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Wu R, Kokabi N, Adler JM, Bhave AD, Morris CS, Saad WE, Majdalany DS, Majdalany BS. Paradoxical Cerebral Embolization during Transjugular Intrahepatic Portosystemic Shunt Creation and Variceal Sclerotherapy. Semin Intervent Radiol 2024; 41:220-225. [PMID: 38993595 PMCID: PMC11236452 DOI: 10.1055/s-0044-1786539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Affiliation(s)
- Richard Wu
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Nima Kokabi
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Jonah M. Adler
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Anant D. Bhave
- Division of Interventional Radiology, Department of Radiology, University of Vermont Medical Center, Burlington, Vermont
| | - Christopher S. Morris
- Division of Interventional Radiology, Department of Radiology, University of Vermont Medical Center, Burlington, Vermont
| | - Wael E. Saad
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Utah Hospital, Salt Lake City, Utah
| | | | - Bill S. Majdalany
- Division of Interventional Radiology, Department of Radiology, University of Vermont Medical Center, Burlington, Vermont
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Petiunin O, Shevchenko R, Brek O, Kolomenskyi O. Clinical classification of liver cirrhosis - a way to plan individual definitive treatment. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2024; 77:160-165. [PMID: 38431821 DOI: 10.36740/wlek202401120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
OBJECTIVE Aim: To develop clinical classification of liver cirrhosis, which can aid individualization and planning definitive treatment for this group of patients. PATIENTS AND METHODS Materials and Methods: Computerized search of the literature was performed via PubMed using the following medical subject headings or keywords: "liver", "cirrhosis" and "classification"; or "liver", "cirrhosis" and "complications"; or "liver", "cirrhosis" and "treatment"; or "portal" ", "hypertension" and "complications". Articles were independently evaluated by each author, the etiological, morphological and current clinical classifications of LC were analyzed, their advantages and disadvantages identified, and after discussion classification of LC was developed by consensus. CONCLUSION Conclusions: The developed clinical classification of liver cirrhosis will facilitate the planning of therapeutic tactics for each patient, allow to personalize the treatment of patients with this pathology.
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Affiliation(s)
| | | | - Ostap Brek
- KHARKIV NATIONAL MEDICAL UNIVERSITY, KHARKIV, UKRAINE
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Madhusudhan KS, Sharma S, Srivastava DN. Percutaneous radiological interventions of the portal vein: a comprehensive review. Acta Radiol 2023; 64:441-455. [PMID: 35187977 DOI: 10.1177/02841851221080554] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The portal vein is the largest vessel supplying the liver. A number of radiological interventions are performed through the portal vein, namely for primary pathologies of the portal vein, for inducing liver hypertrophy or to treat the sequelae of portal hypertension among others. The routes used include direct transhepatic, transjugular, and, uncommonly, trans-splenic and through subcutaneous varices. Portal vein embolization and transjugular intrahepatic portosystemic shunt are among the most common portal vein interventions that are performed to induce hypertrophy of the future liver remnant and to treat complications of portal hypertension, respectively. Other interventions include transhepatic obliteration of varices and shunts, portal vein thrombolysis, portal vein recanalization, pancreatic islet cell transplantation, and embolization of portal vein injuries. We present a detailed illustrative review of the various radiological portal vein interventions.
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Affiliation(s)
- Kumble Seetharama Madhusudhan
- Department of Radiodiagnosis and Interventional Radiology, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Sharma
- Department of Radiodiagnosis and Interventional Radiology, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Deep Narayan Srivastava
- Department of Radiodiagnosis and Interventional Radiology, 28730All India Institute of Medical Sciences, New Delhi, India
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Chooklin SM, Chuklin SS. Esophageal and stomach varices: physiological and anatomical features of formation. KLINICHESKAIA KHIRURGIIA 2022. [DOI: 10.26779/2522-1396.2022.7-8.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Esophageal and stomach varices: physiological and anatomical features of formation
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Lim WX, Lin AN, Cheng YF, Lee SY, Hsu HW, Chen CL, Chang WC, Yu CY, Tsang LLC, Chuang YH, Ou HY. Portosystemic Shunt in Pediatric Living Donor Liver Transplant. Transplant Proc 2022; 54:403-405. [PMID: 35022136 DOI: 10.1016/j.transproceed.2021.09.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 09/28/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND To evaluate the significance of portosystemic shunts and associated long-term outcomes in living donor liver transplant (LDLT) among pediatric patients. METHODS Retrospective review of 121 pediatric patients who underwent LDLT between May 1994 and December 2015 at Taiwan Kaohsiung Chang Gung Memorial Hospital. Pre- and postoperative computed tomography images of the liver were reviewed, and portal vein complications were assessed. RESULTS Ninety-seven pediatric patients were included in the study, and 70 had portosystemic shunts before transplant. Thirty-three patients have portal systemic shunt (PSS) 6 months after transplant (mean [SD] shunt size, 4.59 [1.98] mm). Thirty-seven patients' portosystemic shunts closed spontaneously (mean [SD] shunt size, 3.14 [1.06] mm). Smaller PSSs tend to close spontaneously with a cutoff point of 3.35 mm by receiver operating characteristic curve (P = .01). Patients with PSS have more portal vein complications than those without PSS (44.3% vs 11.1%, P = .02). Among PSS recipients, patients with portal vein complications tend to have larger PSS size (mean [SD], 4.14 [1.96] mm vs 3.59 [1.48] mm), although the difference is not statistically significant (P = .19). CONCLUSIONS In pediatric patients, preoperative portosystemic shunts are significantly correlated with portal venous complications, some of which require minimal interventions after LDLT with good outcomes. Shunts larger than 3.35 mm tend to persist after transplant with increased portal venous complications.
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Affiliation(s)
- Wei-Xiong Lim
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - An-Ni Lin
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Fan Cheng
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Sieh-Yang Lee
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsien-Wen Hsu
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chao-Long Chen
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wan-Ching Chang
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chun-Yen Yu
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Leo Leung-Chit Tsang
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yi-Hsuan Chuang
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsin-You Ou
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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Wongjarupong N, Said HS, Huynh RK, Golzarian J, Lim N. Hemoperitoneum From Bleeding Intra-Abdominal Varices: A Rare, Life-Threatening Cause of Abdominal Pain in a Patient With Cirrhosis. Cureus 2021; 13:e18955. [PMID: 34815901 PMCID: PMC8605961 DOI: 10.7759/cureus.18955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2021] [Indexed: 11/05/2022] Open
Abstract
We report the case of a 54-year-old male with alcoholic cirrhosis who presented several times to the emergency department (ED) with right upper quadrant abdominal pain. Ten days after his initial presentation, the patient represented with hypotension and anemia. An abdominal CT angiogram identified hemorrhage from an ectopic varix successfully treated with emergent glue embolization of mesenteric, omental, and periumbilical varices. Intraperitoneal bleeding from ectopic varices in cirrhosis patients is a rare, life-threatening condition. Consideration and recognition of ectopic variceal hemorrhage in patients with cirrhosis can facilitate prompt life-saving treatment in a population susceptible to significant morbidity and mortality.
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Affiliation(s)
- Nicha Wongjarupong
- Internal Medicine, University of Minnesota, Minneapolis, USA.,Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, USA
| | - Hamdi S Said
- Gastroenterology and Hepatology, University of Minnesota, Minneapolis, USA
| | - Richie K Huynh
- Medicine, M Health Fairview Woodwinds Hospital, Woodbury, USA
| | - Jafar Golzarian
- Interventional Radiology, University of Minnesota, Minneapolis, USA
| | - Nicholas Lim
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, USA
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Chirapongsathorn S, Manatsathit W, Farrell A, Suksamai A. Safety and efficacy of endoscopic cyanoacrylate injection in the management of gastric varices: A systematic review and meta-analysis. JGH Open 2021; 5:1047-1055. [PMID: 34584974 PMCID: PMC8454477 DOI: 10.1002/jgh3.12629] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 07/14/2021] [Accepted: 07/19/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIM Bleeding from gastric varices is a catastrophic event and poses difficulty in management. The efficacy and safety of cyanoacrylate injection remain unclear. We performed a systematic review and meta-analysis to evaluate the effect of endoscopic cyanoacrylate injection in the management of gastric varices. METHODS We conducted a comprehensive search of MEDLINE, Embase, Web of Science, Scopus databases, and Cochrane Database of Systematic Reviews through November 2020 and manually reviewed the literature. Trial-specific risk ratios (RRs) were estimated and pooled using random-effect model meta-analysis. RESULTS We included seven randomized controlled trials (six for secondary prophylaxis and one for primary prophylaxis) at low risk of bias in which 126 deaths were reported among 583 patients with gastric varices. All studies reported the use of N-butyl-2-cyanoacrylate glue. Cyanoacrylate use was associated with significantly lower all-cause mortality (RR, 0.59; 95% confidence interval [CI], 0.36-0.98; I2 = 41%) and rebleeding rate after hemostasis (RR, 0.49; 95% CI, 0.35-0.68, I2 = 0%) compared with any other treatment approach not involving cyanoacrylate. When cyanoacrylate was compared with each individual treatment approach (propranolol only, band ligation, sclerotherapy with alcohol or ethanolamine), data comprised sparse limited comparative conclusions. The use of cyanoacrylate injection was not associated with an increase in serious adverse events. The quality of evidence is moderate, graded down due to the small number of events and wide CIs. CONCLUSION The use of endoscopic cyanoacrylate injection therapy for gastric varices may be associated with lower all-cause mortality and better hemostasis compared with other therapies.
