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Kim HW, Yoon JS, Yu SJ, Kim TH, Seol JH, Kim D, Jung JY, Jeong PH, Kwon H, Lee HS, Lee SH, Choi JS, Park SJ, Jee SR, Lee YJ, Seol SY. Percutaneous Trans-splenic Obliteration for Duodenal Variceal bleeding: A Case Report. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2020; 76:331-336. [PMID: 33361709 DOI: 10.4166/kjg.2020.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/08/2020] [Accepted: 09/15/2020] [Indexed: 06/12/2023]
Abstract
Duodenal varices are a serious complication of portal hypertension. Bleeding from duodenal varices is rare, but when bleeding does occur, it is massive and can be fatal. Unfortunately, the optimal therapeutic modality for duodenal variceal bleeding is unclear. This paper presents a patient with duodenal variceal bleeding that was managed successfully using percutaneous trans-splenic variceal obliteration (PTVO). A 56-year-old man with a history of alcoholic cirrhosis presented with a 6-day history of melena. Emergency esophagogastroduodenoscopy revealed a large, bluish mass with a nipple sign in the second portion of the duodenum. Coil embolization of the duodenal varix was performed via a trans-splenic approach (i.e., PTVO). The patient no longer complained of melena after treatment. The duodenal varix was no longer visible at the follow-up esophagogastroduodenoscopy performed three months after PTVO. The use of PTVO might be a viable option for the treatment of duodenal variceal bleeding.
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Affiliation(s)
- Hyun Woo Kim
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Jun Sik Yoon
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Seung Jung Yu
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Tae Heon Kim
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Jae Heon Seol
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Dan Kim
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Jun Young Jung
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Pyeong Hwa Jeong
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Hoon Kwon
- Department of Radiology, Pusan National University Hospital, Busan, Korea
| | - Hong Sub Lee
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Sang Heon Lee
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Jung Sik Choi
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Sung Jae Park
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Sam Ryong Jee
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Youn Jae Lee
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Sang Yong Seol
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
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Li DH, Liu XY, Xu LB. Duodenal giant stromal tumor combined with ectopic varicose hemorrhage: A case report. World J Clin Cases 2020; 8:6009-6015. [PMID: 33344599 PMCID: PMC7723731 DOI: 10.12998/wjcc.v8.i23.6009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/27/2020] [Accepted: 10/13/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gastrointestinal stromal tumors (GISTs) are mesenchymal tissue tumors originating from Cajal cells, presenting diverse clinical manifestations due to the different sizes, locations, and growth patterns of the lesions. Duodenum is an uncommon site of GISTs, more with gastrointestinal obstruction and bleeding as the first symptoms. Ectopic duodenal varix, as a rare varix occurring outside the gastroesophageal region, is the main type of heterotopic varices and an unusual cause of gas-trointestinal hemorrhage. The etiology is mainly seen in liver cirrhosis, portal hypertension, vasculitis, portal vein embolism and obstruction caused by various factors. Reports of duodenal stromal tumor combined with ectopic variceal hemorrhage are rarely seen; however, when it occurs, the situation can sometimes be urgent and life-threatening, especially when traditional endoscopy and imaging fail to detect the lesion timely.
CASE SUMMARY We report a 52-year-old female patient who had no obvious inducement to develop black stool. Gastroscopy in a local hospital revealed that the duodenal horizontal ectopic varices were ruptured and bleeding. After metal clamping hemostasis, she still had gastrointestinal bleeding and was transferred to our hospital. Gastroscopy showed that active bleeding was still seen in the horizontal part of duodenum, and suspicious submucosal eminence was seen in the bleeding part. Abdominal computed tomography showed a huge stromal tumor of duodenum, specimens were pathologically confirmed after surgery. After a 3-mo follow-up, no gastrointestinal hemorrhage and complications occurred.
CONCLUSION Ectopic variceal hemorrhage is rare but sometimes fatal. It may be combined with stromal tumor, which can be diagnosed by multiple methods. Endoscopic and surgical treatment are effective.
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Affiliation(s)
- Da-Huan Li
- Center of Digestive Endoscopy, The Affiliated Hospital of Guizhou Medical University, Guiyang 550000, Guizhou Province, China
| | - Xue-Ying Liu
- Department of Gastroenterology, Guizhou Medical University, Guiyang 550000, Guizhou Province, China
| | - Liang-Bi Xu
- Center of Digestive Endoscopy, The Affiliated Hospital of Guizhou Medical University, Guiyang 550000, Guizhou Province, China
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Li DH, Liu XY, Xu LB. Duodenal giant stromal tumor combined with ectopic varicose hemorrhage: A case report. World J Clin Cases 2020. [DOI: 10.12998/wjcc.v8.i23.6005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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Maeda H, Kageyama K, Yamamoto A, Jogo A, Sohgawa E, Matsushita K, Asano K, Yonezawa H, Nota T, Murai K, Ogawa S, Miki Y. Usefulness of coil-assisted retrograde transvenous obliteration II (CARTO-II) for the treatment of ascending colonic varix: a case report. CVIR Endovasc 2020; 3:90. [PMID: 33275189 PMCID: PMC7718362 DOI: 10.1186/s42155-020-00187-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/30/2020] [Indexed: 12/17/2022] Open
Abstract
Background Colonic varices are rare among ectopic varices. A previous report demonstrated that once bleeding from colonic varices occurs, it can be fatal. Several treatments for colonic varices exist, including surgical, endoscopic, and endovascular treatments; however, management of colonic varices has not been standardized. For colonic varices, minimally invasive therapies would be desirable. Balloon-occluded retrograde transvenous obliteration (B-RTO) is one of the treatment options for colonic varices to prevent their rupture. Two cases of successful conventional B-RTO for these varices have already been reported. However, B-RTO using coil-assisted retrograde transvenous obliteration II (CARTO-II) procedure for these varices has not been reported. Case presentation A 71-year-old male patient had liver cirrhosis caused by hepatitis C virus infection. A varix was located at the ascending colon, which was coincidentally found on colonic endoscopy. Contrast-enhanced computed tomography (CT) showed that the feeder vein was the ileocolic vein and that the main draining vein was the right renal vein. Physicians concluded that treatment was required to avoid the risk of death from massive bleeding due to varix rupture. However, endoscopic and surgical treatments were difficult due to the anatomical location of the varix and the high risk of operative compilations, respectively. This ascending colonic varix was treated by balloon-occluded retrograde transvenous obliteration (B-RTO) using coil-assisted retrograde transvenous obliteration II (CARTO-II) procedure via the right renal vein. There were no complications during the procedure and no recurrences for 36 months during long-term follow-up. Conclusions CARTO-II can be one of the effective treatment techniques for ascending colonic varices.
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Affiliation(s)
- Hiroyuki Maeda
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Ken Kageyama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan.
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Etsuji Sohgawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Kazuki Matsushita
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Kazuo Asano
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Hiroki Yonezawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Takehito Nota
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Kazuki Murai
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Satoyuki Ogawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
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Yipeng W, Anjiang W, Bimin L, Chenkai H, Size W, Xuan Z. Clinical characteristics and efficacy of endoscopic treatment of gastrointestinal ectopic varices: A single-center study. Saudi J Gastroenterol 2020; 27:35-43. [PMID: 33208560 PMCID: PMC8083249 DOI: 10.4103/sjg.sjg_50_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Ectopic varices (EcVs) may cause massive bleeding, which can be difficult to control, with a high rate of mortality. The purpose of this study was to analyze the clinical characteristics of EcVs and the efficacy of endoscopic treatment. METHODS From January 2008 to July 2017, the clinical data of 150 patients with EcVs in our center were retrospectively collected and analyzed. RESULTS One hundred and fifty patients with EcVs (male 74.7%), with a mean age of: 54.1 ± 14.6 years were included. The prevalence of EcVs was 0.92% in gastrointestinal varices. Cirrhosis was the most common cause of EcVs (67.0%). The rates of bleeding were 57.14%, 4.34%, 30.0%, 33.3%, and 100% in the duodenal varices rectal varices, colonic varices, anastomotic varices, and small bowel varices, respectively. An age under 55 years, varices in the duodenum, and erythema were considered risk factors for EcV bleeding. Endoscopic treatments were performed in 15 patients with EcV bleeding. The follow-up period of the patients who underwent endoscopic treatment ranged from 0.5 to 24 months. The overall rate of treatment success was 73.33% for endoscopic treatment of EcV bleeding. The overall rates of rebleeding and mortality during 2 years were as high as 53.3% and 26.7%, respectively. CONCLUSION Age, erythema, and the location of EcVs are considered risk factors for EcV bleeding, and the rate of bleeding is higher in patients with duodenal varices than in those with other EcVs. Endoscopic treatment is safe, effective, and feasible for controlling EcV bleeding.
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Affiliation(s)
- Wan Yipeng
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Hospital in Nanchang, China
| | - Wang Anjiang
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Hospital in Nanchang, China
| | - Li Bimin
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Hospital in Nanchang, China
| | - Huang Chenkai
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Hospital in Nanchang, China
| | - Wan Size
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Hospital in Nanchang, China
| | - Zhu Xuan
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Hospital in Nanchang, China,Address for correspondence: Dr. Zhu Xuan, Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Nanchang, China. E-mail:
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Rajesh S, George T, Philips CA, Ahamed R, Kumbar S, Mohan N, Mohanan M, Augustine P. Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update. World J Gastroenterol 2020; 26:5561-5596. [PMID: 33088154 PMCID: PMC7545393 DOI: 10.3748/wjg.v26.i37.5561] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/31/2020] [Accepted: 08/29/2020] [Indexed: 02/06/2023] Open
Abstract
More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.
