Case Report
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Dec 6, 2018; 6(15): 1012-1017
Published online Dec 6, 2018. doi: 10.12998/wjcc.v6.i15.1012
Successful endovascular treatment of endoscopically unmanageable hemorrhage from a duodenal ulcer fed by a renal artery: A case report
Shimpei Anami, Hiroki Minamiguchi, Naoaki Shibata, Takao Koyama, Hirotatsu Sato, Akira Ikoma, Motoki Nakai, Takuji Yamagami, Tetsuo Sonomura
Shimpei Anami, Hiroki Minamiguchi, Takao Koyama, Hirotatsu Sato, Akira Ikoma, Motoki Nakai, Tetsuo Sonomura, Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama 641-8510, Japan
Hiroki Minamiguchi, Takuji Yamagami, Department of Radiology, Kochi Medical School Kochi University, Nankokushi, Kochi 783-8505, Japan
Naoaki Shibata, Department of Emergency and Critical Care Medicine, Wakayama Medical University, Wakayamashi, Wakayama 641-8510, Japan
Author contributions: Anami S and Minamiguchi H collected the patient data, prepared the figures and tables and wrote the manuscript; Shibata N, Koyama T, Sato H, Ikoma A, Nakai M, Yamagami T and Sonomura T proofread and revised the manuscript; All authors approved the final version of the manuscript.
Informed consent statement: Written and verbal informed consent was obtained from the patient’s family for publication of this case report and the accompanying images.
Conflict-of-interest statement: The authors declare no conflict of interest.
CARE Checklist (2016) statement: The authors adopted the guidelines of the CARE Checklist (2016) during the preparation and revision of the manuscript.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Hiroki Minamiguchi, MD, PhD, Associate Professor, Department of Radiology, Kochi Medical School Kochi University, Oko-cho, Nankokushi, Kochi 783-8505, Japan. hiromina4@kochi-u.ac.jp
Telephone: +81-88-8802367 Fax: +81-88-8802368
Received: August 21, 2018
Peer-review started: August 22, 2018
First decision: October 5, 2018
Revised: November 13, 2018
Accepted: November 14, 2018
Article in press: November 15, 2018
Published online: December 6, 2018
Processing time: 107 Days and 6.6 Hours
Abstract

A 52-year-old woman was admitted with hypovolemic shock. Emergency endoscopy revealed three hemorrhagic duodenal ulcers (all stage A1) with exposed vessels. Two ulcers were successfully treated by endoscopic clipping; however, the remaining ulcer on the posterior wall of the horizontal portion of the duodenum could not be clipped. Because her vital signs were rapidly worsening, we performed transcatheter arterial embolization (TAE) as it is less invasive than surgery. Computed tomography aortography showed that the duodenal hemorrhage was sourced from the lower branch of the right renal artery. In general, the duodenum is fed by branches from the gastroduodenal artery or superior mesenteric artery. However, this patient had three right renal arteries. The lower branch of the right renal artery at the L3 vertebral level was at the same level as the horizontal portion of the duodenum. Complete hemostasis was achieved by TAE using metallic coils and n-butyl-2-cyanoacrylate. After TAE, she recovered from the hypovolemic shock and was discharged from hospital. She has had no recurrence of the hemorrhagic duodenal ulcer for over 1 yr, and follow-up endoscopy showed no necrosis or stricture of the duodenum. Although she developed a small infarct of her right kidney, her renal function was satisfactory. In summary, the present case is the first reported case of hemorrhagic duodenal ulcer in which the culprit vessel was a renal artery that was successfully treated by TAE. Computed tomography aortography before TAE provides valuable information regarding the source of a duodenal hemorrhage.

Keywords: Transcatheter arterial embolization; Metallic coils; N-butyl-2-cyanoacrylate; Renal artery; Emergency radiology; Case report; Duodenal ulcer

Core tip: We report a rare case of a hemorrhagic duodenal ulcer fed by a renal artery that was successfully treated by transcatheter arterial embolization. Generally, the duodenum is fed by branches from the gastroduodenal artery or superior mesenteric artery. However, this patient had three right renal arteries, and the hemorrhage was fed by the lower branch of the right renal artery. This branch was located at the L3 vertebral level, at the same level as the horizontal portion of the duodenum. To our knowledge, this is the first reported case in which a renal artery fed a hemorrhagic duodenal ulcer.