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Affiliation(s)
- Sakkarin Chirapongsathorn
- Division of Gastroenterology and Hepatology, Department of MedicinePhramongkutklao Hospital, College of Medicine, Royal Thai ArmyBangkokThailand
| | - Wuttiporn Manatsathit
- Department of Gastroenterology and HepatologyUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Ann Farrell
- Mayo Clinic LibrariesMayo ClinicRochesterMinnesotaUSA
| | - Anuchit Suksamai
- Division of Gastroenterology and Hepatology, Department of MedicinePhramongkutklao Hospital, College of Medicine, Royal Thai ArmyBangkokThailand
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Nardelli S, Riggio O, Turco L, Gioia S, Puzzono M, Bianchini M, Ridola L, Aprile F, Gitto S, Pelle G, Di Martino M, Marzocchi G, Caporali C, Spagnoli A, Di Rocco A, Schepis F. Relevance of Spontaneous Portosystemic Shunts Detected with CT in Patients with Cirrhosis. Radiology 2021; 299:133-140. [PMID: 33529134 DOI: 10.1148/radiol.2021203051] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Cirrhosis leads to portal hypertension and to the consequent formation of spontaneous portosystemic shunts (SPSSs), leading to complications related to the diversion of portal blood into the systemic circulation, which is called portosystemic shunt syndrome. Purpose To investigate the characteristics of patients with cirrhosis and an SPSS and secondarily to assess the prognostic impact of SPSSs on portal hypertension-related complications and transplant-free survival. Materials and Methods A retrospective database review of patients with cirrhosis (observed from March 2015 to July 2019) was performed to identify patients with CT imaging and outcomes data. For each patient, clinical and biochemical data were collected, and the presence, types, and sizes of SPSSs were investigated with CT. Patients were followed for a mean of 27.5 months ± 22.8. Multivariable logistic analysis was used to identify the clinical characteristics associated with the presence of SPSSs (any size) and presence of SPSSs 1 cm or larger. Competitive risk analysis (Fine and Gray model) was used to identify the association between SPSSs and complications and mortality. Results Two hundred twenty-two patients with cirrhosis (157 male, 65 female; mean age, 62 years ± 12 [standard deviation]) were evaluated. An SPSS was found in 141 of 222 patients (63.5%), and 40 of 222 (18%) had a shunt diameter of at least 1 cm. At presentation, variables independently associated with the presence of SPSSs (any size) were portal vein thrombosis (odds ratio, 5.5; P = .008) and Child-Pugh class C (odds ratio, 3.0; P = .03). Previous hepatic encephalopathy (odds ratio, 4.4; P = .001) and portal vein thrombosis (odds ratio, 5.3; P = .001) were the only variables associated with SPSSs larger than 1 cm. Patients with SPSSs of any size had higher mortality (subdistribution hazard ratio, 1.9; P < .001) and higher frequency of hepatic encephalopathy (subdistribution hazard ratio, 2.3; P = .023), gastrointestinal bleeding (subdistribution hazard ratio, 2.9; P = .039), and portal vein thrombosis (subdistribution hazard ratio, 7.6; P = .005). Conclusion The presence of spontaneous portosystemic shunts on CT images in patients with cirrhosis was associated with higher mortality and complications, including portal vein thrombosis, hepatic encephalopathy, and gastrointestinal bleeding. © RSNA, 2021 See also the editorial by Reeder in this issue.
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Affiliation(s)
- Silvia Nardelli
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Oliviero Riggio
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Laura Turco
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Stefania Gioia
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Marta Puzzono
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Marcello Bianchini
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Lorenzo Ridola
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Francesca Aprile
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Stefano Gitto
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Giuseppe Pelle
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Michele Di Martino
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Guido Marzocchi
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Cristian Caporali
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Alessandra Spagnoli
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Arianna Di Rocco
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Filippo Schepis
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
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Park JW, Yoo JJ, Kim SG, Jeong SW, Jang JY, Lee SH, Kim HS, Lee JM, Shim JJ, Kim YD, Cheon GJ, Jun BG, Kim YS. Change in Portal Pressure and Clinical Outcome in Cirrhotic Patients with Gastric Varices after Plug-Assisted Retrograde Transvenous Obliteration. Gut Liver 2020; 14:783-791. [PMID: 32050751 PMCID: PMC7667928 DOI: 10.5009/gnl19293] [Citation(s) in RCA: 3] [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: 08/26/2019] [Revised: 10/28/2019] [Accepted: 11/05/2019] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Plug-assisted retrograde transvenous obliteration (PARTO) is widely used to manage gastric varices with a portosystemic shunt. It is not clear whether portal pressure and the incidence of complications increase after PARTO. The aim of this study was to determine the changes in portal pressure and the associated changes in liver function, ascites, hepatic encephalopathy, and especially esophageal varix (EV) after PARTO. Methods From March 2012 to February 2018, 54 patients who underwent PARTO were analyzed retrospectively. The parameters collected included liver function and episodes of cirrhotic complications before and at 1 and 6 months after PARTO. Results The analysis of 54 patients showed improvement in liver function during the 6-month follow-up period (Model for End-Stage Liver Disease score: change from 11.46±4.35 to 10.33±2.96, p=0.021). Among these 54 patients, 25 patients were evaluated for their hepatic venous pressure gradient (HVPG) before and after PARTO (change from 12.52±3.83 to 14.68±5.03 mm Hg; p<0.001). Twenty-five patients with portal pressure measured before and after PARTO were evaluated for risk factors affecting liver function improvement and EV deterioration. No factor associated with portal pressure was affected by liver function improvement. Post-PARTO portal pressure was a risk factor affecting EV deterioration (HVPG-post: odds ratio, 1.341; 95% confidence interval, 1.017 to 1.767; p=0.037). Conclusions The artificial blockade of the portosystemic shunt evidently leads to an increase in HVPG. Liver function was improved over the 6-month follow-up period. Portal pressure after PARTO was a significant risk factor for EV deterioration. Portal pressure measurement is helpful for predicting the patient's clinical outcome.
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Affiliation(s)
- Jae Woo Park
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jeong-Ju Yoo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Sang Gyune Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Soung Won Jeong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jae Young Jang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Sae Hwan Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Hong Soo Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Jae Myung Lee
- Department of Radiology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jong Joon Shim
- Department of Radiology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Young Don Kim
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Gab Jin Cheon
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Baek Gyu Jun
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Young Seok Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
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Philips CA, Ahamed R, Rajesh S, George T, Mohanan M, Augustine P. Beyond the scope and the glue: update on evaluation and management of gastric varices. BMC Gastroenterol 2020; 20:361. [PMID: 33126847 PMCID: PMC7602314 DOI: 10.1186/s12876-020-01513-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/23/2020] [Indexed: 02/08/2023] Open
Abstract
Gastric varices are encountered less frequently than esophageal varices. Nonetheless, gastric variceal bleeding is more severe and associated with worse outcomes. Conventionally, gastric varices have been described based on the location and extent and endoscopic treatments offered based on these descriptions. With improved understanding of portal hypertension and the dynamic physiology of collateral circulation, gastric variceal classification has been refined to include inflow and outflow based hemodynamic pathways. These have led to an improvement in the management of gastric variceal disease through newer modalities of treatment such as endoscopic ultrasound-guided glue-coiling combination therapy and the emergence of highly effective endovascular treatments such as shunt and variceal complex embolization with or without transjugular intrahepatic portosystemic shunt (TIPS) placement in patients who are deemed ‘difficult’ to manage the traditional way. Furthermore, the decisions regarding TIPS and additional endovascular procedures in patients with gastric variceal bleeding have changed after the emergence of ‘portal hypertension theories’ of proximity, throughput, and recruitment. The hemodynamic classification, grounded on novel theories and its cognizance, can help in identifying patients at baseline, in whom conventional treatment could fail. In this exhaustive review, we discuss the conventional and hemodynamic diagnosis of gastric varices concerning new classifications; explore and illustrate new ‘portal hypertension theories’ of gastric variceal disease and corresponding management and shed light on current evidence-based treatments through a ‘new’ algorithmic approach, established on hemodynamic physiology of gastric varices.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit and Monarch Liver Laboratory, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India.
| | - Rizwan Ahamed
- Gastroenterology and Advanced G.I Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
| | - Sasidharan Rajesh
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
| | - Tom George
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
| | - Meera Mohanan
- Anaesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
| | - Philip Augustine
- Gastroenterology and Advanced G.I Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
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11
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Nardelli S, Riggio O, Gioia S, Puzzono M, Pelle G, Ridola L. Spontaneous porto-systemic shunts in liver cirrhosis: Clinical and therapeutical aspects. World J Gastroenterol 2020; 26:1726-1732. [PMID: 32351289 PMCID: PMC7183860 DOI: 10.3748/wjg.v26.i15.1726] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 03/21/2020] [Accepted: 03/26/2020] [Indexed: 02/06/2023] Open
Abstract
Spontaneous porto-systemic shunts (SPSS) are frequent in liver cirrhosis and their prevalence increases as liver function deteriorates, probably as a consequence of worsening portal hypertension, but without achieving an effective protection against cirrhosis' complications. Several types of SPSS have been described in the literature, each one associated with different clinical manifestations. In particular, recurrent or persistent hepatic encephalopathy is more frequent in patients with splenorenal shunt, while the presence of gastric varices and consequently the incidence of variceal bleeding is more common in gastrorenal shunt. In the advanced stage, the presence of large SPSS can lead to the so called “portosystemic shunt syndrome”, characterized by a progressive deterioration of hepatic function, hepatic encephalopathy and, sometimes, portal vein thrombosis. The detection of SPSS in patients with liver cirrhosis is recommended in order to prevent or treat recurrent hepatic encephalopathy or variceal bleeding.