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Affiliation(s)
- Sasidharan Rajesh
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Tom George
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Sandeep Kumbar
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Narain Mohan
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Meera Mohanan
- Anesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
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Frigiolini F, Lo Pinto S, Caputo F, Barranco R, Fraternali Orcioni G, Bonsignore A, Ventura F. Fatal hemorrhage from a periumbilical wound: Stabbing or hemorrhage from a caput medusae? J Forensic Sci 2020; 66:393-397. [PMID: 32956486 DOI: 10.1111/1556-4029.14571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 08/20/2020] [Accepted: 08/20/2020] [Indexed: 11/30/2022]
Abstract
Varices are the main clinical manifestation of portal hypertension, and their bleeding is the predominant cause of mortality from this condition. Periumbilical varices are known as "caput medusae." Reports of their bleeding are rare, with only three fatal cases described in the literature. The antemortem diagnosis is relatively simple, while the postmortem diagnosis is more complex. This paper is the first report of fatal hemorrhage from a caput medusae for which the diagnosis was made postmortem, thanks to a complete diagnostic process including scene and circumstances, medical history, and autopsy with detailed histology. The circumstantial analysis showed the presence of a large amount of blood at the scene, blood which originated from a small abdominal wound; an analysis of the subject's clinical data reported that he was affected by portal hypertension. The autopsy revealed some dilated and convoluted veins in the subcutaneous tissue of the umbilical region; a fistula between these veins and the abdominal wound was detected. The histological study confirmed the presence of periumbilical varices, one of them ruptured and connected with the overlying skin. The cause of death was attributed to a massive hemorrhage generated by a periumbilical varix in a patient affected by portal hypertension.
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Affiliation(s)
| | - Sara Lo Pinto
- Department of Legal and Forensic Medicine, University of Genova, Genova, Italy
| | - Fiorella Caputo
- Department of Legal and Forensic Medicine, University of Genova, Genova, Italy
| | - Rosario Barranco
- Department of Legal and Forensic Medicine, University of Genova, Genova, Italy
| | | | | | - Francesco Ventura
- Department of Legal and Forensic Medicine, University of Genova, Genova, Italy
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Murakami M, Fujimori N, Nagao Y, Yoshizumi T, Matsumoto K, Yasumori S, Teramatsu K, Takamatsu Y, Oono T, Ogawa Y. Colonic varices: a rare complication of pancreatic cancer. Clin J Gastroenterol 2020; 13:1355-1359. [PMID: 32897498 DOI: 10.1007/s12328-020-01225-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/27/2020] [Indexed: 10/23/2022]
Abstract
A 55-year-old man was diagnosed with pancreatic cancer of the uncus and received chemotherapy (modified FOLFIRINOX). Ten months later, he was admitted to our hospital with massive lower gastrointestinal bleeding. Contrast-enhanced CT showed ascending colon varices caused by the occlusion of the superior mesenteric vein (SMV) due to pancreatic cancer invasion. Colonoscopy revealed tortuous varices with red spots in the ascending colon. The patient received blood transfusions and was discharged; however, he was hospitalized for recurrent massive lower gastrointestinal bleeding 3 months later. During this readmission, we performed the transileocolic vein obliteration method due to SMV stenosis and the absence of an obvious shunt. He experienced an uneventful post-operative recovery, and contrast-enhanced CT after 2 months revealed no recurrence of colonic varices. Ectopic varices are portosystemic venous collaterals resulting from portal hypertension occurring in any locations other than the esophagogastric region. Colonic varices have rarely been reported before. Patients with pancreatic cancer may present with gastrointestinal bleeding caused by tumor bleeding or esophagogastric varices; however, ectopic varices such as colon varices, a rare complication of pancreatic cancer, should be considered in patients with obscure gastrointestinal bleeding.
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Affiliation(s)
- Masatoshi Murakami
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Nao Fujimori
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Yoshihiro Nagao
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazuhide Matsumoto
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Sho Yasumori
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Katsuhito Teramatsu
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yu Takamatsu
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takamasa Oono
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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A case of percutaneous transhepatic portal vein stent placement and endoscopic injection sclerotherapy for duodenal variceal rupture occurring during chemotherapy for unresectable perihilar cholangiocarcinoma. Clin J Gastroenterol 2020; 13:1150-1156. [PMID: 32897499 DOI: 10.1007/s12328-020-01213-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 08/13/2020] [Indexed: 10/23/2022]
Abstract
Duodenal varices are ectopic varices that are rare but can involve any site along the digestive tract outside the gastroesophageal region. Ectopic variceal bleeding is generally massive and life threatening; the mortality rate is approximately 40%. Up to 17% of ectopic varices occur in the duodenum. However, duodenal varices pose a significant therapeutic challenge due to the lack of standard treatment guidelines. We report a case of duodenal variceal bleeding secondary to portal vein stenosis in a 77-year-old woman receiving chemotherapy for unresectable perihilar cholangiocarcinoma. The patient presented with melena, nausea, vomiting and unstable vital signs suggestive of hemorrhagic shock. Emergency esophagogastroduodenoscopy revealed large nodular varices with a ruptured erosion on top in the superior duodenal angle, and variceal bleeding had stopped by the time of the procedure. Subsequent computed tomography showed the development of portosystemic collaterals; therefore, we performed percutaneous portal vein stent placement to reduce portal vein pressure. Since persistent bleeding was suspected, we also performed endoscopic injection sclerotherapy and achieved successful hemostasis with an improvement in liver function. This case revealed that a combination of portal vein stent placement and endoscopic injection sclerotherapy might be an effective therapy for duodenal variceal bleeding caused by portal vein stenosis.
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Liu M, Li W, Li P, Ma F, Xue H. Ectopic duodenal variceal bleed successfully treated with TIPS and 2 years follow-up: A Case Report. Radiol Case Rep 2020; 15:1570-1574. [PMID: 32685071 PMCID: PMC7355383 DOI: 10.1016/j.radcr.2020.04.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/18/2020] [Accepted: 04/18/2020] [Indexed: 12/24/2022] Open
Abstract
Duodenal varices are an uncommon presentation of portal hypertension and can result in significant gastrointestinal bleeding with a high mortality. Diagnosis can be difficult and therapeutic options limited. We present a case of upper gastrointestinal bleeding in a woman aged 54 years with primary biliary cholangitis who was ultimately diagnosed with ectopic duodenal variceal bleed, which was successfully treated with transjugular intrahepatic portosystemic shunt. Transjugular intrahepatic portosystemic shunt provide an effective treatment for ectopic duodenal variceal bleed caused by liver cirrhosis, though interventional radiologists need to remain aware of and vigilant for the complications and risks of this treatment option.
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61
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Howe JH, Jr PRB, Commander CW, Kim KR. Transjugular intrahepatic portosystemic shunt and transcatheter embolization treatment of duodenal variceal bleeding. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii200013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jeffrey H. Howe
- Division of Vascular and Interventional Radiology, Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Peter R. Bream Jr
- Division of Vascular and Interventional Radiology, Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Clayton W. Commander
- Division of Vascular and Interventional Radiology, Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kyung Rae Kim
- Division of Vascular and Interventional Radiology, Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Naqvi IH, Mahmood K, Talib A. Haemorrhagic versus non haemorrhagic ascites in cirrhosis: Their relationship and impact on prognosis of liver cirrhosis. Pak J Med Sci 2020; 36:603-608. [PMID: 32494241 PMCID: PMC7260907 DOI: 10.12669/pjms.36.4.2075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives To evaluate the impact of haemorrhagic ascites on prognosis of patients with advance cirrhosis, this study was further aimed to assess the relationship between haemorrhagic ascites and advance cirrhosis and its effect on prognosis. Methods Eight hundred and thirty-eight patients having liver cirrhosis with ascites were analyzed retrospectively (over three years) while segregated into two groups haemorrhagic and non haemorrhagic ascites. Patient outcome variables were identified among both groups and independent predictors for survival were analyzed. Kaplan-Meier survival estimates determined survival rate comparison between groups. Results Haemorrhagic ascites was detected in (26.6%) patients. Spontaneous haemorrhagic ascites(79%) was the main cause of haemorrhagic ascites followed by hepatocellular carcinoma (14%) and iatrogenic (7.6%). Spontaneous bacterial peritonitis and acute kidney injury were statistically significant (p= 0.0001, 0.0001) among groups. Overall mortality at year three was higher (83%) in haemorrhagic ascites group. Survival among both groups (haemorrhagic versus non haemorrhagic) at one month, one year and three year was found to be significant (p= 0.000, 0.000 and 0.000). Conclusion Haemorrhagic ascites impact overall survival with more mortality in comparison to non haemorrhagic ascites. Haemorrhagic ascites was an independent predictor of survival. Haemorrhagic ascites is possibly considered another predictor of survival among advance cirrhosis.
