Fatal hemorrhage from an arterio-portal-peritoneal fistula after percutaneous liver biopsy

Embolization of a giant arterioportal fistula requiring multiple Amplatzer vascular plugs

Arterioportal fistulas (APFs) are rare vascular communications between the mesenteric arterial tree and the portal vein. The causes and presentations of this entity are varied. APFs related to tumor, infection, and trauma have been described. Patients may be asymptomatic or present with hemobilia, portal hypertension, or mesenteric steal syndrome. Small APFs require no intervention, with treatment indicated for large or symptomatic APFs. The treatment has shifted from surgical ligation or hepatic resection to an endovascular-first approach. We describe an endovascular treatment option for the management of an acquired extrahepatic (type 2) APF and present a review of the literature.

Gastric variceal bleeding caused by an intrahepatic arterioportal fistula that formed after liver biopsy: a case report and review of the literature

An intrahepatic arterioportal fistula is a rare cause of portal hypertension and variceal bleeding. We report on a patient with an intrahepatic arterioportal fistula following liver biopsy who was successfully treated by hepatectomy after unsuccessful arterial embolization. We also review the literature on symptomatic intrahepatic arterioportal fistulas after liver biopsy. A 48-year-old male with bleeding gastric varices and hepatitis B virus-associated liver cirrhosis was transferred to our hospital; this patient previously underwent percutaneous liver biopsies 3 and 6 years ago. Abdominal examination revealed a bruit over the liver, tenderness in the right upper quadrant, and splenomegaly. Ultrasonographic examination, computed tomography, and angiography confirmed an arterioportal fistula between the right hepatic artery and the right portal vein with portal hypertension. After admission, the patient suffered a large hematemesis and developed shock. He was treated with emergency transarterial embolization using microcoils. Since some collateral vessels bypassed the obstructive coils and still fed the fistulous area, embolization was performed again. Despite the second embolization, the collateral vessels could not be completely controlled. Radical treatment involving resection of his right hepatic lobe was performed. For nearly 6 years postoperatively, this patient has had no further episodes of variceal bleeding.

Nonoperative management of iatrogenic lesions of celiac branches by using transcatheter arterial embolization

We present our experience in the nonoperative management of iatrogenic lesions of celiac branches by using transcatheter arterial embolization. We treated 6 pseudoaneurysms (5 intrahepatic and 1 of the gastroduodenal artery), 6 vessel lacerations (1 common hepatic artery, 1 right hepatic artery, 1 gastroduodenal artery, 2 pancreatoduodenal, 1 polar intrasplenic artery), 1 arterioportal fistula, and 1 arteriobiliary fistula; all the bleeding lesions were secondary to surgical, endoscopic, or interventional radiologic procedures.

Use of fibrin sealant to reduce bleeding after needle liver biopsy in an anticoagulated canine model: work in progress

PURPOSE

Needle biopsy of the liver is a common diagnostic procedure. Although relatively safe, bleeding remains a potential complication and may occur more frequently in patients with coagulopathy. The purpose of this study was to evaluate the utility of a fibrin sealant in preventing bleeding after a 15-gauge needle biopsy of the liver in a canine model heparinized to simulate coagulopathy.

MATERIALS AND METHODS

Fibrin sealant was delivered to biopsy tract sites in eight dogs anticoagulated with heparin (activated clotting time 387 seconds +/- 94) using the same sheath system that was employed to obtain the biopsy specimen.

RESULTS

The results demonstrated complete hemostasis in the sealant-plugged tracts as compared to controls. Continuous bleeding was observed in none of the fibrin sealant-treated sites, compared with all of the control biopsy sites (P = .0078).

CONCLUSION

These results demonstrate the high degree of efficacy of fibrin sealant delivered through a sheath system in plugging liver biopsy tracts and eliminating bleeding in a severely coagulopathic animal model. This indicates that fibrin sealant use in cutting needle biopsies can reduce major and minor complications associated with the procedure.

Formation of a fatal arterioportal fistula following needle liver biopsy in a child with a living-related liver transplant: report of a case

A 2 1/2-year-old girl underwent a living-related liver transplantation for biliary atresia, following which four percutaneous liver biopsies were performed uneventfully during her hospital stay for the evaluation of recurrent rejection. Her condition improved without any complications, and she was discharged from hospital in a stable condition on postoperative day (POD) 51. However, 3 months later she was readmitted with marked ascites and a moderate elevation of her liver function tests. A color Doppler ultrasound (US) confirmed hepatofugal portal blood flow, and selective celiac arteriography demonstrated an intrahepatic arterioportal (A-P) fistula. An attempt to embolize the fistula failed and a surgical approach was attempted without success. The patient died from irreversible liver failure on POD 152. A review of the previous histologic analyses revealed that arterial components were present in the fourth biopsy specimen; for this reason it was hypothesized that this procedure may have led to the development of the A-P fistula.