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Affiliation(s)
- Silvia Nardelli
- Department of Translational and Precision Medicine, “Sapienza” University of Rome, Rome 00185, Italy
| | - Oliviero Riggio
- Department of Translational and Precision Medicine, “Sapienza” University of Rome, Rome 00185, Italy
| | - Stefania Gioia
- Department of Translational and Precision Medicine, “Sapienza” University of Rome, Rome 00185, Italy
| | - Marta Puzzono
- Department of Translational and Precision Medicine, “Sapienza” University of Rome, Rome 00185, Italy
| | - Giuseppe Pelle
- Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina 04100, Italy
| | - Lorenzo Ridola
- Department of Translational and Precision Medicine, “Sapienza” University of Rome, Rome 00185, Italy
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12
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Lee EW, Shahrouki P, Alanis L, Ding P, Kee ST. Management Options for Gastric Variceal Hemorrhage. JAMA Surg 2020; 154:540-548. [PMID: 30942880 DOI: 10.1001/jamasurg.2019.0407] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Varices are one of the main clinical manifestations of cirrhosis and portal hypertension. Gastric varices are less common than esophageal varices but are often associated with poorer prognosis, mainly because of their higher propensity to bleed. Observations Currently, treatments used to control and manage gastric variceal bleeding include β-blockers, endoscopic injection sclerotherapy, endoscopic variceal ligation, endoscopic variceal obturation, shunt surgery, transjugular intrahepatic portosystemic shunts, balloon-occluded retrograde transvenous obliteration (BRTO), and modified BRTO. In the past few decades, Western (United States and Europe) interventional radiologists have preferred transjugular intrahepatic portosystemic shunts that aim to decompress the liver and reduce portal pressure. Conversely, Eastern radiologists (Japan and South Korea) have preferred BRTO that directly targets the gastric varices. Over the past 20 years, BRTO has evolved and procedure-related risks have decreased. Owing to its safety and efficiency in treating gastric varices, BRTO is now starting to gain popularity among Western interventional radiologists. In this review, we present a comprehensive literature review of current and emerging management options, including BRTO and modified BRTO, for the treatment of gastric varices in the setting of cirrhosis and portal hypertension. Conclusions and Relevance Balloon-occluded retrograde transvenous obliteration has emerged as a safe and effective alternative treatment option for gastric variceal hemorrhage. A proper training, evidence-based consensus and guideline, thorough preprocedural and postprocedural evaluation, and a multidisciplinary team approach with BRTO and modified BRTO are strongly recommended to ensure best patient care.
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Affiliation(s)
- Edward Wolfgang Lee
- Division of Interventional Radiology, Department of Radiology, University of California at Los Angeles Medical Center, David Geffen School of Medicine at University of California, Los Angeles.,Division of Liver and Pancreas Transplantation, Department of Surgery, University of California at Los Angeles Medical Center, David Geffen School of Medicine at University of California, Los Angeles
| | - Puja Shahrouki
- Division of Interventional Radiology, Department of Radiology, University of California at Los Angeles Medical Center, David Geffen School of Medicine at University of California, Los Angeles
| | - Lourdes Alanis
- Division of Interventional Radiology, Department of Radiology, University of California at Los Angeles Medical Center, David Geffen School of Medicine at University of California, Los Angeles
| | - Pengxu Ding
- Division of Interventional Radiology, Department of Radiology, University of California at Los Angeles Medical Center, David Geffen School of Medicine at University of California, Los Angeles
| | - Stephen T Kee
- Division of Interventional Radiology, Department of Radiology, University of California at Los Angeles Medical Center, David Geffen School of Medicine at University of California, Los Angeles
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McCarty TR, Bazarbashi AN, Hathorn KE, Thompson CC, Ryou M. Combination therapy versus monotherapy for EUS-guided management of gastric varices: A systematic review and meta-analysis. Endosc Ultrasound 2020; 9:6-15. [PMID: 31417066 PMCID: PMC7038733 DOI: 10.4103/eus.eus_37_19] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Cyanoacrylate (CYA), coil embolization, and/or combination thereof are available EUS-guided therapies for the treatment of gastric varices (GV). The primary aim of this study was to perform a structured systematic review and meta-analysis to evaluate the comparative effectiveness of EUS-guided interventions for the treatment of GV. Individualized search strategies were developed for PubMed, EMBASE, and Cochrane Library databases, from inception through November 2018 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This cumulative meta-analysis was performed using calculating pooled proportions. Measured outcomes included technical success, clinical success, adverse events, and rate of rebleeding or reintervention. Comparative subgroup analyses were performed for three treatment cohorts (EUS-guided CYA injection, EUS-guided coil embolization + CYA injection, and EUS-guided coil injection alone). Heterogeneity was assessed with I2 statistics. Eleven studies (n = 536 patients; 62.20% of males) were included. The mean age was 58.21 ± 4.15 years with an average follow-up of 12.93 ± 7.69 months. Overall technical success, clinical success, and adverse events for EUS treatments was 100% ([95% confidence interval [CI] 98–100]; I2 = 30.54%), 97% ([95% CI 92–100]; I2 = 59.99%), and 14% ([95% CI 6–23]; I2 = 82.23%), respectively. On subgroup analysis, EUS-guided CYA + coil embolization resulted in a better technical and clinical success compared to CYA alone (100% vs. 97%; P < 0.001 and 98% vs. 96%; P < 0.001) and coil embolization alone (99% vs. 97%; P < 0.001 and 96% vs. 90%; P < 0.001). CYA + coil embolization also resulted in lower adverse event rates compared to CYA alone (10% vs. 21%; P < 0.001), and comparable rates to coil embolization alone (10% vs. 3%; P = 0.057). EUS-guided treatment overall appears to be an effective and safe modality for GV. Among a variety of EUS-therapies available, EUS combination therapy with coil embolization + CYA injection appears to be a preferred strategy for the treatment of GV over EUS-based monotherapy.
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Affiliation(s)
- Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ahmad Najdat Bazarbashi
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kelly E Hathorn
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marvin Ryou
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Mukund A, Rangarh P, Shasthry SM, Patidar Y, Sarin SK. Salvage Balloon Occluded Retrograde Transvenous Obliteration for Gastric Variceal Bleed in Cirrhotic Patients With Endoscopic Failure to Control Bleed/Very Early Rebleed: Long-term Outcomes. J Clin Exp Hepatol 2020; 10:421-428. [PMID: 33029050 PMCID: PMC7527839 DOI: 10.1016/j.jceh.2020.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 04/09/2020] [Indexed: 12/12/2022] Open
Abstract
AIMS To analyze the outcomes of balloon occluded retrograde transvenous obliteration (BRTO) as salvage therapy in cirrhotic patients with gastric variceal bleed (GVB) after failed endotherapy or very early rebleeds. We assessed for technical/clinical success of BRTO and transplantation-free survival. MATERIAL AND METHODS Patients with GVB who underwent BRTO as salvage therapy (between 2011 and 2017) were analyzed. Rebleed rate, Child Pugh score (CTP), Model for end-stage liver disease (MELD) values were calculated at 1,6,12, and 24 months follow-up. RESULTS Fifty-two patients who underwent BRTO as salvage therapy were assessed for rebleed rate and transplantation-free survival. Technical success was 100% with rebleed rate being 1.9% (n = 1) and clinical success rate of 92.3% (n = 48) at 12-months follow-up and transplantation-free one-year survival of 90.4% (n = 47). Five patients (9.6%) failed to achieve one-year transplantation-free survival. Four patients died within 30 days; one rebleed, 3 (all Child C) progressive liver and multiorgan failure and one required liver transplantation (day 88) after BRTO. Thus, a total of 4 of 9 (44.4%) Child C patients failed to achieve one-year transplantation-free survival. Improvement in liver functions was noted in the rest with improved CTP, MELD scores, and albumin levels in the 12-month follow-up. Six of 52 (11.5%) developed new onset medically manageable ascites, whereas 7 of 52 (13.5%) had progression of esophageal varices at 12-months follow-up requiring prophylactic band ligation in follow-up. CONCLUSIONS Salvage BRTO is a safe and effective procedure for patients with acute GVB with failure to control bleed with endotherapy or very early rebleed after endotherapy. Salvage BRTO has good short/long-term outcomes with lower rebleed, higher survival, and improved liver disease severity.
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Affiliation(s)
- Amar Mukund
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India,Address for correspondence: Dr Amar Mukund, Additional Professor, Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.
| | - Pulkit Rangarh
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Saggere Muralikrishna Shasthry
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India,Address for correspondence: Dr Saggere Muralikrishna Shasthry, Associate Professor, Department of Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.
| | - Yashwant Patidar
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
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15
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Goldis A, Goldis R, Chirila TV. Biomaterials in Gastroenterology: A Critical Overview. ACTA ACUST UNITED AC 2019; 55:medicina55110734. [PMID: 31726779 PMCID: PMC6915447 DOI: 10.3390/medicina55110734] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 10/30/2019] [Accepted: 11/08/2019] [Indexed: 02/07/2023]
Abstract
In spite of the large diversity of diagnostic and interventional devices associated with gastrointestinal endoscopic procedures, there is little information on the impact of the biomaterials (metals, polymers) contained in these devices upon body tissues and, indirectly, upon the treatment outcomes. Other biomaterials for gastroenterology, such as adhesives and certain hemostatic agents, have been investigated to a greater extent, but the information is fragmentary. Much of this situation is due to the paucity of details disclosed by the manufacturers of the devices. Moreover, for most of the applications in the gastrointestinal (GI) tract, there are no studies available on the biocompatibility of the device materials when in intimate contact with mucosae and other components of the GI tract. We have summarized the current situation with a focus on aspects of biomaterials and biocompatibility related to the device materials and other agents, with an emphasis on the GI endoscopic procedures. Procedures and devices used for the control of bleeding, for polypectomy, in bariatrics, and for stenting are discussed, particularly dwelling upon the biomaterial-related features of each application. There are indications that research is progressing steadily in this field, and the establishment of the subdiscipline of "gastroenterologic biomaterials" is not merely a remote projection. Upon the completion of this article, the gastroenterologist should be able to understand the nature of biomaterials and to achieve a suitable and beneficial perception of their significance in gastroenterology. Likewise, the biomaterialist should become aware of the specific tasks that the biomaterials must fulfil when placed within the GI tract, and regard such applications as both a challenge and an incentive for progressing the research in this field.
