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Solanki S, Jena SS, Das SAP, Yadav A, Mehta NN, Nundy S. Isolated ectopic jejunal varices in a patient with extrahepatic portal vein obstruction - A case report. Int J Surg Case Rep 2021; 86:106299. [PMID: 34419724 PMCID: PMC8379621 DOI: 10.1016/j.ijscr.2021.106299] [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: 06/28/2021] [Revised: 08/06/2021] [Accepted: 08/07/2021] [Indexed: 01/17/2023] Open
Abstract
Introduction and importance Among the various causes for lower gastrointestinal bleeding, ectopic varices constitute a small chunk. Though rare, these can pose a diagnostic challenge with recurrent bleed leading to multiple admission and blood transfusions. Case presentation A 41-year-old male presented to our department with multiple episodes of melena. On further evaluation with CT angiography, a diagnosis of extrahepatic portal vein obstruction with moderate splenomegaly and ectopic jejunal varix was made. He underwent splenectomy with resection of involved jejunal segment with side to side anastomosis. Clinical discussion The diagnosis of ectopic varices remains elusive in a large number of cases in view of the varied etiology. Various newer endoscopic and imaging modalities can play a diagnostic as well as therapeutic role but this also further complicates the management as there is a lack of substantial guidelines directing the treatment protocol. As a result, we have to resort to a case by case approach for the optimal management in these cases. Conclusion The main modality of management for bleeding ectopic varices is percutaneous or endoscopic. Surgery is reserved for refractory cases, with decompressive shunts combined with segmental resection of involved intestine being at the forefront of surgical options. Ectopic varices are an unusual cause of lower GI bleeding caused by porto-systemic collaterals. Ectopic varices most commonly occur at jejuno-ileum, but duodenal varices are more prone to bleed. The optimal management varies with each case due to paucity of treatment guidelines. Decompressive shunt with splenectomy and segmental resection of intestine effectively prevents rebleeding.
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Affiliation(s)
- Sanket Solanki
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, Delhi 110060, India.
| | - Suvendu Sekhar Jena
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, Delhi 110060, India
| | - Sri Aurobindo Prasad Das
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, Delhi 110060, India
| | - Amitabh Yadav
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, Delhi 110060, India
| | - Naimish N Mehta
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, Delhi 110060, India
| | - Samiran Nundy
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, Delhi 110060, India
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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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Yoon JK, Kim MD, Lee DY, Han SJ. Mesocaval Shunt Creation for Jejunal Variceal Bleeding with Chronic Portal Vein Thrombosis. Yonsei Med J 2018; 59:162-166. [PMID: 29214793 PMCID: PMC5725356 DOI: 10.3349/ymj.2018.59.1.162] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 07/21/2017] [Accepted: 07/26/2017] [Indexed: 01/27/2023] Open
Abstract
The creation of transjugular intrahepatic portosystemic shunt (TIPS) is a widely performed technique to relieve portal hypertension, and to manage recurrent variceal bleeding and refractory ascites in patients where medical and/or endoscopic treatments have failed. However, portosystemic shunt creation can be challenging in the presence of chronic portal vein occlusion. In this case report, we describe a minimally invasive endovascular mesocaval shunt creation with transsplenic approach for the management of recurrent variceal bleeding in a portal hypertension patient with intra- and extrahepatic portal vein occlusion.
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Affiliation(s)
- Ja Kyung Yoon
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
| | - Man Deuk Kim
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea.
| | - Do Yun Lee
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
| | - Seok Joo Han
- Department of Pediatric Surgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
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4
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Trans-splenic Access for Portal Venous Interventions in Children: Do Benefits Outweigh Risks? Cardiovasc Intervent Radiol 2017; 41:87-95. [PMID: 28741138 DOI: 10.1007/s00270-017-1756-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 07/19/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND The primary concern of trans-splenic access for portal interventions is the risk of life-threatening intraperitoneal bleeding. OBJECTIVE To review the clinical indications and efficacy and evaluate the risk factors for intraperitoneal bleeding during trans-splenic portal interventions in children. MATERIALS AND METHODS A retrospective review of consecutive patients who underwent trans-splenic portal interventions at a tertiary care pediatric institution between March 2011 and April 2017 was performed. Forty-four procedures were performed in 30 children with a median age of 5 (0.3-18) years. Clinical indications, technical success, procedural success, and incidence of complications were recorded. Potential risk factors for intraperitoneal bleeding were evaluated using Wilcoxon rank and Fisher's exact tests. RESULTS Trans-splenic access was 100% successful. In 35/44 (79%) procedures, the subsequent intervention was successful including recanalization of post-transplant portal vein occlusion in 10/13, embolization of bleeding Roux limb varices in 8/8, recanalization of chronic portal vein thrombosis in native liver in 7/13, splenoportography and manometry in 6/6, and occlusion of portosystemic shunts in 4/4 procedures. Intraperitoneal bleeding occurred during 12/44 (27%) procedures and was managed with analgesics, blood transfusion, and peritoneal drainage without the need for splenectomy or splenic artery embolization. Statistically significant correlation of bleeding was found with intraprocedural anticoagulation, but not with patient age, weight, platelet count, INR, ascites, splenic length, splenic venous pressure, vascular sheath size, or tract embolization technique. CONCLUSION Trans-splenic access is a useful technique for successful pediatric portal interventions. Although it entails a substantial risk of intraperitoneal bleeding, this can be managed conservatively.