Study of Helicobacter pylori colonization of patches of heterotopic gastric mucosa (HGM) at the upper esophagus

Helicobacter pylori (HP), known to cause active chronic gastritis, has primarily been found in gastric-type mucosa. Even in the duodenum, the organism was detected in islands of metaplastic gastric mucosa. HP has also been found in gastric metaplasia of Barrett's esophagus in 15-50%. The aim of our study was to determine: (1) the frequency with which HP is found on histopathological sections of heterotopic gastric mucosa (HGM) patch(es) at the upper esophagus, as compared to that of the stomach proper, and (2) the histopathological significance of infection in the HGM patches. From 63 patients with HGM patches at the upper esophagus, 48 patients were found to have concurrent adequate specimen from the stomach for modified Steiner's stain. In 22 patients (45.8%), pair sections from HGM and stomach were negative for HP. Of 26 patients (54.1%) HP-positive on sections from the antrum and/or body (both in 21 cases) nine patients (18.7%) demonstrated HP in the HGM patches. Whereas focal acute inflammatory changes on the H&E section of HGM was present in six patients, HP was detected in HGM only in one. Chronic inflammatory cell infiltration was detected in all nine HP-positive HGM patches and in 37 of 39 HP-negative patches. A mixed acute and chronic inflammatory cell infiltration was found in five of these 37 patients. Our data demonstrate that HP infection of HGM patches at the upper esophagus is part of the HP gastritis and an independent colonization of HGM patches without gastric infection does not occur.(ABSTRACT TRUNCATED AT 250 WORDS)

Nutritional support in inflammatory bowel disease: current status and future directions

Malnutrition is a frequent occurrence in patients with acute inflammatory bowel disease. Total nutritional support provided either parentally (TPN) or enterally (TEN) has been advocated not only as an adjunct for improving nutrition but also as primary therapy. For patients with acute Crohn's disease, short-term rates of remission after TEN are equivalent to TPN. Coupled with certain advantages when compared with TPN, including simpler administration, fewer side effects, and preservation of the intestinal mucosal barrier, TEN may therefore be the preferred route for nutrient delivery. Controlled trials indicate equivalent or superior efficacy when enteral polymeric diets are compared with elemental diets for inducing remission in acute Crohn's disease. Moreover, when provided as an elemental diet, TEN is as effective as corticosteroids for achieving remission in acute Crohn's disease, but corticosteroids appear to be more effective than polymeric diets. Although the provision of nutritional support rather than bowel rest is the major factor contributing to symptomatic improvement, the optimal nutrient composition and the precise mechanisms whereby nutritional support achieves clinical remission remain to be clarified. In contrast to Crohn's disease, nutritional support is not effective for achieving remission in patients with ulcerative colitis. Thus, enteral nutritional support is an effective therapy for the short-term management of acute Crohn's disease. Whether long-term remission is equivalent to treatment with drugs or surgery requires prospective evaluation. Future avenues of investigation also include defining the optimal nutrient composition and the underlying mechanisms that achieve maximal nutritional repletion, promote mucosal cell renewal, and potentially directly retard production of inflammatory mediators.

Incidence of ultrasound-detected intrahepatic hematomas due to Tru-cut needle liver biopsy

This is a prospective study in which 120 patients with diffuse liver disease undergoing liver biopsy were followed by serial ultrasounds to determine the incidence of postbiopsy intrahepatic hematoma formation. Forty-five of the patients had a blind biopsy, while the remaining 75 patients had a biopsy performed during laparoscopy. In both groups a 2.0-mm Tru-cut needle was employed. The overall incidence of postbiopsy hematoma formation was 18.3%, with approximately the same results occurring in blind biopsy patients (20%) and laparoscopy-guided biopsy patients (17%). Only two patients had significant pain associated with the hematoma formation (one from each group), one of whom had evidence of intraperitoneal bleed and rebleed. Our results suggest that postbiopsy asymptomatic hematomas occur more frequently than had been generally thought and that laparoscopy-guided biopsy is not safer than blind biopsy.