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Affiliation(s)
- Adrian Goldis
- Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, 300041 Timisoara, Romania
- Correspondence:
| | | | - Traian V. Chirila
- Queensland Eye Institute, South Brisbane, QL 4101, Australia;
- Science & Engineering Faculty, Queensland University of Technology, Brisbane, QL 4000, Australia
- Faculty of Medicine, University of Queensland, Herston, QL 4029, Australia
- Australian Institute for Bioengineering and Nanotechnology, University of Queensland, St Lucia, 4072 QL, Australia
- Faculty of Science, University of Western Australia, Crawley, WA 6009, Australia
- University of Medicine, Pharmacy, Sciences and Technology, 540139 Targu Mures, Romania
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16
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Abstract
PURPOSE OF REVIEW There are no well-established guidelines for the management of gastric variceal bleeding. Endoscopic management of acute gastric variceal bleeding has been premised on the injection of sclerosants and synthetic glue. However, these therapies are associated with various complications including systemic embolization and recurrent bleeding. Recently, endoscopic ultrasound (EUS)-guided interventions including coil injection have emerged as promising modalities with high technical and clinical success rates and low rates of recurrence. RECENT FINDINGS In this review we discuss the classification, natural history, prognosis, and treatment options of gastric variceal. Discussion of treatment is further subdivided into primary and secondary prophylaxis and the management of acute gastric variceal bleeding with a focus on emerging endoscopic interventions. SUMMARY Cyanoacrylate injection may have a role in the primary and secondary prophylaxis of gastric variceal. Endoscopic band ligation should be considered for GOV1. EUS-guided injection of synthetic glues like cyanoacrylate is superior to direct injection. However, EUS-guided coil injections with or without cyanoacrylate should be considered first-line endoscopic treatment in all bleeding gastric variceal except for GOV1. Balloon retrograde transvenous obliteration (BRTO) and transjugular intrahepatic portosystemic shunts (TIPS) remain important interventional radiologic therapeutic options as primary therapy in centers without EUS expertise or as salvage therapy.
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Affiliation(s)
- Ahmad Najdat Bazarbashi
- Department of Medicine, Brigham and Women's Hospital, Division of Gastroenterology, Hepatology and Endoscopy, Boston, Massachusetts, USA
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17
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Endoscopic Ultrasound-Guided Coil Injection Therapy for Gastric Variceal Bleeding Not Amenable to Interventional Radiology-Guided Therapies. ACG Case Rep J 2019; 6:e00013. [PMID: 31598533 PMCID: PMC6657985 DOI: 10.14309/crj.0000000000000013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 12/07/2018] [Indexed: 12/13/2022] Open
Abstract
Gastric varices account for 10%–30% of all variceal bleeds and are associated with significant morbidity and mortality. Interventional radiology–guided therapies such as balloon-occluded retrograde transvenous obliteration and coil-assisted retrograde transvenous obliteration can provide hemostasis when traditional endoscopic treatments such as cyanoacrylate injection fail. However, their applicability in certain cases can be limited because of anatomical constraints. We describe the use of endoscopic ultrasound–guided coil and absorbable gelatin sponge injection for the treatment of bleeding gastric varices arising from pancreatitis-induced splenic vein thrombosis not amenable to interventional radiology–guided therapies.
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18
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Al-Khazraji A, Curry MP. The current knowledge about the therapeutic use of endoscopic sclerotherapy and endoscopic tissue adhesives in variceal bleeding. Expert Rev Gastroenterol Hepatol 2019; 13:893-897. [PMID: 31389265 DOI: 10.1080/17474124.2019.1652092] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: The most recent guidelines vary in their approach to the management of variceal bleeding especially with the use of endoscopic sclerotherapy (ES) and endoscopic tissue adhesive (ETA). This review highlights their clinical use for variceal bleeding from different guidelines perspectives. Areas covered: A comprehensive literature review of three major guidelines including the American Association for the Study of Liver Diseases (AASLD) 2017, United Kingdom (UK) guidelines 2015 and Baveno VI Consensus workshop guidelines in 2015 on the use of ES and ETA in variceal bleeding. Expert opinion: While endoscopic band ligation (EBL) completely replaced endoscopic sclerotherapy (ES) for esophageal varices. There is a valuable use of endoscopic sclerotherapy (ES) and endoscopic tissue adhesive (ETA) especially for patients with gastroesophageal varices (GOV2) and isolated gastric varices (IGV2). The current standard of care heading toward portosystemic shunting with Trans-jugular-Intrahepatic Portosystemic Shunt (TIPS) and balloon retrograde transvenous obliteration (BRTO). However, recent advancement in endoscopic ultrasound (EUS) allowing direct injection of sclerosant and tissue adhesive into the varix bringing promising results in achieving hemostasis and lowering the risk of complications. Also, ES and ETA have great clinical value in achieving hemostasis for isolated (ectopic) varices and stomal varices.
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Affiliation(s)
- Ahmed Al-Khazraji
- Department of Gastroenterology & Hepatology, Transplant Liver Center, Harvard School of Medicine, Beth Israel Deaconess Medical Center , Boston , MA , USA
| | - Michael P Curry
- Department of Gastroenterology & Hepatology, Transplant Liver Center, Harvard School of Medicine, Beth Israel Deaconess Medical Center , Boston , MA , USA
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Balloon Retrograde Transvenous Obliteration Versus Endoscopic Cyanoacrylate in Bleeding Gastric Varices: Comparison of Rebleeding and Mortality with Extended Follow-up. J Vasc Interv Radiol 2019; 30:187-194. [PMID: 30717949 DOI: 10.1016/j.jvir.2018.12.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 12/05/2018] [Accepted: 12/06/2018] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To assess short- and long-term mortality and rebleeding with endoscopic cyanoacrylate (EC) versus balloon-occluded retrograde transvenous obliteration (BRTO). MATERIALS AND METHODS A retrospective cohort comparison was conducted of 90 EC patients and 71 BRTO patients from 1997 through 2015 with portal hypertension who presented due to endoscopically confirmed bleeding cardiofundal gastric varices. Patients underwent either endoscopic intra-varix injection of 4-carbon-n-butyl-2-cyanoacrylate or sclerosis with sodium tetradecyl sulfate with balloon occlusion for primary variceal treatment. RESULTS Seventy-one BRTO patients and 90 EC patients, of whom 89% had cirrhosis and 35% were women, were included, with a respective average Model for End-Stage Liver Disease (MELD) score of 13.4 and 14.4, respectively. Mortality at 6 weeks was 14.4% for EC patients and 13.1% for BRTO patients (Kaplan-Meier/Wilcoxon, P = .85). No long-term mortality difference was observed (Cox hazard ratio [HR] = 0.89, P = .64). Also, 5.1% of EC patients and 3.5% of BRTO patients (Kaplan-Meier/Wilcoxon, P = .62) rebled at 6 weeks, but at 1 year, 22.0% of EC patients and 3.5% of BRTO patients had rebled (Kaplan-Meier/Wilcoxon, P < .01). Lower rates of long-term rebleeding were found with BRTO (Cox HR = 0.25, P = .03). No difference was seen in the rate of new portal hypertensive complications (Cox HR = 1.21, P = .464). However, 16/71 patients who underwent BRTO had simultaneous transjugular intrahepatic portosystemic shunt. Age, sex, MELD score, and presence of cirrhosis were the primary predictors of mortality. One death in the EC group and 5 deaths in the BRTO group were deemed to be procedurally related (chi-square, P = .088). CONCLUSIONS BRTO is associated with a lower rate of rebleeding but no change in mortality.
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Ishikawa T, Sasaki R, Nishimura T, Matsuda T, Maeda M, Iwamoto T, Saeki I, Hidaka I, Takami T, Sakaida I. Comparison of patients with hepatic encephalopathy and those with gastric varices before and after balloon-occluded retrograde transvenous obliteration. Hepatol Res 2018; 48:1020-1030. [PMID: 29882396 DOI: 10.1111/hepr.13199] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 05/15/2018] [Accepted: 05/23/2018] [Indexed: 12/13/2022]
Abstract
AIM To compare the clinical characteristics of patients with hepatic encephalopathy (HE) and those with gastric varices (GV) before and after balloon-occluded retrograde transvenous obliteration (BRTO). METHODS Eighty cirrhotic patients who underwent BRTO, including 42 men and 38 women, and whose mean age was 68 years, comprised the HE (n = 18) and GV (n = 62) groups. The patients' data before and 1 month after BRTO were analyzed. RESULTS Before BRTO, the groups did not differ in their portal flow volume (PFV) or hepatic venous pressure gradient (HVPG). The portal vein (PV) was narrower and the splenic vein (SpV) was wider in the HE group than in the GV group. The SpV flow was hepatofugal in 75.0% of HE patients and hepatopetal in 92.6% of GV patients. The Child-Pugh (CP) score of the HE group was significantly higher than that of the GV group pre-BRTO. After BRTO, the PFV and HVPG increases in the HE group equaled those in the GV group, and the PV dilation was similar in both groups. Conversely, the SpV was significantly contracted for HE patients, but significantly dilated for GV patients. Postoperatively, the SpV flow was hepatopetal in all patients. Compared to that in the GV group, the CP score decreased markedly in the HE group, and no significant increases in complications occurred post-BRTO for HE patients. CONCLUSIONS The HE patients showed distinct portal-splenic hemodynamics before and after BRTO. Balloon-occluded retrograde transvenous obliteration markedly improved hepatic function in the HE group compared with the GV group.