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Shim DJ, Shin JH. Management of jejunal bleeding by jejunal variceal embolization and portal venous recanalization after pylorus-preserving pancreaticoduodenectomy. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2015. [DOI: 10.18528/gii1150002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Dong Jae Shim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Kang DH, Park JW, Jeon EY, Kim SE, Kim JH, Kwon YS, Park SA, Park CK. Successful Treatment of Bleeding Duodenal Varix by Percutaneous Transsplenic Embolization. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2015; 66:286-90. [PMID: 26586353 DOI: 10.4166/kjg.2015.66.5.286] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Variceal bleeding occurs primarily in the esophagus or stomach in patients with liver cirrhosis, but can also occur rarely in the duodenum. Duodenal variceal bleeding has a high mortality and poor prognosis due to heavy blood flow originating from the portal vein (PV) and the technical difficulty of hemostatic procedures. Treatments including endoscopic sclerotherapy, endoscopic ligations, endoscopic clipping and transjugular intrahepatic portosystemic shunt have been tried, with only moderate and variable success. A percutaneous transsplenic approach offers another way of accessing the PV. Here we report a case of successfully treated duodenal variceal bleeding by percutaneous transsplenic embolization.
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Affiliation(s)
- Dong Hun Kang
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Ji Won Park
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Eui Yong Jeon
- Department of Radiology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Sung Eun Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Jong Hyeok Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Young Seok Kwon
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Seung Ah Park
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Choong Kee Park
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
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Pulitano C, Rogan C, Sandroussi C, Verran D, McCaughan GW, Waugh R, Crawford M. Percutaneous Retroperitoneal Splenorenal Shunt for Symptomatic Portal Vein Thrombosis After Liver Transplantation. Am J Transplant 2015; 15:2261-4. [PMID: 25980940 DOI: 10.1111/ajt.13243] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 01/25/2015] [Accepted: 01/25/2015] [Indexed: 01/25/2023]
Abstract
Acute or recurrent bleeding from ectopic varices is a potentially life-threatening condition in rare patients with extrahepatic complete portal vein thrombosis (PVT) after liver transplantation (LT). In this setting, the role of interventional radiology is very limited and surgical shunts, in particular splenorenal shunts are usually used, despite the high associated mortality. We present the first reports of the clinical use of a new minimally invasive technique, percutaneous retroperitoneal splenorenal shunt (PRESS), in two LT recipients with life-threatening variceal hemorrhage secondary to PVT. Both patients had a successful PRESS using a transplenic approach with resolution of bleeding, avoiding the need for a potentially complicated laparotomy. The PRESS procedure is a useful addition to the interventional armamentarium that can be used in cases unsuitable for surgical shunt, and refractory to endoscopic management. In the future, this technique may be an alternative to surgical shunts as the standard procedure in patients with extra-hepatic PVT, just as the transjugular intrahepatic portosystemic shunt (TIPS) procedure has become for the management of portal hypertension in the absence of PVT. Longer-term follow-up will be needed to establish the long-term success of this procedure.
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Affiliation(s)
- C Pulitano
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Centenary Research Institute, University of Sydney, Camperdown, New South Wales, Australia
| | - C Rogan
- Radiology Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - C Sandroussi
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - D Verran
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - G W McCaughan
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Centenary Research Institute, University of Sydney, Camperdown, New South Wales, Australia
| | - R Waugh
- Radiology Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - M Crawford
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Hsu WF, Tsang YM, Teng CJ, Chung CS. Protein C deficiency related obscure gastrointestinal bleeding treated by enteroscopy and anticoagulant therapy. World J Gastroenterol 2015; 21:1024-1027. [PMID: 25624741 PMCID: PMC4299320 DOI: 10.3748/wjg.v21.i3.1024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Revised: 07/05/2014] [Accepted: 07/30/2014] [Indexed: 02/06/2023] Open
Abstract
Obscure gastrointestinal bleeding is an uncommonly encountered and difficult-to-treat clinical problem in gastroenterology, but advancements in endoscopic and radiologic imaging modalities allow for greater accuracy in diagnosing obscure gastrointestinal bleeding. Ectopic varices account for less than 5% of all variceal bleeding cases, and jejunal variceal bleeding due to extrahepatic portal hypertension is rare. We present a 47-year-old man suffering from obscure gastrointestinal bleeding. Computed tomography of the abdomen revealed multiple vascular tufts around the proximal jejunum but no evidence of cirrhosis, and a visible hypodense filling defect suggestive of thrombus was visible in the superior mesenteric vein. Enteroscopy revealed several serpiginous varices in the proximal jejunum. Serologic data disclosed protein C deficiency (33.6%). The patient was successfully treated by therapeutic balloon-assisted enteroscopy and long-term anticoagulant therapy, which is normally contraindicated in patients with gastrointestinal bleeding. Diagnostic modalities for obscure gastrointestinal bleeding, such as capsule endoscopy, computed tomography enterography, magnetic resonance enterography, and enteroscopy, were also reviewed in this article.
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Chu HH, Kim HC, Hur S, Jae HJ, Chung JW. Percutaneous transhepatic portal vein stent-graft placement and jejunal varices embolization after hepaticojejunostomy. GASTROINTESTINAL INTERVENTION 2014. [DOI: 10.1016/j.gii.2013.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ahn DW, Jeong JB. Jejunal varices causing recurrent obscure gastrointestinal hemorrhage. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2014; 63:191-193. [PMID: 24783319 DOI: 10.4166/kjg.2014.63.3.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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