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Affiliation(s)
- Iftikhar Haider Naqvi
- Dr. Iftikhar Haider Naqvi, FCPS. Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Khalid Mahmood
- Prof. Khalid Mahmood, FCPS, FRCP(Edin), FRCP(Glasgow). Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Abu Talib
- Prof. Abu Talib, FCPS, FRCP(Glasgow). Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
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63
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KASL clinical practice guidelines for liver cirrhosis: Varices, hepatic encephalopathy, and related complications. Clin Mol Hepatol 2020; 26:83-127. [PMID: 31918536 PMCID: PMC7160350 DOI: 10.3350/cmh.2019.0010n] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 02/06/2023] Open
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Bleeding from gastrointestinal ectopic varices is not associated with haemorrhage from oesophageal or gastric varices. GASTROENTEROLOGY REVIEW 2020; 15:60-64. [PMID: 32215130 PMCID: PMC7089859 DOI: 10.5114/pg.2020.93632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 05/27/2019] [Indexed: 11/21/2022]
Abstract
Introduction Ectopic varices are those that appear in a different region of the gastroesophageal junction. Bleeding from ectopic varices is rare but is usually massive and deadly. Aim To identify the possible factors that cause bleeding from ectopic varices in patients with portal hypertension. Material and methods A cross-sectional and retrospective study; the data were collected between January 2004 and June 2014. We included patients with portal hypertension and gastrointestinal ectopic varices diagnosed by endoscopy. Results We found 31 patients with gastrointestinal ectopic varices. Of these, 25 had liver cirrhosis, and six showed non-cirrhotic portal hypertension. There were 16 men and 15 women in the study. The median age of the patients was 60 years (range minimum–maximum of 27 to 80 years). Nineteen (61%) patients had rectal varices, 10 (32%) had duodenal varices, 1 (3%) had ileal varices, and 1 (3%) had colonic varices. We found bleeding in 4 (13%) of the 31 patients with ectopic varices; two belonged to the cirrhosis group, and the other two were from the non-cirrhotic portal hypertension group. Three of the 4 patients with bleeding from gastrointestinal ectopic varices had exhibited haemorrhage from oesophageal varices (odds ratio = 4.09, 95% CI: 0.37–44.78, p = 0.249), but none of them showed bleeding from gastric varices. Conclusions Bleeding from gastrointestinal ectopic varices is not necessarily associated with bleeding from oesophageal or gastric varices.
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Liu C, Srinivasan S, Babu SB, Chung R. Balloon-occluded retrograde transvenous obliteration of colonic varices: a case report. CVIR Endovasc 2020; 3:17. [PMID: 32173771 PMCID: PMC7073350 DOI: 10.1186/s42155-020-00108-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 02/12/2020] [Indexed: 02/07/2023] Open
Abstract
Background Ectopic varices are uncommon and typically due to underlying liver cirrhosis. They can be located in the duodenum, small intestines, colon or rectum, and may result in massive haemorrhage. While established guidelines exist for the management of oesophageal and gastric variceal bleeding, this is currently lacking for colonic varices. Beta-blockers, transjugular intrahepatic portosystemic shunt insertion and subtotal colectomy have been reported as management methods. However, there are only two other cases that have reported successfully treating colonic varices using balloon-occluded retrograde transvenous obliteration (BRTO), an endovascular procedure typically performed for gastric varices. Case presentation A 55-year-old man with background of alcoholic liver cirrhosis presented with per-rectal bleeding due to caecal varices. Grade 2–3 oesophageal varices were identified on oesophago-gastro-duodenoscopy, and computed tomography showed multiple right para-colic portosystemic collaterals around the hepatic flexure and ascending colon. Colonoscopy confirmed fresh blood in the colon up to the caecum, with a submucosal varix deemed the most likely source of haemorrhage. As transjugular intrahepatic portosystemic shunt insertion was potentially technically difficult, due to left portal vein thrombosis and a small right portal venous system, he underwent BRTO, which successfully embolised and thrombosed the colonic varices without complications. Conclusions Whilst further studies are required to conclude its effectiveness and efficacy, BRTO may be considered a viable solution in managing ectopic, colonic, variceal haemorrhage especially when traditional techniques are unsuccessful or contraindicated.
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Affiliation(s)
- Chantal Liu
- St George's Hospital Medical School, Cranmer Terrace, Tooting, London, SW17 0RE, UK.
| | - Sivasubramanian Srinivasan
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
| | - Suresh B Babu
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
| | - Raymond Chung
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
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Rodrigues SG, Mendoza YP, Bosch J. Beta-blockers in cirrhosis: Evidence-based indications and limitations. JHEP Rep 2020; 2:100063. [PMID: 32039404 PMCID: PMC7005550 DOI: 10.1016/j.jhepr.2019.12.001] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 11/29/2019] [Accepted: 12/03/2019] [Indexed: 02/07/2023] Open
Abstract
Non-selective beta-blockers (NSBBs) are the mainstay of treatment for portal hypertension in the setting of liver cirrhosis. Randomised controlled trials demonstrated their efficacy in preventing initial variceal bleeding and subsequent rebleeding. Recent evidence indicates that NSBBs could prevent liver decompensation in patients with compensated cirrhosis. Despite solid data favouring NSBB use in cirrhosis, some studies have highlighted relevant safety issues in patients with end-stage liver disease, particularly with refractory ascites and infection. This review summarises the evidence supporting current recommendations and restrictions of NSBB use in patients with cirrhosis.
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Key Words
- ACLF
- ACLF, acute-on-chronic liver failure
- AKI, acute kidney injury
- ALD, alcohol-related liver disease
- ARD, absolute risk difference
- AV, atrioventricular
- EBL, endoscopic band ligation
- GOV, gastroesophageal varices
- HRS, hepatorenal syndrome
- HVPG, hepatic venous pressure gradient
- IGV, isolated gastric varices
- IRR, incidence rate ratio
- ISMN, isosorbide mononitrate
- MAP, mean arterial pressure
- NASH, non-alcoholic steatohepatitis
- NNH, number needed to harm
- NNT, number needed to treat
- NR, not reported
- NSBBs
- NSBBs, non-selective beta-blockers
- OR, odds ratio
- PH, portal hypertension
- PHG, portal hypertensive gastropathy
- RCT, randomised controlled trials
- RR, risk ratio
- SBP, spontaneous bacterial peritonitis
- SCL, sclerotherapy
- TIPS, transjugular intrahepatic portosystemic shunt
- ascites
- cirrhosis
- portal hypertension
- spontaneous bacterial peritonitis
- varices
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Affiliation(s)
- Susana G. Rodrigues
- Swiss Liver Center, UVCM, Inselspital, Bern University Hospital, Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Yuly P. Mendoza
- Swiss Liver Center, UVCM, Inselspital, Bern University Hospital, Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Jaime Bosch
- Swiss Liver Center, UVCM, Inselspital, Bern University Hospital, Department of Biomedical Research, University of Bern, Bern, Switzerland
- Corresponding author. Address: Swiss Liver Center, UVCM, Inselspital, Bern University Hospital, Department of Biomedical Research, University of Bern, Bern, Switzerland.
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67
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Sharma B, Mitchell R, Parapini M, Donnellan F. Cyanoacrylate injection of an ectopic variceal bleed at a choledochojejunal anastomotic site in a patient with post-Whipple anatomy. VideoGIE 2020; 5:29-31. [PMID: 31922079 PMCID: PMC6945273 DOI: 10.1016/j.vgie.2019.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Balraj Sharma
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Robert Mitchell
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Marina Parapini
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Fergal Donnellan
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
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Shinno N, Kawabata R, Furukawa H, Goda S, Sueda T, Matsumura T, Koga C, Noura S, Shimizu J, Okada A, Hasegawa J. A case of esophagojejunal varices rupture after proximal gastrectomy with double-tract reconstruction. Surg Case Rep 2020; 6:12. [PMID: 31919714 PMCID: PMC6952481 DOI: 10.1186/s40792-020-0775-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/31/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The varices after proximal or total gastrectomy are uncommon because the supplying vessels are all divided. Emergent upper gastrointestinal endoscopy is the cornerstone of first-line management for the diagnosis and treatment of esophageal varices. However, there is no widely accepted standard strategy for esophagojejunal varices. We report a patient with esophagojejunal varices rupture 3 months after proximal gastrectomy treated with percutaneous transhepatic obliteration. CASE PRESENTATION A 50-year-old man who had undergone proximal gastrectomy with double-tract reconstruction for esophagogastric junctional cancer 3 months before was admitted to the hospital due to gastrointestinal perforation. We performed emergency surgery and abdominal symptoms and inflammatory response improved postoperative. However, on POD3, he had eruptive bleeding at the just anal side of esophagojejunal anastomosis. Endoscopic clipping was unsuccessful because the mucosa was fragile and easily lacerated. Contrast-enhanced CT scan revealed the dilatation of the jejunal vein flowing into the ascending jejunal limb. Therefore, he was diagnosed as esophagojejunal varices rupture and percutaneous transhepatic obliteration (PTO) was tried for hemostasis. The portal and superior mesenteric veins were catheterized with the percutaneous transhepatic approach. Contrast agent injection into the jejunal branch demonstrated retrograde flow to the azygos vein through esophagojejunal varices. The microcatheter was inserted into the variceal blood supply branch and 10 mL of 5% ethanolamine oleate with iopamidol was injected. After obliteration therapy, the superior mesenteric venogram showed complete occlusion of the variceal supply branch. The patient was discharged from the hospital without any complications after 14 days. CONCLUSION PTO can be effective for gastroesophageal varices rupture with a dilated jejunal vein of the ascending limb, few supplying vessels, and little ascites.