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Affiliation(s)
- Tsuyoshi Ishikawa
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Ryo Sasaki
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Tatsuro Nishimura
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Takashi Matsuda
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Masaki Maeda
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Takuya Iwamoto
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Issei Saeki
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Isao Hidaka
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Taro Takami
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Isao Sakaida
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, Ube, Japan
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21
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The Role of Therapeutic Endoscopy in Patients With Cirrhosis-Related Causes of Gastrointestinal Bleeding. Curr Gastroenterol Rep 2018; 20:31. [PMID: 29886513 DOI: 10.1007/s11894-018-0637-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW This article aims to review current therapeutic endoscopic treatments available for the management of gastrointestinal bleeding related to cirrhosis. RECENT FINDINGS Endoscopic band ligation is an effective treatment for primary prophylaxis, acute bleeding, and secondary prophylaxis of esophageal varices as well as for acute bleeding and secondary prophylaxis of select gastric varices. Sclerotherapy is a treatment option for acute bleeding and secondary prophylaxis of esophageal varices when band ligation is technically difficult. Cyanoacrylate glue injection is an effective treatment for acute bleeding of gastric and ectopic varices. Argon plasma coagulation is first-line and radiofrequency ablation is second-line treatment for chronic bleeding secondary to gastric antral vascular ectasia. There are a variety of endoscopic treatment modalities for cirrhosis-related gastrointestinal bleeding, and the appropriate therapy depends on the location of the bleed, history or presence of acute bleeding, and risk factors for intervention-related adverse events.
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22
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Abstract
Acute variceal bleeding is one of the most fatal complications of cirrhosis and is responsible for about one-third of cirrhosis-related deaths. Therefore, every effort should be made to emergently resuscitate the patients, start pharmacotherapy as soon as possible and do endoscopic therapy in a timely manner. Despite the recent advances in treatment, mortality rate is still high. We provide a comprehensive review of evaluation and management of variceal bleeding.
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Affiliation(s)
- Obada Tayyem
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Mohammad Bilal
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX.
| | - Ronald Samuel
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Sheharyar K Merwat
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX
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24
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Lupascu-Ursulescu C, Trofin AM, Zabara M, Vornicu A, Cadar R, Apopei O, Stefanescu G, Lupascu C. Bleeding from isolated gastric varices as complication of a mucinous cystic neoplasm of the pancreas: A case report. Medicine (Baltimore) 2017; 96:e8775. [PMID: 29381977 PMCID: PMC5708976 DOI: 10.1097/md.0000000000008775] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Bleeding from isolated gastric varices, though uncommon, may be life threatening and may occur as a consequence of splenic vein thrombosis by tumoral compression and subsequent left-sided portal hypertension. CASE OVERVIEW We report the case of a 37-year old woman, previously diagnosed with a benign pancreatic cyst, who presented with severe gastric variceal bleeding. DIAGNOSIS, THERAPEUTICS INTERVENTIONS, AND OUTCOMES Abdominal ultrasound (US) and computed-tomography (CT) revealed enlargement and changed morphology of the cystic tumor located on the body of the pancreas. Left-sided portal hypertension was disclosed resulting from splenic vein occlusion. Salvage left spleno-pancreatectomy with lymphadenectomy was undertaken with an excellent postoperative outcome. Histological analysis established the diagnosis of mucinous cystic neoplasm with foci of adenocarcinoma. CONCLUSION Surgical treatment proved to be the election one, leading to a steady hemostasis, removal of the lesion, positive diagnosis, and resolution of the varices. Imaging follow-up of pancreatic cyst should also assess vascular patency to identify the patient at risk for gastric bleeding and to select patients who benefits from surgical resection.
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Affiliation(s)
| | - Ana-Maria Trofin
- Department of Surgery, University of Medicine and Pharmacy “Grigore T. Popa”
| | | | | | | | - Oana Apopei
- Intensive Care Unit, “Sf. Spiridon” Hospital Iasi
| | - Gabriela Stefanescu
- Department of Gastroenterology and Hepatology, University of Medicine and Pharmacy “Grigore T. Popa” Iasi, Iasi, Romania
| | - Cristian Lupascu
- Department of Surgery, University of Medicine and Pharmacy “Grigore T. Popa”
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25
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Moyana TN, Macdonald DB, Martel G, Pyatibrat S, Lee G, Capitano M. Pancreatic Neuroendocrine Tumors Complicated by Sinistral Portal Hypertension: Insights into Pathogenesis. J Pancreat Cancer 2017; 3:71-77. [PMID: 30631846 DOI: 10.1089/pancan.2017.0017%' and 2*3*8=6*8 and 'emoy'!='emoy%] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024] Open
Abstract
Purpose: To investigate the association between pancreatic neuroendocrine tumors (panNETs) and sinistral portal hypertension (SPH) and provide insights into the pathogenesis. Methods: A retrospective review of panNETs was conducted from our institution for 12 years. Medical imaging findings were analyzed to determine any association with splenic vein thrombosis (SVT) at diagnosis. The cases were further selected based on the criteria for SPH, namely, (1) presence of SVT, (2) gastric varices, (3) patent portal vein, and (4) normal liver function tests. Results: There were 61 patients with panNETs and 8 (8/61) had SVT and gastric varices at diagnosis. Four (4/8) met the strict criteria for SPH while the other four had more conventional portal hypertension. The four with SPH had large tumors located in the tail with splenic vein invasion and three of four presented with bleeding gastric varices. All four patients underwent surgical resection. Mean follow-up was 8.5 years and the hematemesis never recurred. The other four patients (four of eight) with gastric varices had unresectable disease and all died after a mean survival of 29 months. Conclusion: PanNETs appear to be more commonly associated with SVT and SPH compared with other tumors. This could be related to their relatively indolent nature and their intrinsic vascularity. From a surgical viewpoint, the decision to operate depends on many factors including but not limited to the size/stage, grade, and functionality of the tumor and comorbidities. These considerations notwithstanding, the association between panNETs and SPH suggests that there is benefit in timely resection of panNETs located in the tail.
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Affiliation(s)
- Terence N Moyana
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - D Blair Macdonald
- Department of Medical Imaging, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Guillaume Martel
- Division of Hepatobiliary Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Sergey Pyatibrat
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Goo Lee
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Mario Capitano
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
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26
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Moyana TN, Macdonald DB, Martel G, Pyatibrat S, Lee G, Capitano M. Pancreatic Neuroendocrine Tumors Complicated by Sinistral Portal Hypertension: Insights into Pathogenesis. J Pancreat Cancer 2017; 3:71-77. [PMID: 30631846 DOI: 10.1089/pancan.2017.0017'||'] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024] Open
Abstract
Purpose: To investigate the association between pancreatic neuroendocrine tumors (panNETs) and sinistral portal hypertension (SPH) and provide insights into the pathogenesis. Methods: A retrospective review of panNETs was conducted from our institution for 12 years. Medical imaging findings were analyzed to determine any association with splenic vein thrombosis (SVT) at diagnosis. The cases were further selected based on the criteria for SPH, namely, (1) presence of SVT, (2) gastric varices, (3) patent portal vein, and (4) normal liver function tests. Results: There were 61 patients with panNETs and 8 (8/61) had SVT and gastric varices at diagnosis. Four (4/8) met the strict criteria for SPH while the other four had more conventional portal hypertension. The four with SPH had large tumors located in the tail with splenic vein invasion and three of four presented with bleeding gastric varices. All four patients underwent surgical resection. Mean follow-up was 8.5 years and the hematemesis never recurred. The other four patients (four of eight) with gastric varices had unresectable disease and all died after a mean survival of 29 months. Conclusion: PanNETs appear to be more commonly associated with SVT and SPH compared with other tumors. This could be related to their relatively indolent nature and their intrinsic vascularity. From a surgical viewpoint, the decision to operate depends on many factors including but not limited to the size/stage, grade, and functionality of the tumor and comorbidities. These considerations notwithstanding, the association between panNETs and SPH suggests that there is benefit in timely resection of panNETs located in the tail.
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Affiliation(s)
- Terence N Moyana
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - D Blair Macdonald
- Department of Medical Imaging, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Guillaume Martel
- Division of Hepatobiliary Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Sergey Pyatibrat
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Goo Lee
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Mario Capitano
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
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27
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Moyana TN, Macdonald DB, Martel G, Pyatibrat S, Lee G, Capitano M. Pancreatic Neuroendocrine Tumors Complicated by Sinistral Portal Hypertension: Insights into Pathogenesis. J Pancreat Cancer 2017. [PMID: 30631846 DOI: 10.1089/crpc.2017.0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Terence N. Moyana
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - D. Blair Macdonald
- Department of Medical Imaging, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Guillaume Martel
- Division of Hepatobiliary Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Sergey Pyatibrat
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Goo Lee
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Mario Capitano
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
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28
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Moyana TN, Macdonald DB, Martel G, Pyatibrat S, Lee G, Capitano M. Pancreatic Neuroendocrine Tumors Complicated by Sinistral Portal Hypertension: Insights into Pathogenesis. J Pancreat Cancer 2017; 3:71-77. [PMID: 30631846 DOI: 10.1089/pancan.2017.0017ml1uu1cg] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024] Open
Abstract
Purpose: To investigate the association between pancreatic neuroendocrine tumors (panNETs) and sinistral portal hypertension (SPH) and provide insights into the pathogenesis. Methods: A retrospective review of panNETs was conducted from our institution for 12 years. Medical imaging findings were analyzed to determine any association with splenic vein thrombosis (SVT) at diagnosis. The cases were further selected based on the criteria for SPH, namely, (1) presence of SVT, (2) gastric varices, (3) patent portal vein, and (4) normal liver function tests. Results: There were 61 patients with panNETs and 8 (8/61) had SVT and gastric varices at diagnosis. Four (4/8) met the strict criteria for SPH while the other four had more conventional portal hypertension. The four with SPH had large tumors located in the tail with splenic vein invasion and three of four presented with bleeding gastric varices. All four patients underwent surgical resection. Mean follow-up was 8.5 years and the hematemesis never recurred. The other four patients (four of eight) with gastric varices had unresectable disease and all died after a mean survival of 29 months. Conclusion: PanNETs appear to be more commonly associated with SVT and SPH compared with other tumors. This could be related to their relatively indolent nature and their intrinsic vascularity. From a surgical viewpoint, the decision to operate depends on many factors including but not limited to the size/stage, grade, and functionality of the tumor and comorbidities. These considerations notwithstanding, the association between panNETs and SPH suggests that there is benefit in timely resection of panNETs located in the tail.
