸静脈瘤破裂と診断し,内視鏡的静脈瘤結紮術(EVL)にて一次止血に成功した.しかしその2日後に出血性ショックに陥ったため,EVLで止血した上で引き続きバルーン閉塞下逆行性経静脈的塞栓術(B-RTO)を施行して完全止血を得た.十二指腸静脈瘤破裂は非常に稀な難治性消化管出血であるが,今回我々はEVL･B-RTO併用療法で止血し救命し得た症例を経験したので報告する.

A 57-year-old male with hepatitis B virus-related liver cirrhosis, who had undergone right lobectomy and radiofrequency ablation for hepatocellular carcinoma, was admitted to our department for the purpose of examination and treatment of melena. Esophagogastroduodenoscopy (EGD) on admission showed duodenal varices without active bleeding in the 2nd portion of duodenum. In addition, total colonoscopy, capsule endoscopy, and double-balloon endoscopy via the anal demonstrated massive dark-red clot in the ileum and colon, but not pointed out a source of bleeding. Thereafter, the angiography via superior mesenteric artery revealed large portalsystemic shunts around the duodenum and computed tomography during arteriography showed extravasation at the 2nd portion of duodenum. Urgent EGD enabled us to diagnose as ruptured duodenal varices and endoscopic variceal ligation (EVL) was successfully performed. However, two days later, he suffered from hemorrhagic shock because of rebleeding of duodenal varices and balloon-occluded retrograde transvenous obliteration (B-RTO) after second EVL finally led to complete hemostasis. We report this rare case of ruptured duodenal varices treated by combination therapy of EVL and BRTO in a cirrhotic patient.

十二指腸静脈瘤破裂

Ruptured duodenal varices

内視鏡的静脈瘤結紮療術

Endoscopic variceal ligation

バルーン閉塞下逆行性経静脈的塞栓術

Balloon-occluded retrograde transvenous obliteration