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Affiliation(s)
- Naoki Shinno
- Departments of Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan. .,Departments of Surgery, Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai, 591-8025, Japan.
| | - Ryohei Kawabata
- Departments of Surgery, Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai, 591-8025, Japan
| | - Haruna Furukawa
- Departments of Surgery, Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai, 591-8025, Japan
| | - Seiichi Goda
- Departments of Radiology, Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai, 591-8025, Japan
| | - Toshinori Sueda
- Departments of Surgery, Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai, 591-8025, Japan
| | - Tae Matsumura
- Departments of Surgery, Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai, 591-8025, Japan
| | - Chikato Koga
- Departments of Surgery, Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai, 591-8025, Japan
| | - Shingo Noura
- Departments of Surgery, Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai, 591-8025, Japan.,Departments of Surgery, Toyonaka Municipal Hospital, 4-14-1 Shibahara-cho, Toyonaka, 560-8565, Japan
| | - Junzo Shimizu
- Departments of Surgery, Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai, 591-8025, Japan.,Departments of Surgery, Toyonaka Municipal Hospital, 4-14-1 Shibahara-cho, Toyonaka, 560-8565, Japan
| | - Atsuya Okada
- Departments of Radiology, Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai, 591-8025, Japan
| | - Junichi Hasegawa
- Departments of Surgery, Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai, 591-8025, Japan
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69
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Greco L, Zhang J, Ross H. Surgical Options and Approaches for Lower Gastrointestinal Bleeding: When do we operate and what do we do? Clin Colon Rectal Surg 2020; 33:10-15. [PMID: 31915420 PMCID: PMC6946603 DOI: 10.1055/s-0039-1693439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Lower gastrointestinal bleeding (LGIB) is a common entity encountered by the surgeon. Though most LGIB stops on its own, familiarity with the diagnoses and their treatments is critical to optimal patient care. Even in 2016, surgery may be required. Advances in imaging have led to an enhanced ability to localize bleeding. Newer anticoagulants have developed which provide ease of use to the patient, but challenges to caregivers when bleeding arises.
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Affiliation(s)
- Laura Greco
- Department of Surgery, Lewis Katz School of Medicine at Temple University, Pennsylvania
| | - Jeanette Zhang
- Department of Surgery, Lewis Katz School of Medicine at Temple University, Pennsylvania
| | - Howard Ross
- Department of Surgery, Lewis Katz School of Medicine at Temple University, Pennsylvania
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70
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Lee JH, Kim TH, Choi JW, Kim SY, Choi JY, Lee CK, Park BK, Chung JB. A case report of bleeding from duodenal varices treated with percutaneous transhepatic obliteration. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2019. [DOI: 10.18528/ijgii190002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Ji Hyun Lee
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Hwan Kim
- Department of Vascular and Interventional Radiology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jong Won Choi
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Sun Young Kim
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jin Young Choi
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Chun Kyon Lee
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Byung Kyu Park
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jae Bok Chung
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
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71
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Anand R, Ali SE, Raissi D, Frandah WM. Duodenal variceal bleeding with large SPSS treated with transjugular intrahepatic portosystemic shunt and embolization: A case report. World J Radiol 2019; 11:110-115. [PMID: 31523400 PMCID: PMC6715580 DOI: 10.4329/wjr.v11.i8.110] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 08/14/2019] [Accepted: 08/19/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Duodenal variceal bleeding is a rare cause of gastrointestinal bleeding. The most common site is the duodenal bulb. It is usually detected endoscopically but it can be very challenging to diagnose if it is located distal to the second part of duodenum. The pre- transjugular intrahepatic portosystemic shunt (TIPS) presence of SPSS was found to be associated with an increased risk of early morbidity and mortality after TIPS placement.
CASE SUMMARY A 43-year-old cirrhotic male presented with melena for three days. Upper endoscopy was performed and showed active blood oozing from the distal duodenum concerning for ectopic duodenal varix. A computed tomography (CT) angiogram was performed and showed an enlarged cluster of venous collaterals around the distal duodenum. He underwent TIPS placement. He had another episode of melena three days later. Push enteroscopy with injection sclerotherapy into the duodenal varices was performed with no success. A repeat CT angiogram showed occluded TIPS shunt. Therefore, a TIPS revision was performed and there was an extensive portal venous thrombosis with a large shunt between the inferior mesenteric vein and left renal vein via the left gonadal vein. Thrombectomy and TIPS shunt balloon angioplasty was performed, followed by embolization of the portosystemic. The melena was resolved, and patient was discharged with arranged hepatology follow up.
CONCLUSION It important to look and embolize the SPSS shunts in patients with early TIPS dysfunction and recurrent duodenal variceal bleeding.
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Affiliation(s)
- Rohit Anand
- Departament of Internal Medicine, University of Kentucky, Lexington, KY 40536, United States
| | - Saad Emhmed Ali
- Departament of Internal Medicine, University of Kentucky, Lexington, KY 40536, United States
| | - Driss Raissi
- Department of Interventional Radiology, University of Kentucky, Lexington, KY 40536, United States
| | - Wesam M Frandah
- Department of Interventional Radiology, University of Kentucky, Lexington, KY 40536, United States
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72
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Despott EJ, May A, Lazaridis N, Vlachou E, Koukias N, Patch D, Planche K, Hayashi Y, Murino A. Double-balloon enteroscopy-facilitated cyanoacrylate-injection endotherapy of small-bowel varices: an international experience from 2 European tertiary centers (with videos). Gastrointest Endosc 2019; 90:302-306. [PMID: 30980796 DOI: 10.1016/j.gie.2019.03.1171] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 03/28/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Small-bowel varices (SBVs) are an uncommon consequence of portal hypertension. Radiologic intervention is usually considered for first-line management. When radiologic intervention is not possible, management options become very limited. The aim of this study was to evaluate the usefulness of double-balloon enteroscopy (DBE)-facilitated cyanoacrylate-injection endotherapy of SBVs. METHODS This was a retrospective review of DBE-facilitated cyanoacrylate-injection endotherapy of SBVs (December 2015 to October 2016). RESULTS Ten DBEs were performed in 6 patients (4 women; median age, 68.5 years). No radiologic or surgical options were deemed feasible. Thirteen nests of SBVs were identified and injected with cyanoacrylate glue without hemorrhagic or embolic adverse events. At the 30-day follow-up after therapy, only 1 patient had experienced a mild recurrence of mid-gut bleeding; this was managed conservatively. One patient presented with acute GI bleeding 7 months later, and a repeat DBE with cyanoacrylate-injection endotherapy was successfully performed. One patient succumbed to his underlying advanced cholangiocarcinoma after 2 months. The remaining patients had a median follow-up of 12 months without any recurrent GI bleeding. CONCLUSIONS DBE-facilitated cyanoacrylate-injection endotherapy of SBVs appears to be a safe and effective option when other first-line options are not feasible.
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Affiliation(s)
- Edward J Despott
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK
| | - Andrea May
- Department of Gastroenterology, Sana Klinikum Offenbach GmbH and University of Mainz, Germany
| | - Nikolaos Lazaridis
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK
| | - Erasmia Vlachou
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK; NIMTS Army Veterans Hospital, Athens, Greece
| | - Nikolaos Koukias
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK
| | - David Patch
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK
| | - Katie Planche
- Department of Radiology, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK
| | - Yoshikazu Hayashi
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK; Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
| | - Alberto Murino
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK
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Abdalla AO, Abdallah MA, Calvo LA. Successful Treatment of a Case of Ectopic Jejunal Varices with Portal Venous Stenting. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:948-952. [PMID: 31266933 PMCID: PMC6621934 DOI: 10.12659/ajcr.916003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patient: Female, 77 Final Diagnosis: Ectopic variceal bleeding of the jejunum Symptoms: Abdominal pain • hematemesis • melena Medication: — Clinical Procedure: Portal vein stenting Specialty: Gastroenterology and Hepatology
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Affiliation(s)
- Abubaker O Abdalla
- Department to Internal Medicine, University of Nevada, School of Medicine, Reno, NV, USA
| | - Mohamed A Abdallah
- Department to Internal Medicine, University of South Dakota, Sioux Falls, SD, USA
| | - Lisa A Calvo
- Department to Internal Medicine, University of Nevada, School of Medicine, Reno, NV, USA
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74
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Fukumoto G, Kimura H, Kanagaki M, Oka S, Tanaka H, Wang Y, Tanaka H, Yamauchi Y, Kimura T. Intraabdominal Hemorrhage from Ruptured Ectopic Varices Treated by Antegrade Embolization via a Recanalized Paraumbilical Vein. Cardiovasc Intervent Radiol 2019; 42:1204-1207. [PMID: 31073821 DOI: 10.1007/s00270-019-02235-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 04/25/2019] [Indexed: 12/17/2022]
Abstract
A 49-year-old man with alcoholic liver cirrhosis was admitted to our hospital with abdominal pain. Contrast-enhanced CT demonstrated massive hemorrhagic ascites and ectopic varices fed by right colic and ileocolic veins. The varices were treated with selective embolization via a recanalized paraumbilical vein using N-butyl cyanoacrylate. Currently, no complications and rebleeding have occurred for 7 months. Antegrade embolization via a recanalized paraumbilical vein is feasible and less-invasive in a patient with massive ascites. Flow reduction may be effective for intraabdominal hemorrhage from ruptured ectopic varices. LEVEL OF EVIDENCE: Level 5, case report.
