| Summary: | A 76-year-old man had a history of liver cirrhosis secondary to chronic hepatitis B infection. A hepatoma had also been noted 2 years previously. This time, he presented initially at the emergency department because of dysuria and fever for 2 days and tarry stool since the afternoon. The initial upper gastrointestinal endoscopy revealed esophageal varices, gastric ulcer, and duodenitis that was not actively bleeding. Proton pump inhibitors were prescribed. Unfortunately, massive blood stools were noted 3 days later. Emergency esophagogastroscopy and colonoscopy were performed, but no active bleeder was detected. Contrast-enhanced abdominal computed tomography (CT) showed duodenal varices in the second and third portions of the duodenum (Fig. A). The feeding vein of the varices was the pancreaticoduodenal vein originating in the superior mesenteric vein, while the right testicular vein was the draining vein (Fig. B). Owing to the persistent massive bleeding, surgical variceal ligation was performed, following which the patient had no further bleeding episodes.
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