Trans-anastomotic porto-portal varices in patients with gastrointestinal haemorrhage

Ectopic varices: anatomical features for surgeons and interventional radiologists

Ectopic varices are defined as dilated portosystemic collateral veins located in unusual sites, other than the gastroesophageal region. They develop secondary to portal hypertension, surgical procedures, anomalies in venous outflow, or abdominal vascular thrombosis and may be familial. Ectopic varices represent a clinical challenge because they are difficult to localize. Missing or misinterpreting these lesions can have serious consequences, and treatment options are unclear. Ectopic varices may be detected during panendoscopy, enteroscopy, endoscopic ultrasound, wireless capsule endoscopy, diagnostic angiography, multislice helical computed tomography, magnetic resonance angiography, color Doppler flow imaging, laparotomy, laparoscopy and occasionally during autopsy. They can be an important cause of bleeding and hepatic encephalopathy, so radiologists must effectively identify them to assist in making therapeutic decisions. Knowledge of the anatomy and course of these unusual portosystemic collaterals is also important for interventional radiologists and surgeons as it helps avoid inadvertent vascular damage during invasive procedures. In this article, we explore the parts of the gastrointestinal tract and organs that may be involved in ectopic varices. Literature search was conducted in the MedLine database on the PubMed platform.

Spectrum of hepatofugal collateral pathways in portal hypertension: an illustrated radiological review

The purpose of this article is to describe the various portosystemic collateral pathways pertinent to portal hypertension on multi-detector row computed tomography (MDCT) and their clinical relevance, with special emphasis on the uncommon ones. The knowledge and understanding of the various patterns of portosystemic collateral channels has important implications both for the clinician and the interventionist. MDCT with its advanced post processing capabilities can exquisitely demonstrate these vascular pathways to help in therapeutic decision making.

Teaching points

• Portosystemic collaterals are an important cause of bleeding and hepatic encephalopathy.

• Radiologists should be familiar with the imaging findings to effectively identify them.

• Pre-operative knowledge of portosystemic collaterals is essential to avoid inadvertent vascular injury.

Ectopic varices in the gastrointestinal tract: an analysis of 37 cases

AIM: To investigate the incidence and causes of ectopic varices (EV) in the gastrointestinal tract and to analyze the relationship between EV and portal hypertension (PH).

METHODS: The clinical data for 37 patients with EV in the gastrointestinal tract were retrospectively analyzed. Of these patients, 26 were diagnosed by endoscopic examination, 10 during transjugular intrahepatic portosystemic stent shunt (TIPSS) procedures, and one by percutaneous transhepatic inferior mesenteric venography. The diagnosis of PH was based upon the finding of portal vein dilatation in patients with hepatic cirrhosis (HC) and extrahepatic portal vein obstruction (EPVO) in patients without cirrhosis. Portal pressure was measured directly in patients who underwent TIPSS.

RESULTS: Patients with EV in the gastrointestinal tract were infrequently seen, representing 0.09% (26/28 967) of all patients undergoing endoscopic examination. Of all 37 cases of EV in the gastrointestinal tract, 6 occurred in the duodenum, 11 in the small intestine, 4 in the colon, and 16 in the anorectal region. In patients undergoing TIPSS, portal pressure ranged between 3.18 and 6.13 kPa, with a mean value of 4.07 kPa ± 0.92 kPa. The etiology of PH was HC in 26 cases and EPVO in 4 cases. In the remaining 7 cases, a specific cause had not been determined.

CONCLUSION: EV in the gastrointestinal tract is a rare condition, occurring most commonly in the duodenum, colon, and anorectal region. PH is the primary cause of EV, often resulting from HC and EPVO. Both EV and PH may be easily overlooked, and EV may occur in patients lacking the classic signs of PH.