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Affiliation(s)
- Genki Fukumoto
- Department of Diagnostic Radiology, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa-cho, Amagasaki, Hyogo, Japan.
| | - Hiroyuki Kimura
- Department of Diagnostic Radiology, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa-cho, Amagasaki, Hyogo, Japan
| | - Mitsunori Kanagaki
- Department of Diagnostic Radiology, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa-cho, Amagasaki, Hyogo, Japan
| | - Shojiro Oka
- Department of Diagnostic Radiology, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa-cho, Amagasaki, Hyogo, Japan
| | - Hiroki Tanaka
- Department of Diagnostic Radiology, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa-cho, Amagasaki, Hyogo, Japan
| | - Yang Wang
- Department of Diagnostic Radiology, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa-cho, Amagasaki, Hyogo, Japan
| | - Hiroaki Tanaka
- Department of Diagnostic Radiology, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa-cho, Amagasaki, Hyogo, Japan
| | - Yuki Yamauchi
- Department of Gastroenterology and Hepatology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Toshiyuki Kimura
- Department of Gastroenterology and Hepatology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
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75
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Nett A, Binmoeller KF. Endoscopic Management of Portal Hypertension-related Bleeding. Gastrointest Endosc Clin N Am 2019; 29:321-337. [PMID: 30846156 DOI: 10.1016/j.giec.2018.12.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Gastrointestinal bleeding as a sequela of portal hypertension can be catastrophic and fatal. Endoscopic and endosonographic therapy play a critical role in management of such bleeding- both for hemostasis of active bleeding and bleeding prophylaxis. Variceal band ligation is established as the standard intervention for esophageal varices. For other sources of portal hypertension-related bleeding, or for salvage therapy for esophageal varices, a variety of endoscopic techniques are available. Endoscopic ultrasound may be used to enhance endoscopic management, particularly for gastric and ectopic varices.
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Affiliation(s)
- Andrew Nett
- Interventional Endoscopy Services, California Pacific Medical Center, 2351 Clay Street, 6th Floor Suite 600, San Francisco, CA 94115, USA.
| | - Kenneth F Binmoeller
- Interventional Endoscopy Services, California Pacific Medical Center, 2351 Clay Street, 6th Floor Suite 600, San Francisco, CA 94115, USA
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76
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Wang X, Yu S, Chen X, Duan L. Endoscopic ultrasound-guided injection of coils and cyanoacrylate glue for the treatment of gastric fundal varices with abnormal shunts: a series of case reports. J Int Med Res 2019; 47:1802-1809. [PMID: 30819006 PMCID: PMC6460599 DOI: 10.1177/0300060519830207] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Gastric varices are found in approximately 20% of patients with portal hypertension. Endoscopic procedures involving the injection of cyanoacrylate (CYA) have proven to be the therapies of choice for primary treatment of gastric varices and have resulted in higher hemostasis rates and lower recurrent bleeding rates compared with band ligation and sclerotherapy. Nevertheless, serious adverse events associated with CYA injection, including glue embolization, have been reported in numerous articles and have occasionally led to fatal adverse events. Gastric fundal varices with abnormal shunts are higher-risk than those without abnormal shunts, and their treatment is more challenging. Endoscopic ultrasound (EUS)-guided puncture is an important technique in the field of digestive endoscopy. EUS has advantages that include improved therapeutic targeting, enhanced variceal detection, the ability to confirm varix obliteration with Doppler examination, and the ability to perform accurate observations of gastric varices that are not affected by blood in the stomach. The coils currently used for intravascular embolization can be precisely delivered into a varix through fine-needle puncture under EUS guidance, and this technique has provided a new approach for varix obliteration. We herein describe two patients with severe gastric fundal varices who were treated with EUS-guided coil injection and CYA embolization.
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Affiliation(s)
- XiaoMing Wang
- Department of Gastroenterology, Panzhihua Central Hospital, Sichuan, People's Republic of China
| | - Shan Yu
- Department of Gastroenterology, Panzhihua Central Hospital, Sichuan, People's Republic of China
| | - Xin Chen
- Department of Gastroenterology, Panzhihua Central Hospital, Sichuan, People's Republic of China
| | - Lei Duan
- Department of Gastroenterology, Panzhihua Central Hospital, Sichuan, People's Republic of China
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Jejunal Varices Bleeding in a Patient with Extensive Portomesenteric Thrombosis Secondary to Factor V Leiden Mutation: A Management Dilemma. Case Rep Gastrointest Med 2019; 2019:4526472. [PMID: 30881706 PMCID: PMC6381577 DOI: 10.1155/2019/4526472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 12/06/2018] [Accepted: 01/22/2019] [Indexed: 02/05/2023] Open
Abstract
Ectopic varices are portosystemic collaterals that occur away from the gastroesophageal junction and account for 1-5% of all variceal bleeding. Its occurrence in the jejunum is rare. Most common cause of ectopic jejunal varices is portal hypertension especially in those patients who have undergone prior abdominal surgery. Portomesenteric thrombosis is a rare cause of ectopic jejunal varices. Ectopic varices are rare cause of obscure GI bleeding and hence should be always suspected in patients with history of portal hypertension who present with GI bleeding and have negative upper and lower GI endoscopies. Management of patients with ectopic varices is often very challenging and requires multidisciplinary approach. Therapeutic options include endoscopic therapy, interventional radiologic procedures, surgically creating shunting, or surgical resection. We present the case of a 52-year-old patient who was on anticoagulation for extensive portomesenteric thrombosis secondary to factor V Leiden heterozygous mutation and presented with melena and symptomatic anemia. Investigations showed bleeding jejunal varices as the cause of anemia. We discuss the therapeutic options and dilemma in the management of such cases.
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78
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Romano J, Welden CV, Orr J, McGuire B, Shoreibah M. Case Series Regarding Parastomal Variceal Bleeding: Presentation and Management. Ann Hepatol 2019; 18:250-257. [PMID: 31113601 DOI: 10.5604/01.3001.0012.7934] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 01/18/2018] [Indexed: 02/04/2023]
Abstract
Parastomal variceal bleeding (PVB) is a serious complication occurring in up to 27% of patients with an ostomy and concurrent cirrhosis and portal hypertension. The management of PVB is difficult and there are no clear guidelines on this matter. Transjugular intrahepatic portosystemic shunt (TIPS), sclerotherapy, and /or coil embolization are all therapies that have been shown to successfully manage PVB. We present a case series with five different patients who had a PVB at our institution. The aim of this case series is to report our experience on the management of this infrequently reported but serious condition. We also conducted a systemic literature review focusing on the treatment modalities of 163 patients with parastomal variceal bleeds. In our series, patient 1 had embolization and sclerotherapy without control of bleed and expired on the day of intervention due to hemorrhagic shock. Patient 2 had TIPS in conjunction with embolization and sclerotherapy and had no instance of rebleed 441 days after therapy. Patient 3 did not undergo any intervention due to high risk for morbidity and mortality, the bleed self-resolved and there was no further rebleed, this same patient died of sepsis 73 days later. Patient 4 had embolization and sclerotherapy and had no instance of rebleed 290 days after therapy. Patient 5 had TIPS procedure and was discharged five days post procedure without rebleed, patient has since been lost to follow-up.
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Affiliation(s)
- John Romano
- Department of Medicine, University of Alabama at Birmingham, Birmingham AL, USA.
| | - Charles V Welden
- Department of Medicine, University of Alabama at Birmingham, Birmingham AL, USA
| | - Jordan Orr
- Department of Medicine, Division of Gastroenterology and Hepatology, Vanderbilt University, Nashville TN, USA
| | - Brendan McGuire
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham AL, USA
| | - Mohamed Shoreibah
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham AL, USA
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79
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Goenka MK, Shah BB, Rai VK, Jajodia S, Goenka U. Mucosal Changes in the Small Intestines in Portal Hypertension: First Study Using the Pillcam SB3 Capsule Endoscopy System. Clin Endosc 2018; 51:563-569. [PMID: 30300988 PMCID: PMC6283757 DOI: 10.5946/ce.2018.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 07/18/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND/AIMS To evaluate patients with portal hypertension (PH) of varied etiologies for portal hypertensive enteropathy (PHE) using the PillCam SB3 capsule endoscopy (CE) system. METHODS Consecutive patients with PH presenting with unexplained anemia and/or occult gastrointestinal bleeding were evaluated using the PillCam SB3 CE system. Abnormal findings were categorized as vascular or non-vascular. The patients with ongoing bleeding caused by PHE were treated. The correlation of the CE scores of PHE with the clinical, laboratory, and endoscopic features was determined. RESULTS Of the 43 patients included in the study, 41 (95.3%) showed PHE findings. These included varices (67.4%), red spots (60.5%), erythema (44.2%), villous edema (46.5%), telangiectasia (16.3%), and polyps (16.3%). The CE scores varied from 0 to 8 (mean±standard deviation, 4.09±1.8). Five patients (11.6%) showed evidence of ongoing or recent bleeding due to PHE. Three of these five patients underwent endotherapy, and one patient underwent radiological coil placement. CONCLUSION The PillCam SB3 CE system revealed a high prevalence of PHE in the patients with PH. Using this system, evidence of bleeding due to PHE was found in a small but definite proportion of the patients.