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Affiliation(s)
- Terence N Moyana
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - D Blair Macdonald
- Department of Medical Imaging, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Guillaume Martel
- Division of Hepatobiliary Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Sergey Pyatibrat
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Goo Lee
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Mario Capitano
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
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29
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Moyana TN, Macdonald DB, Martel G, Pyatibrat S, Lee G, Capitano M. Pancreatic Neuroendocrine Tumors Complicated by Sinistral Portal Hypertension: Insights into Pathogenesis. J Pancreat Cancer 2017; 3:71-77. [PMID: 30631846 DOI: 10.1089/pancan.2017.0017" and 2*3*8=6*8 and "03xf"="03xf] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024] Open
Abstract
Purpose: To investigate the association between pancreatic neuroendocrine tumors (panNETs) and sinistral portal hypertension (SPH) and provide insights into the pathogenesis. Methods: A retrospective review of panNETs was conducted from our institution for 12 years. Medical imaging findings were analyzed to determine any association with splenic vein thrombosis (SVT) at diagnosis. The cases were further selected based on the criteria for SPH, namely, (1) presence of SVT, (2) gastric varices, (3) patent portal vein, and (4) normal liver function tests. Results: There were 61 patients with panNETs and 8 (8/61) had SVT and gastric varices at diagnosis. Four (4/8) met the strict criteria for SPH while the other four had more conventional portal hypertension. The four with SPH had large tumors located in the tail with splenic vein invasion and three of four presented with bleeding gastric varices. All four patients underwent surgical resection. Mean follow-up was 8.5 years and the hematemesis never recurred. The other four patients (four of eight) with gastric varices had unresectable disease and all died after a mean survival of 29 months. Conclusion: PanNETs appear to be more commonly associated with SVT and SPH compared with other tumors. This could be related to their relatively indolent nature and their intrinsic vascularity. From a surgical viewpoint, the decision to operate depends on many factors including but not limited to the size/stage, grade, and functionality of the tumor and comorbidities. These considerations notwithstanding, the association between panNETs and SPH suggests that there is benefit in timely resection of panNETs located in the tail.
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Affiliation(s)
- Terence N Moyana
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - D Blair Macdonald
- Department of Medical Imaging, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Guillaume Martel
- Division of Hepatobiliary Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Sergey Pyatibrat
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Goo Lee
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Mario Capitano
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
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30
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Moyana TN, Macdonald DB, Martel G, Pyatibrat S, Lee G, Capitano M. Pancreatic Neuroendocrine Tumors Complicated by Sinistral Portal Hypertension: Insights into Pathogenesis. J Pancreat Cancer 2017; 3:71-77. [PMID: 30631846 DOI: 10.1089/pancan.2017.0017����%2527%2522\'\"] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024] Open
Abstract
Purpose: To investigate the association between pancreatic neuroendocrine tumors (panNETs) and sinistral portal hypertension (SPH) and provide insights into the pathogenesis. Methods: A retrospective review of panNETs was conducted from our institution for 12 years. Medical imaging findings were analyzed to determine any association with splenic vein thrombosis (SVT) at diagnosis. The cases were further selected based on the criteria for SPH, namely, (1) presence of SVT, (2) gastric varices, (3) patent portal vein, and (4) normal liver function tests. Results: There were 61 patients with panNETs and 8 (8/61) had SVT and gastric varices at diagnosis. Four (4/8) met the strict criteria for SPH while the other four had more conventional portal hypertension. The four with SPH had large tumors located in the tail with splenic vein invasion and three of four presented with bleeding gastric varices. All four patients underwent surgical resection. Mean follow-up was 8.5 years and the hematemesis never recurred. The other four patients (four of eight) with gastric varices had unresectable disease and all died after a mean survival of 29 months. Conclusion: PanNETs appear to be more commonly associated with SVT and SPH compared with other tumors. This could be related to their relatively indolent nature and their intrinsic vascularity. From a surgical viewpoint, the decision to operate depends on many factors including but not limited to the size/stage, grade, and functionality of the tumor and comorbidities. These considerations notwithstanding, the association between panNETs and SPH suggests that there is benefit in timely resection of panNETs located in the tail.
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Affiliation(s)
- Terence N Moyana
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - D Blair Macdonald
- Department of Medical Imaging, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Guillaume Martel
- Division of Hepatobiliary Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Sergey Pyatibrat
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Goo Lee
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Mario Capitano
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
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31
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Moyana TN, Macdonald DB, Martel G, Pyatibrat S, Lee G, Capitano M. Pancreatic Neuroendocrine Tumors Complicated by Sinistral Portal Hypertension: Insights into Pathogenesis. J Pancreat Cancer 2017; 3:71-77. [PMID: 30631846 DOI: 10.1089/pancan.2017.0017' and 2*3*8=6*8 and 'hwd1'='hwd1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024] Open
Abstract
Purpose: To investigate the association between pancreatic neuroendocrine tumors (panNETs) and sinistral portal hypertension (SPH) and provide insights into the pathogenesis. Methods: A retrospective review of panNETs was conducted from our institution for 12 years. Medical imaging findings were analyzed to determine any association with splenic vein thrombosis (SVT) at diagnosis. The cases were further selected based on the criteria for SPH, namely, (1) presence of SVT, (2) gastric varices, (3) patent portal vein, and (4) normal liver function tests. Results: There were 61 patients with panNETs and 8 (8/61) had SVT and gastric varices at diagnosis. Four (4/8) met the strict criteria for SPH while the other four had more conventional portal hypertension. The four with SPH had large tumors located in the tail with splenic vein invasion and three of four presented with bleeding gastric varices. All four patients underwent surgical resection. Mean follow-up was 8.5 years and the hematemesis never recurred. The other four patients (four of eight) with gastric varices had unresectable disease and all died after a mean survival of 29 months. Conclusion: PanNETs appear to be more commonly associated with SVT and SPH compared with other tumors. This could be related to their relatively indolent nature and their intrinsic vascularity. From a surgical viewpoint, the decision to operate depends on many factors including but not limited to the size/stage, grade, and functionality of the tumor and comorbidities. These considerations notwithstanding, the association between panNETs and SPH suggests that there is benefit in timely resection of panNETs located in the tail.
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Affiliation(s)
- Terence N Moyana
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - D Blair Macdonald
- Department of Medical Imaging, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Guillaume Martel
- Division of Hepatobiliary Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Sergey Pyatibrat
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Goo Lee
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Mario Capitano
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
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32
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Moyana TN, Macdonald DB, Martel G, Pyatibrat S, Lee G, Capitano M. Pancreatic Neuroendocrine Tumors Complicated by Sinistral Portal Hypertension: Insights into Pathogenesis. J Pancreat Cancer 2017; 3:71-77. [PMID: 30631846 DOI: 10.1089/pancan.2017.0017'"] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024] Open
Abstract
Purpose: To investigate the association between pancreatic neuroendocrine tumors (panNETs) and sinistral portal hypertension (SPH) and provide insights into the pathogenesis. Methods: A retrospective review of panNETs was conducted from our institution for 12 years. Medical imaging findings were analyzed to determine any association with splenic vein thrombosis (SVT) at diagnosis. The cases were further selected based on the criteria for SPH, namely, (1) presence of SVT, (2) gastric varices, (3) patent portal vein, and (4) normal liver function tests. Results: There were 61 patients with panNETs and 8 (8/61) had SVT and gastric varices at diagnosis. Four (4/8) met the strict criteria for SPH while the other four had more conventional portal hypertension. The four with SPH had large tumors located in the tail with splenic vein invasion and three of four presented with bleeding gastric varices. All four patients underwent surgical resection. Mean follow-up was 8.5 years and the hematemesis never recurred. The other four patients (four of eight) with gastric varices had unresectable disease and all died after a mean survival of 29 months. Conclusion: PanNETs appear to be more commonly associated with SVT and SPH compared with other tumors. This could be related to their relatively indolent nature and their intrinsic vascularity. From a surgical viewpoint, the decision to operate depends on many factors including but not limited to the size/stage, grade, and functionality of the tumor and comorbidities. These considerations notwithstanding, the association between panNETs and SPH suggests that there is benefit in timely resection of panNETs located in the tail.