Duodenal and jejunal varices due to superior mesenteric vein thrombosis presenting as a massive gastrointestinal tract bleeding: a case report

Duodenal and jejunal varices usually occur due to portal hypertension and are rare causes of gastrointestinal tract bleeding. We report the case of a patient with no clinically significant history of a coagulopathy disorder, cirrhosis, or portal hypertension who presented with duodenal and jejunal varices that resulted in lower gastrointestinal bleeding with superior mesenteric vein thrombosis. Mesenteric angiography revealed superior mesenteric vein thrombosis and varices at the fourth part of the duodenum and the proximal jejunum draining into the main portal vein, but no active bleeding source was recognized. The patient was hemodynamically unstable. Emergency laparotomy was performed and revealed duodenal and jejunal varices, with occlusion of the superior mesenteric vein. Partial resection of the duodenum and jejunum and end-to-end anastomosis were performed. After surgery, the patient was hemodynamically stable with no recurrence of bleeding.

Chronic portal vein thrombosis: transcapsular hepatic collateral vessels and communicating ectopic varices

PURPOSE

To assess patients with chronic portal vein thrombosis (PVT) with respect to transcapsular collateral veins, the communication between these veins and ectopic varices, and the cause of PVT.

MATERIALS AND METHODS

This study was approved by the institutional review committees, and written informed consent was obtained. From November 2003 to March 2008, 145 consecutive patients with chronic PVT due to a variety of causes were assessed for transcapsular collaterals and ectopic varices with ultrasonography (US). Analysis of contingency tables was performed with the Fisher exact test.

RESULTS

Transcapsular collaterals were detected in 15 (10.3%) of 145 patients with chronic PVT. They were restricted to patients with a history of hepatobilary surgery, severe pancreatitis, or abdominal surgery (n = 21) and were not detected in patients with liver cirrhosis, systemic coagulopathy, extrahepatic malignancy, idiopathic PVT, chronic pancreatitis, or infectious or inflammatory diseases (n = 124) (P < .001). Ectopic varices were infrequent in 70 patients with liver cirrhosis (n = 2, 3%) but were common in 14 patients with PVT after hepatobiliary surgery (n = 9, 64%) (P < .001, odds ratio = 21.4). Direct communication between transcapsular collaterals and ectopic varices was visible in all nine patients in this cohort. In eight of these patients, ectopic varices were found to be the bleeding source in gastrointestinal hemorrhage.

CONCLUSION

Transcapsular collaterals frequently occur in patients with chronic PVT due to hepatobilary surgery or necrotizing pancreatitis. They are associated with ectopic varices; therefore, awareness of transcapsular collaterals in this patient subgroup will help to localize ectopic varices as potential bleeding source.

Updates in the pathogenesis, diagnosis and management of ectopic varices

Ectopic varices (EcV) comprise large portosystemic venous collaterals located anywhere other than the gastro-oesophageal region. No large series or randomized-controlled trials address this subject, and therefore its management is based on available expertise and facilities, and may require a multidisciplinary team approach. EcV are common findings during endoscopy in portal hypertensive patients and their bleeding accounts for only 1–5% of all variceal bleeding. EcV develop secondary to portal hypertension (PHT), surgical procedures, anomalies in venous outflow, or abdominal vascular thrombosis and may be familial in origin. Bleeding EcV may present with anaemia, shock, haematemesis, melaena or haematochezia and should be considered in patients with PHT and gastrointestinal bleeding or anaemia of obscure origin. EcV may be discovered during panendoscopy, enteroscopy, endoscopic ultrasound, wireless capsule endoscopy, diagnostic angiography, multislice helical computed tomography, magnetic resonance angiography, colour Doppler-flow imaging, laparotomy, laparoscopy and occasionally during autopsy. Patients with suspected EcV bleeding need immediate assessment, resuscitation, haemodynamic stabilization and referral to specialist centres. Management of EcV involves medical, endoscopic, interventional radiological and surgical modalities depending on patients’ condition, site of varices, available expertise and patients’ subsequent management plan.