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Affiliation(s)
| | - Bhavik Bharat Shah
- Institute of Gastro-Sciences, Apollo Gleneagles Hospitals, Kolkata, India
| | - Vijay Kumar Rai
- Institute of Gastro-Sciences, Apollo Gleneagles Hospitals, Kolkata, India
| | - Surabhi Jajodia
- Department of Clinical Imaging and Interventional Radiology, Apollo Gleneagles Hospitals, Kolkata, India
| | - Usha Goenka
- Department of Clinical Imaging and Interventional Radiology, Apollo Gleneagles Hospitals, Kolkata, India
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80
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Endoscopic Sclerotherapy with a Large Volume of High Concentration of Cyanoacrylate for Jejunal Variceal Bleeding bys Single-Balloon Enteroscopy. ACTA ACUST UNITED AC 2018; 54:medicina54050068. [PMID: 30344299 PMCID: PMC6262278 DOI: 10.3390/medicina54050068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 09/04/2018] [Accepted: 09/06/2018] [Indexed: 12/14/2022]
Abstract
Jejunal varices are a rare manifestation of portal hypertension, and they are associated with a high mortality and poor prognosis when bleeding occurs. A bleeding jejunal varix is much more challenging to diagnose and manage because of its anatomic location. Herein, we describe the case of a 62-year-old man with active jejunal variceal bleeding who presented with massive hematochezia and hypovolemic shock. He was treated successfully with a high volume and concentration of a glue mixture as endoscopic sclerotherapy using single-balloon enteroscopy in the intensive care unit. Enteroscopic sclerotherapy is an effective option for jejunal variceal bleeding.
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81
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Direct Percutaneous Embolization of Peristomal Ileostomy Varices in an Emergency Setting. Case Rep Radiol 2018; 2018:6239183. [PMID: 30174978 PMCID: PMC6106803 DOI: 10.1155/2018/6239183] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 07/09/2018] [Indexed: 12/17/2022] Open
Abstract
Patients with liver disease and portal hypertension who have had surgical formation of an abdominal stoma are at risk of developing peristomal varices. These varices have a predilection for bleeding. Ideally, portal decompression via TIPS procedure is performed, with or without direct embolization of the bleeding varix. When TIPS is not an appropriate option due to significant liver disease and hepatic encephalopathy there are other approaches to treat peristomal variceal hemorrhage. We report the embolization of such a varix via direct percutaneous puncture under ultrasound guidance when portal decompression was not an appropriate option.
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82
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Kim CL, Kim T, Lee WH, Seo JW, Park SH, Choi JH, Heo NY. [Ascending Colon Variceal Bleeding in Cirrhotic Patient with Emergent Endoscopic Variceal Obturation with N-butyl-2-cyanoacrylate]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2018; 72:37-41. [PMID: 30049177 DOI: 10.4166/kjg.2018.72.1.37] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Ectopic varices are rare among patients with portal hypertension, especially in the ascending colon. It is difficult to evaluate massive lower gastrointestinal bleeding in patients with liver cirrhosis by colonoscopy due to hemodynamic instability and poor bowel preparation. In Korea, there has only been one case report about ascending colon variceal bleeding, in which hemostasis was performed by venous coil embolization. We report another rare case of ascending colon variceal bleeding in a patient with alcoholic cirrhosis, who was successfully treated via two sessions of N-butyl-2-cyanoacrylate injection through colonoscopy. This case suggests that the careful endoscopic approach and hemostasis with glue injection might be an option for treating massive bleeding in the lower gastrointestinal varix.
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Affiliation(s)
- Chang Lae Kim
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Taehong Kim
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Won Hyuk Lee
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Joo Wan Seo
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Seung Ha Park
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Joon Hyuk Choi
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Nae Yun Heo
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
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83
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Khor V, Soon Y, Aung L. A case report of bleeding from a duodenal varix: Rare cause of upper gastrointestinal bleeding. Int J Surg Case Rep 2018; 49:205-208. [PMID: 30029079 PMCID: PMC6077164 DOI: 10.1016/j.ijscr.2018.06.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 06/25/2018] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Ectopic variceal bleeding is uncommon, accounts for 2-5% of variceal bleeding, of which 17% is in duodenum. PRESENTATION OF CASE 62-year-old lady with newly diagnosed liver cirrhosis on admission, presented with severe upper gastrointestinal bleeding (UGIB), was ultimately diagnosed with bleeding duodenal varices with single-balloon enteroscopy, after multiple oesophagogastroduodenoscopies (OGDs) and CT scans which failed to identify the varices. She was treated successfully with duodenectomy. DISCUSSION Endoscopy and CT angiography remain the diagnostic modalities of choice. However, diagnosis can be difficult as evidenced by three OGDs and two CTMAs yielding negative findings in this case. Endoscopic diagnosis is challenging and often delayed due to its rarity and unusual location. CONCLUSION Ectopic variceal bleeding is a rare but important cause of UGIB. Diagnosis is challenging and management of this condition should take a multidisciplinary approach, involving experienced gastroenterologists, interventional radiologists and surgeons. Endoscopic ligation or sclerotherapy is the first-line of treatment.
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Affiliation(s)
- Vincent Khor
- MOH Holdings Singapore, 1 Maritime Square, #11-25 HarbourFront Centre, 099235, Singapore; Department of General Surgery, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, 609606, Singapore.
| | - Yuen Soon
- Department of General Surgery, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, 609606, Singapore
| | - Lwin Aung
- Department of General Surgery, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, 609606, Singapore
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84
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Park CJ, Lee BE, Jeon HK, Kim GH, Song GA, Ko SH, Lee SJ, Park DY. Case of Bleeding Ileal Varices after a Colectomy Diagnosed by Capsule Endoscopy. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2018; 71:349-353. [PMID: 29943562 DOI: 10.4166/kjg.2018.71.6.349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We report a case of bleeding ileal varices associated with intra-abdominal adhesions after colectomy which was successfully diagnosed using capsule endoscopy. A 77-year-old woman visited the emergency department for several episodes of melena. She had a medical history of neoadjuvant chemo-radiation therapy and subsequent surgery for rectal cancer 6 years previously. Conventional diagnostic examinations including upper endoscopy, colonoscopy, and abdominal computed tomography could not detect any bleeding focus, however, following capsule endoscopy revealed venous dilatations with some fresh blood in the distal ileum, indicating bleeding ileal varices. The patient underwent exploratory laparotomy and the affected ileum was successfully resected. No further gastrointestinal bleeding occurred during the 6 months follow-up. Small intestinal varices are important differential for obscure gastrointestinal bleeding especially in patients with a history of abdominal surgery in the absence of liver cirrhosis, and capsule endoscopy can be a good option for diagnosing small intestinal varices.
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Affiliation(s)
- Chang Joon Park
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Bong Eun Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Hye Kyung Jeon
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Gwang Ha Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Geun Am Song
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Sang Hwa Ko
- Department of Surgery, Pusan National University School of Medicine, Busan, Korea
| | - So Jeong Lee
- Department of Pathology, Pusan National University School of Medicine, Busan, Korea
| | - Do Youn Park
- Department of Pathology, Pusan National University School of Medicine, Busan, Korea
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85
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Park SW, Jun CH, Choi SK, Kim HS, Park CH, Rew JS, Park SY, Cho E, Kim JK, Kim HO. Successful Transjugular Intrahepatic Portosystemic Shunt with Embolization Subsequent to Endoscopic Variceal Band Ligation for Bleeding Anorectal Varices. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2018; 71:234-238. [PMID: 29684973 DOI: 10.4166/kjg.2018.71.4.234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Anorectal variceal bleeding is a rare occurrence; however, in such event, it could be fatal due to large size and high blood flow rate of varices. However, to date, there is no standardized treatment modality. Although endoscopic treatment can be provided, in cases of recurrent anorectal variceal bleeding, other therapeutic modalities for hemostasis are necessary. Here, we present a case of 58-year-old female patient with liver cirrhosis, who suffered from massive bleeding of anorectal varices. Endoscopic variceal band ligation was performed for primary hemostasis. Additionally, transjugular intrahepatic portosystemic shunt (TIPS) with embolization was performed to reduce the risk of rebleeding. Following the procedure, she had no further bleeding episodes, and the size of anorectal varices decreased, as seen on an abdomino-pelvic computed tomography. Our case illustrates the effectiveness of combined radiological intervention of TIPS with embolization after endoscopic hemostasis, for variceal obliteration and prevention of rebleeding.
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Affiliation(s)
- Sang Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Chung Hwan Jun
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Sung Kyu Choi
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Hyun Soo Kim
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Chang Hwan Park
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Jong Sun Rew
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Seon Young Park
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Eunae Cho
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Jae Kyu Kim
- Department of Radiology, Chonnam National University Medical School, Gwangju, Korea
| | - Hyoung Ook Kim
- Department of Radiology, Chonnam National University Medical School, Gwangju, Korea
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86
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Matsumoto K, Imai Y, Takano M, Nakazawa M, Ando S, Sugawara K, Nakayama N, Tomiya T, Mochida S. A case of colonic varices complicated by alcoholic cirrhosis treated using balloon-occluded retrograde transvenous obliteration. Clin J Gastroenterol 2018; 11:343-347. [PMID: 29696582 DOI: 10.1007/s12328-018-0857-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 03/30/2018] [Indexed: 02/07/2023]
Abstract
A 44-year-old man with cirrhosis arising from alcohol abuse manifested melena caused by the rupture of esophageal varices. He received endoscopic variceal ligation for the initial hemostasis, followed by endoscopic injection sclerotherapy as an additional consolidation therapy. A CT examination performed at the time of admission revealed collateral veins developing around the ascending colon, in which the feeding and draining vessels were identified as the superior mesenteric vein and the right testicular vein, respectively. Moreover, large nodular varices were observed in the ascending colon during a colonoscopy. To prevent the rupture of the colonic varices, balloon-occluded retrograde transvenous obliteration (B-RTO) was performed through the right testicular vein using a microballoon catheter. A CT examination performed 4 days after the B-RTO procedure revealed the disappearance of blood flow with thrombosis formation in both the colonic varices and the feeding vein. The varices in the ascending colon had completely disappeared when examined during a colonoscopy performed 4 months after the B-RTO procedure. B-RTO is a useful and minimally invasive procedure for the treatment of colonic varices to prevent bleeding.