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Affiliation(s)
- Terence N Moyana
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - D Blair Macdonald
- Department of Medical Imaging, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Guillaume Martel
- Division of Hepatobiliary Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Sergey Pyatibrat
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Goo Lee
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Mario Capitano
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
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33
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Moyana TN, Macdonald DB, Martel G, Pyatibrat S, Lee G, Capitano M. Pancreatic Neuroendocrine Tumors Complicated by Sinistral Portal Hypertension: Insights into Pathogenesis. J Pancreat Cancer 2017; 3:71-77. [PMID: 30631846 PMCID: PMC5933486 DOI: 10.1089/pancan.2017.0017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Purpose: To investigate the association between pancreatic neuroendocrine tumors (panNETs) and sinistral portal hypertension (SPH) and provide insights into the pathogenesis. Methods: A retrospective review of panNETs was conducted from our institution for 12 years. Medical imaging findings were analyzed to determine any association with splenic vein thrombosis (SVT) at diagnosis. The cases were further selected based on the criteria for SPH, namely, (1) presence of SVT, (2) gastric varices, (3) patent portal vein, and (4) normal liver function tests. Results: There were 61 patients with panNETs and 8 (8/61) had SVT and gastric varices at diagnosis. Four (4/8) met the strict criteria for SPH while the other four had more conventional portal hypertension. The four with SPH had large tumors located in the tail with splenic vein invasion and three of four presented with bleeding gastric varices. All four patients underwent surgical resection. Mean follow-up was 8.5 years and the hematemesis never recurred. The other four patients (four of eight) with gastric varices had unresectable disease and all died after a mean survival of 29 months. Conclusion: PanNETs appear to be more commonly associated with SVT and SPH compared with other tumors. This could be related to their relatively indolent nature and their intrinsic vascularity. From a surgical viewpoint, the decision to operate depends on many factors including but not limited to the size/stage, grade, and functionality of the tumor and comorbidities. These considerations notwithstanding, the association between panNETs and SPH suggests that there is benefit in timely resection of panNETs located in the tail.
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Affiliation(s)
- Terence N Moyana
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - D Blair Macdonald
- Department of Medical Imaging, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Guillaume Martel
- Division of Hepatobiliary Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Sergey Pyatibrat
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Goo Lee
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Mario Capitano
- Department of Pathology and Lab Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
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Abstract
Probiotics contain microorganisms, most of which are bacteria similar to the beneficial bacteria that occur naturally in the human gut. Probiotics have been widely studied in a variety of gastrointestinal diseases. The most-studied species include Lactobacillus, Bifidobacterium, and Saccharomyces. However, a lack of clear guidelines on when to use probiotics and the most effective probiotic for different gastrointestinal conditions may be confusing for family physicians and their patients. Probiotics have an important role in the maintenance of immunologic equilibrium in the gastrointestinal tract through the direct interaction with immune cells. Probiotic effectiveness can be species-, dose-, and disease-specific, and the duration of therapy depends on the clinical indication. There is high-quality evidence that probiotics are effective for acute infectious diarrhea, antibiotic-associated diarrhea, Clostridium difficile- associated diarrhea, hepatic encephalopathy, ulcerative colitis, irritable bowel syndrome, functional gastrointestinal disorders, and necrotizing enterocolitis. Conversely, there is evidence that probiotics are not effective for acute pancreatitis and Crohn disease. Probiotics are safe for infants, children, adults, and older patients, but caution is advised in immunologically vulnerable populations.
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Affiliation(s)
- Thad Wilkins
- Medical College of Georgia at Augusta University, Augusta, GA, USA
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Khera PS, Myungsu L, Joonsung C. Balloon occluded retrograde transvenous obliteration for bleeding gastric varices: Eyes see what the mind knows. Indian J Radiol Imaging 2017; 27:100-104. [PMID: 28515596 PMCID: PMC5385763 DOI: 10.4103/0971-3026.202952] [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] [Indexed: 12/16/2022] Open
Abstract
Approximately one in six patients with portal hypertension who develop varices at sites of portosystemic venous collaterals has gastric varices due to hepatofugal flow into the gastric veins. Bleeding from gastric varices, though less common, has a higher mortality and morbidity compared to bleeding esophageal varices, which are easier to manage endoscopically. The efferent channel for gastric varices is mostly the gastrorenal shunt (GRS) which opens into the left renal vein. Balloon-occluded transvenous obliteration (BRTO) involves accessing the GRS with an aim to temporarily occlude its outflow using a balloon catheter and at the same time injecting sclerosant mixture within the varix so as to cause its thrombosis and thereby obliteration. BRTO is one of the mainstays of minimally invasive treatment for bleeding gastric varices. In the minority of cases where the GRS is absent, conventional BRTO is technically not possible. However, accessing the small alternate shunt from the inferior phrenic vein may be possible if one is aware of its existence.
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Affiliation(s)
- Pushpinder S Khera
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea
| | - Lee Myungsu
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea
| | - Choi Joonsung
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea
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Sharma M, Singh P, Pathak A, Arya S. Diagnostic dilemma in gastric varices: Endoscopic ultrasound resolves the issue (with videos). Endosc Ultrasound 2017; 6:409-411. [PMID: 28663534 PMCID: PMC5752764 DOI: 10.4103/2303-9027.199764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Malay Sharma
- Department of Gastroenterology, Jaswant Rai Speciality Hospital, Meerut, India
| | - Parvinder Singh
- Department of Surgical Gastroenterology, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
| | - Amit Pathak
- Department of Gastroenterology, Jaswant Rai Speciality Hospital, Meerut, India
| | - Shalini Arya
- Department of Medicine, Muzaffarnagar Medical College, Muzaffarnagar, Uttar Pradesh, India
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Philips CA, Arora A, Shetty R, Kasana V. A Comprehensive Review of Portosystemic Collaterals in Cirrhosis: Historical Aspects, Anatomy, and Classifications. Int J Hepatol 2016; 2016:6170243. [PMID: 28074159 PMCID: PMC5198179 DOI: 10.1155/2016/6170243] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 11/01/2016] [Accepted: 11/17/2016] [Indexed: 02/07/2023] Open
Abstract
Portosystemic collateral formation in cirrhosis plays an important part in events that define the natural history in affected patients. A detailed understanding of collateral anatomy and hemodynamics in cirrhotics is essential to envisage diagnosis, management, and outcomes of portal hypertension. In this review, we provide detailed insights into the historical, anatomical, and hemodynamic aspects to portal hypertension and collateral pathways in cirrhosis with emphasis on the various classification systems.
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Affiliation(s)
- Cyriac Abby Philips
- Department of Hepatology and Transplant Medicine, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India
| | - Ankur Arora
- Department of Radiodiagnosis, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India
| | - Rajesh Shetty
- Department of Radiodiagnosis, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India
| | - Vivek Kasana
- Department of Radiodiagnosis, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India
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Kim SK, Sauk S, Guevara CJ. Transjugular intrahepatic portosystemic shunts versus balloon-occluded retrograde transvenous obliteration for the management of gastric varices: Treatment algorithm according to clinical manifestations. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii150030] [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)
- Seung Kwon Kim
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, MO, USA
| | - Steven Sauk
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, MO, USA
| | - Carlos J. Guevara
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, MO, USA
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Wu Q, Jiang H, Linghu E, Zhang L, Wang W, Zhang J, He Z, Wang J, Yang Y, Sun G, Sun G. BRTO assisted endoscopic Histoacryl injection in treating gastric varices with gastrorenal shunt. MINIM INVASIV THER 2016; 25:337-344. [PMID: 27309571 DOI: 10.1080/13645706.2016.1192552] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIMS We evaluated the feasibility, efficacy and safety of a novel technique of balloon-occluded retrograde transvenous obliteration (BRTO) assisted endoscopic Histoacryl (N-buthyl-2-cyanoacrylate) injection. MATERIAL AND METHODS A total with 11 patients were enrolled and analyzed in this single center, open-label, prospective study. Patients with high-risk gastric varices (defined as fundal varices, large GV (>5 mm), presence of a red spot, and Child-Pugh score C) and concurrent gastrorenal shunt underwent endoscopic Histoacryl injection while the gastrorenal shunt was temporarily occluded with an occlusion balloon. Feasibility, hemostatic effect, intra- and postoperative complications, and varices recurrence were evaluated. RESULTS All procedures were successfully done per protocol. Except for one patient who underwent rescue Histoacryl injection due to residual varices, single therapy was sufficient to eliminate gastric varices in ten patients. Intra-operative hemorrhage occurred in one case and was stopped after additional Histoacryl injection. One patient was confirmed to have treatment-related fungemia. No death or major complications occurred, including ectopic embolism, worsening of hepatic and renal function, etc. No recurrence of the varices was found during a median follow-up time (mean ± SD) of 228 ± 153 days. CONCLUSIONS BRTO assisted endoscopic Histoacryl injection is effective and safe for patients with high-risk gastric varices and concurrent gastrorenal shunt.
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Affiliation(s)
- Qiong Wu
- a Medical Center , Tsinghua University , Beijing , China.,b Department of Gastroenterology and Hepatology , Chinese People's Liberation Army General Hospital , Beijing , China
| | - Hua Jiang
- b Department of Gastroenterology and Hepatology , Chinese People's Liberation Army General Hospital , Beijing , China
| | - Enqiang Linghu
- b Department of Gastroenterology and Hepatology , Chinese People's Liberation Army General Hospital , Beijing , China
| | - Lanjing Zhang
- c Department of Pathology , University Medical Center of Princeton , Plainsboro , NJ , USA.,d Department of Chemical Biology, Ernest Mario School of Pharmacy , Piscataway , NJ , USA.,e Department of Pathology , Robert Wood Johnson Medical School , New Brunwick , NJ , USA.,f Cancer Institute of New Jersey, Rutgers University , New Brunswick , NJ , USA
| | - Weifeng Wang
- b Department of Gastroenterology and Hepatology , Chinese People's Liberation Army General Hospital , Beijing , China
| | - Jie Zhang
- b Department of Gastroenterology and Hepatology , Chinese People's Liberation Army General Hospital , Beijing , China
| | - Zhandi He
- b Department of Gastroenterology and Hepatology , Chinese People's Liberation Army General Hospital , Beijing , China
| | - Juan Wang
- b Department of Gastroenterology and Hepatology , Chinese People's Liberation Army General Hospital , Beijing , China
| | - Yunsheng Yang
- b Department of Gastroenterology and Hepatology , Chinese People's Liberation Army General Hospital , Beijing , China
| | - Guohui Sun
- b Department of Gastroenterology and Hepatology , Chinese People's Liberation Army General Hospital , Beijing , China
| | - Gang Sun
- b Department of Gastroenterology and Hepatology , Chinese People's Liberation Army General Hospital , Beijing , China.,g Department of Gastroenterology and Hepatology , Hainan branch of Chinese PLA General Hospital , Sanya , China
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40
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Crisan D, Tantau M, Tantau A. Endoscopic management of bleeding gastric varices--an updated overview. Curr Gastroenterol Rep 2015; 16:413. [PMID: 25189661 DOI: 10.1007/s11894-014-0413-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Gastric varices (GVs) are known to bleed massively and often difficult to manage with conventional techniques. This article aims to overview the endoscopic methods for the management of acute gastric variceal bleeding, especially the advantages and limits of GV obliteration with tissue adhesives, by comparison with band ligation and other direct endoscopic techniques of approach. The results of indirect radiological and surgical techniques of GV treatment are shortly discussed. A special attention is payed to the emerging role of endoscopic ultrasound in the therapy of bleeding GV, in the confirmation of its eradication and in follow-up strategies.
