Portal Hypertensive Duodenopathy

Portal hypertensive duodenopathy is a group of duodenal mucosal changes (erythema, friability, congestion, erosions, angiodysplasia like lesions and duodenal varices) in patients with portal hypertension.

Reported in 8% to 60% of cirrhotic patients, depending on definitions. Overt bleeding from duodenal lesions is uncommon. Duodenal varices account for under 5% of variceal bleeds.

Risk factors are severity of portal hypertension, presence of oesophageal varices and portal hypertensive gastropathy, and previous variceal eradication therapy.

Pathophysiology.

Raised portal pressure causes mucosal and submucosal venous congestion, vascular ectasia and impaired mucosal defence. Collaterals form through pancreaticoduodenal veins.

Often incidental. Features include iron deficiency anaemia, melaena, haematemesis or haematochezia (rare, but can be massive from duodenal varices).

Red flags.

• Haemodynamic instability or acute bleeding.
• Hepatic decompensation (ascites, encephalopathy).

Endoscopy shows a diffuse erythematous or mosaic pattern, red spots, friability and erosions, or varices that are bluish, tortuous and nodular. Endoscopic ultrasound and CT angiography define varices and feeding vessels. Assess liver function, platelets, INR and the cause of cirrhosis. Exclude other sources of bleeding.

Differential diagnosis.

• Peptic ulcer disease.
• Duodenitis from infection or drugs.
• Angiodysplasia.
• Ampullary or duodenal tumour.
• Portal hypertensive gastropathy.
• Gastric antral vascular ectasia.

Acute bleeding follows the approach to variceal bleeding.

• Terlipressin: 2 mg IV every 4 hours for the first 24 to 48 hours, then 1 mg every 4 hours; up to 5 days; maximum 12 mg daily initially; monitor ischaemia, sodium, ECG and fluid overload; avoid in ischaemic heart disease, peripheral vascular disease and severe asthma.
• Octreotide (alternative): 50 microgram IV bolus, then 50 microgram/h by infusion; 2 to 5 days; maximum 50 microgram/h; monitor glucose and heart rate; reduce in renal impairment.
• Ceftriaxone: 1 g IV once daily; up to 7 days; maximum 2 g daily; monitor renal function and rash; no adjustment in mild impairment.

Restrict transfusion to a haemoglobin threshold of 70 g/L (target 70 to 90 g/L). Endoscopic therapy (argon plasma coagulation for mucosal lesions, band ligation or cyanoacrylate injection for varices) and radiological therapy (balloon occluded retrograde transvenous obliteration or coil embolisation) control bleeding; transjugular intrahepatic portosystemic shunt is used for refractory bleeding.

Prevention of rebleeding:

• Carvedilol: 6.25 mg orally once daily for 3 days, then 12.5 mg once daily; long term; maximum 12.5 mg daily (25 mg without ascites in some practice); monitor blood pressure (systolic 90 mmHg or more) and heart rate; reduce or stop in refractory ascites with low blood pressure, renal failure or sepsis.
• Iron replacement for anaemia: ferrous sulphate 200 mg orally once daily or alternate days, maximum 200 mg three times daily; monitor ferritin.

Monitoring. Haemoglobin, liver function and renal function; repeat endoscopy for variceal eradication at 2 to 4 weeks.

Referral and escalation. Hepatology, interventional radiology and liver transplant assessment.