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Affiliation(s)
- Keisuke Matsumoto
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-gun, Saitama, 350-0495, Japan
| | - Yukinori Imai
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-gun, Saitama, 350-0495, Japan
| | - Masashi Takano
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-gun, Saitama, 350-0495, Japan
| | - Manabu Nakazawa
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-gun, Saitama, 350-0495, Japan
| | - Satsuki Ando
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-gun, Saitama, 350-0495, Japan
| | - Kayoko Sugawara
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-gun, Saitama, 350-0495, Japan
| | - Nobuaki Nakayama
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-gun, Saitama, 350-0495, Japan
| | - Tomoaki Tomiya
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-gun, Saitama, 350-0495, Japan
| | - Satoshi Mochida
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-gun, Saitama, 350-0495, Japan.
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87
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Masuda K, Takenaga S, Ashida H, Ojiri H. Variceal bleeding in the small intestine successfully treated with balloon-occluded retrograde transvenous obliteration using N-butyl-2-cyanoacrylate: A case report. Radiol Case Rep 2018; 13:400-403. [PMID: 29904482 PMCID: PMC6000062 DOI: 10.1016/j.radcr.2018.01.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 01/15/2018] [Indexed: 02/07/2023] Open
Abstract
Rupture of small intestinal varices associated with portal hypertension can be a serious condition that is difficult to diagnose early and to manage. Moreover, optimal guidelines for the treatment of small intestinal varices have not yet been established. We herein report a case of a 73-year-old man with small intestinal varices. The man presented with bleeding from a stoma in the small intestine, which subsequently led to hemorrhagic shock. We successfully treated the patient with balloon-occluded retrograde transvenous obliteration via the right inferior epigastric vein using N-butyl-2-cyanoacrylate.
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Affiliation(s)
- Koichi Masuda
- Department of Radiology, The Jikei University Katsushika Medical Center, 6-41-2, Aoto, Katsushika-ku, Tokyo, 125-8506, Japan
| | - Shinsuke Takenaga
- Department of Radiology, The Jikei University Katsushika Medical Center, 6-41-2, Aoto, Katsushika-ku, Tokyo, 125-8506, Japan
| | - Hirokazu Ashida
- Department of Radiology, The Jikei Medical University Hospital, Minato-ku, Tokyo, Japan
| | - Hiroya Ojiri
- Department of Radiology, The Jikei Medical University Hospital, Minato-ku, Tokyo, Japan
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88
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Tran-Harding K, Winkler M, Raissi D. Bleeding stomal varices in portal hypertension. Radiol Case Rep 2018; 13:356-360. [PMID: 29904472 PMCID: PMC5999933 DOI: 10.1016/j.radcr.2018.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 01/04/2018] [Indexed: 02/09/2023] Open
Abstract
We report a case of a 50-year-old man with a history of liver cirrhosis and colon cancer post end colostomy presenting to the emergency department with stomal bleeding and passage of clots into the colostomy bag. The patient was treated with transjugular intrahepatic portosystemic shunt (TIPS) and concomitant embolization of the stomal varices via the TIPS shunt using N-butyl cyanoacrylate mixed with ethiodol. Although stomal variceal bleeding is uncommon, this entity can have up to 40% mortality upon initial presentation, given the challenges in diagnosis and management. Currently, there are no established standard treatments for stomal variceal bleeding. In addition, to the best of our knowledge, there are no cases in the current literature in which treatment of this entity is performed with a combination of TIPS shunt placement and N-butyl cyanoacrylate variceal embolization.
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Affiliation(s)
- Karen Tran-Harding
- Department of Diagnostic Radiology, University of Kentucky Chandler Medical Center, 800 Rose St, HX315E, Lexington, KY, USA
| | - Michael Winkler
- Department of Diagnostic Radiology, University of Kentucky Chandler Medical Center, 800 Rose St, HX315E, Lexington, KY, USA
| | - Driss Raissi
- Department of Diagnostic Radiology, University of Kentucky Chandler Medical Center, 800 Rose St, HX315E, Lexington, KY, USA
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89
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Minowa K, Komatsu S, Takashina K, Tanaka S, Kumano T, Imura K, Shimomura K, Ikeda J, Taniguchi F, Ueshima Y, Lee T, Ikeda E, Otsuji E, Shioaki Y. Ectopic gastrointestinal variceal bleeding with portal hypertension. World J Gastrointest Surg 2017; 9:288-292. [PMID: 29359035 PMCID: PMC5752964 DOI: 10.4240/wjgs.v9.i12.288] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 10/07/2017] [Accepted: 11/12/2017] [Indexed: 02/07/2023] Open
Abstract
Massive gastrointestinal bleeding from gastrointestinal varices is one of the most serious complications in patients with portal hypertension. However, if no bleeding point can be detected by endoscopy in the predilection sites of gastrointestinal varices, such as the esophagus and stomach, ectopic gastrointestinal variceal bleeding should be considered as a differential diagnosis. Herein, we report a case of ectopic ileal variceal bleeding in a 57-year-old woman, which was successfully diagnosed by multi-detector row CT (MDCT) and angiography and treated by segmental ileum resection. To date, there have been no consensus for the treatment of ectopic ileal variceal bleeding. This review was designed to clarify the clinical characteristics of patients with ectopic ileal variceal and discuss possible treatment strategies. From the PubMed database and our own database, we reviewed 21 consecutive cases of ileal variceal bleeding diagnosed from 1982 to 2017. MDCT and angiography is useful for the rapid examination and surgical resection of an affected lesion and is a safe and effective treatment strategy to avoid further bleeding.
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Affiliation(s)
- Keita Minowa
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
- Emergency and Critical Care Center, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
| | - Shuhei Komatsu
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Kenichiro Takashina
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
- Emergency and Critical Care Center, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
| | - Sachie Tanaka
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
| | - Tatsuya Kumano
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
| | - Kenichiro Imura
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
| | - Katsumi Shimomura
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
| | - Jun Ikeda
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
| | - Fumihiro Taniguchi
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
| | - Yasuo Ueshima
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
| | - Tecchuu Lee
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
| | - Eito Ikeda
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
| | - Eigo Otsuji
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Yasuhiro Shioaki
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
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Balogh J, Gordon-Burroughs S, Schwarz P, Galati J, McFadden R, Cusick M, Snyder M, Bailey H, Weiner M, Wong A, Ochoa R, Saharia A, Gaber A, Ghobrial R. Treatment of Refractory Gastrointestinal Bleeding in Patients With Portal Hypertension: A Case Series and Treatment Algorithm. Transplant Proc 2017; 49:1864-1869. [DOI: 10.1016/j.transproceed.2017.06.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 06/16/2017] [Indexed: 12/29/2022]
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92
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Soape MP, Lichliter A, Cura M, Lepe-Suastegui MR, Burdick JS. Rare Duodenal Varix Coil Erosion Post TIPS Creation and Coil Embolization of Mesenteric-Systemic Shunt. Dig Dis Sci 2017; 62:2601-2603. [PMID: 28687942 DOI: 10.1007/s10620-017-4663-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 06/23/2017] [Indexed: 12/24/2022]
Affiliation(s)
- Matthew P Soape
- Baylor University Medical Center, Baylor Scott and White, 3600 Gaston Ave, Wadley Tower Ste. 260, Dallas, TX, 75246, USA.
| | - Andrew Lichliter
- Baylor University Medical Center, Baylor Scott and White, 3600 Gaston Ave, Wadley Tower Ste. 260, Dallas, TX, 75246, USA
| | - Marco Cura
- Baylor University Medical Center, Baylor Scott and White, 3600 Gaston Ave, Wadley Tower Ste. 260, Dallas, TX, 75246, USA
| | - Maria R Lepe-Suastegui
- Baylor University Medical Center, Baylor Scott and White, 3600 Gaston Ave, Wadley Tower Ste. 260, Dallas, TX, 75246, USA
| | - J Steven Burdick
- Baylor University Medical Center, Baylor Scott and White, 3600 Gaston Ave, Wadley Tower Ste. 260, Dallas, TX, 75246, USA
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93
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Hyun D, Park KB, Cho SK, Park HS, Shin SW, Choo SW, Do YS, Choo IW, Choi DW. Portal Vein Stenting for Delayed Jejunal Varix Bleeding Associated with Portal Venous Occlusion after Hepatobiliary and Pancreatic Surgery. Korean J Radiol 2017; 18:828-834. [PMID: 28860900 PMCID: PMC5552466 DOI: 10.3348/kjr.2017.18.5.828] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 01/08/2017] [Indexed: 12/14/2022] Open
Abstract
Objective The study aimed to describe portal stenting for postoperative portal occlusion with delayed (≥ 3 months) variceal bleeding in the afferent jejunal loop. Materials and Methods Eleven consecutive patients (age range, 2–79 years; eight men and three women) who underwent portal stenting between April 2009 and December 2015 were included in the study. Preoperative medical history and the postoperative clinical course were reviewed. Characteristics of portal occlusion and details of procedures were also investigated. Technical success, treatment efficacy (defined as disappearance of jejunal varix on follow-up CT), and clinical success were analyzed. Primary stent patency rate was plotted using the Kaplan-Meier method. Results All patients underwent hepatobiliary-pancreatic cancer surgery except two children with liver transplantation for biliary atresia. Portal occlusion was caused by benign postoperative change (n = 6) and local tumor recurrence (n = 5). Variceal bleeding occurred at 27 months (4 to 72 months) and portal stenting was performed at 37 months (4 to 121 months), on average, postoperatively. Technical success, treatment efficacy, and clinical success rates were 90.9, 100, and 81.8%, respectively. The primary patency rate of portal stent was 88.9% during the mean follow-up period of 9 months. Neither procedure-related complication nor mortality occurred. Conclusion Interventional portal stenting is an effective treatment for delayed jejunal variceal bleeding due to portal occlusion after hepatobiliary-pancreatic surgery.
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Affiliation(s)
- Dongho Hyun
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Kwang Bo Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Sung Ki Cho
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Hong Suk Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Sung Wook Shin
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Sung Wook Choo
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Young Soo Do
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - In Wook Choo
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Dong Wook Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
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Sokhandon F, Al-katib S, Bahoura L, Copelan A, George D, Scola D. Multidetector CT enterography of focal small bowel lesions: a radiological-pathological correlation. Abdom Radiol (NY) 2017; 42:1319-1341. [PMID: 27999885 DOI: 10.1007/s00261-016-1015-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Focal small bowel lesions present a diagnostic challenge for both the radiologist and gastroenterologist. Both the detection and characterization of small bowel masses have greatly improved with the advent of multidetector CT enterography (MD-CTE). As such, MD-CTE is increasingly utilized in the workup of occult gastrointestinal bleeding. In this article, we review the spectrum of focal small bowel masses with pathologic correlation. Adenocarcinoma, the most common primary small bowel malignancy, presents as a focal irregular mass occasionally with circumferential extension leading to obstruction. Small bowel carcinoid tumors most commonly arise in the ileum and are characterized by avid enhancement and marked desmoplastic response of metastatic lesions. Aneurysmal dilatation of small bowel is pathognomonic for lymphoma and secondary findings of lymphadenopathy and splenomegaly should be sought. Benign small bowel masses such as leiomyoma and adenoma may be responsible for occult gastrointestinal bleeding. However, primary vascular lesions of the small bowel remain the most common cause for occult small bowel gastrointestinal bleeding. The arterial phase of contrast obtained with CTE aids in recognition of the vascular nature of these lesions. Systemic conditions such as Peutz-Jeghers syndrome and Crohn's disease may be suggested by the presence of multiple small bowel lesions. Lastly, potential pitfalls such as ingested material should be considered when faced with focal small bowel masses.
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Gulamhusein AF, Kamath PS. The epidemiology and pathogenesis of gastrointestinal varices. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017. [DOI: 10.1016/j.tgie.2017.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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96
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Shim DJ, Shin JH, Ko GY, Kim Y, Han K, Gwon DI, Ko HK. Portal vein stent placement with or without varix embolization of jejunal variceal bleeding after hepatopancreatobiliary surgery. Acta Radiol 2017; 58:423-429. [PMID: 27307028 DOI: 10.1177/0284185116654329] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Extrahepatic portal hypertension after surgery involving the duodenum or jejunum might result in massive ectopic variceal bleeding. Purpose To report the results of portal vein stent placement with the addition of variceal embolization. Material and Methods Between January 2000 and June 2015, portal vein stent placement was attempted in 477 patients. Of these, 22 patients (age, 63 ± 10 years) with jejunal variceal bleeding caused by portal vein obstruction after surgery were included in this study. Computed tomography (CT) findings before and after treatment and the rates of technical and clinical success, complications, and clinical outcomes were retrospectively evaluated. Results Stent placement was successful in 19 of 22 patients. Additional variceal embolization was performed in five cases. Clinical success, defined as the cessation of bleeding without recurrence within 1 month, was achieved in 18 of 19 patients with technical success. One patient developed recurrent bleeding 4 days after stent placement and was successfully treated with additional variceal embolization. There were no procedure-related complications. A regression of the jejunal varices was noted in 14 of 19 patients on follow-up CT scans. During the follow-up period (258 days; range, 7-1196 days), stent occlusion and recurrent bleeding occurred in six and four patients, respectively, of the 19 patients who achieved technical success. Statistical analyses revealed no significant differences regarding stent patency between benign and malignant strictures. Conclusion Percutaneous, transhepatic, portal vein stent placement with or without jejunal variceal embolization appears to be a safe and effective treatment for jejunal variceal bleeding after surgery.
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Affiliation(s)
- Dong Jae Shim
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Gi-Young Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Yook Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Kichang Han
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Dong-Il Gwon
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Heung-Kyu Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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Bhagani S, Winters C, Moreea S. Duodenal variceal bleed: an unusual cause of upper gastrointestinal bleed and a difficult diagnosis to make. BMJ Case Rep 2017; 2017:bcr-2016-218669. [PMID: 28242804 PMCID: PMC5337649 DOI: 10.1136/bcr-2016-218669] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
We present a case of recurrent upper gastrointestinal (GI) bleeding in a man aged 57 years with primary biliary cholangitis who was ultimately diagnosed with an isolated duodenal variceal bleed, which was successfully treated with histoacryl glue injection. Duodenal varices are an uncommon presentation of portal hypertension and can result in significant GI bleeding with a high mortality. Diagnosis can be difficult and therapeutic options limited. Endoscopic variceal sclerotherapy with histoacryl glue provides an effective treatment, though endoscopists need to remain aware of and vigilant for the serious complications of this treatment option.
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Affiliation(s)
- Shradha Bhagani
- Department of Gastroenterology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Conchubhair Winters
- Department of Gastroenterology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Sulleman Moreea
- Department of Gastroenterology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
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Park SW, Cho E, Jun CH, Choi SK, Kim HS, Park CH, Rew JS, Cho SB, Kim HJ, Han M, Cho KM. Upper gastrointestinal ectopic variceal bleeding treated with various endoscopic modalities: Case reports and literature review. Medicine (Baltimore) 2017; 96:e5860. [PMID: 28072750 PMCID: PMC5228710 DOI: 10.1097/md.0000000000005860] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
RATIONALE Ectopic variceal bleeding is a rare (2-5%) but fatal gastrointestinal bleed in patients with portal hypertension. Patients with ectopic variceal bleeding manifest melena, hematochezia, or hematemesis, which require urgent managements. Definitive therapeutic modalities of ectopic varices are not yet standardized because of low incidence. Various therapeutic modalities have been applied on the basis of the experiences of experts or availability of facilities, with varying results. PATIENT CONCERNS We have encountered eight cases of gastrointestinal ectopic variceal bleeding in five patients in the last five years. DIAGNOSES All patients were diagnosed with liver cirrhosis presenting melena or hematemesis. INTERVENTIONS All patients were treated with various endoscopic modalities (endoscopic variceal obturation [EVO] with cyanoacrylate in five cases, endoscopic variceal band ligation (EVL) in two cases, hemoclipping in one case). OUTCOMES Satisfactory hemostasis was achieved without radiologic interventions in all cases. EVO and EVL each caused one case of portal biliopathy, and EVL induced ulcer bleeding in one case. LESSONS EVO generally accomplished better results of variceal obturations than EVL or hemoclipping, without serious adverse events. EVO may be an effective modality for control of ectopic variceal bleeding without radiologic intervention or surgery.
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Affiliation(s)
- Sang Woo Park
- Division of Gastroenterology, Department of Internal Medicine
| | - Eunae Cho
- Division of Gastroenterology, Department of Internal Medicine
| | - Chung Hwan Jun
- Division of Gastroenterology, Department of Internal Medicine
| | - Sung Kyu Choi
- Division of Gastroenterology, Department of Internal Medicine
| | - Hyun Soo Kim
- Division of Gastroenterology, Department of Internal Medicine
| | - Chang Hwan Park
- Division of Gastroenterology, Department of Internal Medicine
| | - Jong Sun Rew
- Division of Gastroenterology, Department of Internal Medicine
| | - Sung Bum Cho
- Division of Gastroenterology, Department of Internal Medicine
| | - Hee Joon Kim
- Department of Surgery, Chonnam National University Hospital, Gwangju, South Korea
| | - Mingui Han
- Division of Gastroenterology, Department of Internal Medicine
| | - Kyu Man Cho
- Division of Gastroenterology, Department of Internal Medicine
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Kim DH. A massive bleeding from a duodenal mass: what treatment option should be chosen? Intest Res 2017; 15:548-549. [PMID: 29142527 PMCID: PMC5683990 DOI: 10.5217/ir.2017.15.4.548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 09/04/2017] [Accepted: 09/04/2017] [Indexed: 11/08/2022] Open
Affiliation(s)
- Duk Hwan Kim
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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