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Affiliation(s)
- Dana Crisan
- 3rd Medical Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania,
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41
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A rare case of splenic lymphoma in a patient with polymyositis manifesting as gastric variceal bleeding. Clin J Gastroenterol 2015; 8:92-6. [PMID: 25808874 DOI: 10.1007/s12328-015-0561-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Accepted: 03/12/2015] [Indexed: 12/19/2022]
Abstract
We report an unusual case of upper gastrointestinal bleeding due to isolated gastric variceal bleeding in a patient with splenomegaly who was subsequently diagnosed with diffuse large B-cell lymphoma. The patient is a 47-year-old male with a history of polymyositis who presented to the emergency room with complaints of lightheadedness and melena for 2 days. On initial presentation, the patient had positive orthostatic vital signs. He was found to be anemic with presenting hemoglobin of 5.8 g/dl (compared with 13.4 g/dl 4 months prior to presentation). The patient was aggressively resuscitated with intravenous fluid and blood transfusions. An emergency esophagogastroduodenoscopy was performed which showed isolated gastric varices in the fundus of the stomach, with no active bleeding or high-risk stigmata. Abdominal computed tomography revealed focal splenic vein thrombosis and splenomegaly with ill-defined hypodensities. Portal and superior mesenteric veins were patent. Mild edema was seen surrounding the spleen and non-specific abdominal lymphadenopathy was also reported. A surgical consultation recommended an urgent splenectomy. Pathology of the removed spleen revealed diffuse large B-cell lymphoma. Positron emission tomography-computed tomography revealed lymphomatous disease in the thorax, abdomen, pelvis and bone marrow. The patient was subsequently started on chemotherapy.
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42
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Parekh PJ, Buerlein RC, Shams R, Vingan H, Johnson DA. Evaluation of gastrointestinal bleeding: Update of current radiologic strategies. World J Gastrointest Pharmacol Ther 2014; 5:200-208. [PMID: 25374760 PMCID: PMC4218949 DOI: 10.4292/wjgpt.v5.i4.200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 06/10/2014] [Accepted: 09/24/2014] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal bleeding (GIB) is a common presentation with significant associated morbidity and mortality, the prevalence of which continues to rise with the ever-increasing aging population. Initial evaluation includes an esophagoduodeonscopy and/or colonoscopy, which may fail to reveal a source. Such cases prove to be a dilemma and require collaboration between gastroenterology and radiology in deciding the most appropriate approach. Recently, there have been a number of radiologic advances in the approach to GIB. The purpose of this review is to provide an evidence-based update on the most current radiologic modalities available and an algorithmic approach to GIB.
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43
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Triantafyllou M, Stanley AJ. Update on gastric varices. World J Gastrointest Endosc 2014; 6:168-75. [PMID: 24891929 PMCID: PMC4024489 DOI: 10.4253/wjge.v6.i5.168] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Revised: 04/03/2014] [Accepted: 04/16/2014] [Indexed: 02/05/2023] Open
Abstract
Although less common than oesophageal variceal haemorrhage, gastric variceal bleeding remains a serious complication of portal hypertension, with a high associated mortality. In this review we provide an update on the aetiology, classification and management of gastric varices, including acute bleeding, prevention of rebleeding and primary prophylaxis. We describe the optimum management strategies for gastric varices including drug, endoscopic and radiological therapies, focusing on recent published evidence.
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44
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Saad WE, Bleibel W, Adenaw N, Wagner CE, Anderson C, Angle JF, Al-Osaimi AM, Davies MG, Caldwell S. Thrombocytopenia in Patients with Gastric Varices and the Effect of Balloon-occluded Retrograde Transvenous Obliteration on the Platelet Count. J Clin Imaging Sci 2014; 4:24. [PMID: 24987571 PMCID: PMC4060402 DOI: 10.4103/2156-7514.131743] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 03/26/2014] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES Gastric varices primarily occur in cirrhotic patients with portal hypertension and splenomegaly and thus are probably associated with thrombocytopenia. However, the prevalence and severity of thrombocytopenia are unknown in this clinical setting. Moreover, one-third of patients after balloon-occluded retrograde transvenous obliteration (BRTO) have aggravated splenomegaly, which potentially may cause worsening thrombocytopenia. The aim of the study is to determine the prevalence and degree of thrombocytopenia in patients with gastric varices associated with gastrorenal shunts undergoing BRTO, to determine the prognostic factors of survival after BRTO (platelet count included), and to assess the effect of BRTO on platelet count over a 1-year period. MATERIALS AND METHODS This is a retrospective review of 35 patients who underwent BRTO (March 2008-August 2011). Pre- and post-BRTO platelet counts were noted. Potential predictors of bleeding and survival (age, gender, liver disease etiology, platelet count, model for end stage liver disease [MELD]-score, presence of ascites or hepatocellular carcinoma) were analyzed (multivariate analysis). A total of 91% (n = 32/35) of patients had thrombocytopenia (<150,000 platelet/cm(3)) pre-BRTO. Platelet counts at within 48-h, within 2 weeks and at 30-60 days intervals (up to 6 months) after BRTO were compared with the baseline pre-BRTO values. RESULTS 35 Patients with adequate platelet follow-up were found. A total of 92% and 17% of patients had a platelet count of <150,000/cm(3) and <50,000/cm(3), respectively. There was a trend for transient worsening of thrombocytopenia immediately (<48 h) after BRTO, however, this was not statistically significant. Platelet count was not a predictor of post-BRTO rebleeding or patient survival. However, MELD-score, albumin, international normalized ratio (INR), and etiology were predictors of rebleeding. CONCLUSION Thrombocytopenia is very common (>90% of patients) in patients undergoing BRTO. However, BRTO (with occlusion of the gastrorenal shunt) has little effect on the platelet count. Long-term outcomes of BRTO for bleeding gastric varices using sodium tetradecyl sulfate in the USA are impressive with a 4-year variceal rebleed rate and transplant-free survival rate of 9% and 76%, respectively. Platelet count is not a predictor of higher rebleeding or patient survival after BRTO.
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Affiliation(s)
- W E Saad
- Department of Radiology, University of Virginia, Virginia, United States
| | - W Bleibel
- Department of Internal Medicine, Owensboro Health Gastroenterology and Hepatology, Kentucky, United States
| | - N Adenaw
- Department of Radiology, University of Virginia, Virginia, United States
| | - C E Wagner
- Department of Surgery, University of Virginia, Virginia, United States
| | - C Anderson
- Department of Radiology, University of Virginia, Virginia, United States
| | - J F Angle
- Department of Radiology, University of Virginia, Virginia, United States
| | - A M Al-Osaimi
- Department of Medicine, University of Virginia, Virginia, United States
| | - M G Davies
- Department of Surgery, Methodist Hospital, Cornell-Weiel School of Medicine, Houston, Texas, United States
| | - S Caldwell
- Department of Medicine, University of Virginia, Virginia, United States
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45
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Saad WEA. Vascular anatomy and the morphologic and hemodynamic classifications of gastric varices and spontaneous portosystemic shunts relevant to the BRTO procedure. Tech Vasc Interv Radiol 2014; 16:60-100. [PMID: 23830670 DOI: 10.1053/j.tvir.2013.02.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The pathologic anatomy and hemodynamics of the left-sided portal circulation that is associated with gastric varices (GVs) are complex and highly variable. Understanding the pathologic anatomy and hemodynamics associated with GVs is important for clinical management decisions and for the technical descriptive details of the balloon-occluded retrograde transvenous obliteration (BRTO) and balloon-occluded antegrade transvenous obliteration procedures. A reflection of the considerable variability in anatomy, pathology, and hemodynamics is the numerous descriptive and categorical classifications that have been described in the past 2 decades. This article reviews the detailed descriptive gross anatomy, radiographic anatomy, and portosystemic venous hemodynamics that are associated with GVs and that can be encountered during the BRTO or balloon-occluded antegrade transvenous obliteration procedure(s) or both. Definitions are also set to clarify this detailed anatomy that received limited description in the prior literature. Moreover, all the classifications that have been described (to the best of the author's knowledge) that are relevant to the BRTO procedure are detailed in the article.
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Affiliation(s)
- Wael E A Saad
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA.
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46
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Stone PA, Phang D, Richmond B, Gill G, Campbell JE. Splenic artery embolization for the treatment of bleeding gastric varices secondary to splenic vein thrombosis. Ann Vasc Surg 2013; 28:737.e7-11. [PMID: 24495333 DOI: 10.1016/j.avsg.2013.07.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 06/21/2013] [Accepted: 07/10/2013] [Indexed: 01/10/2023]
Abstract
Splenic vein thrombosis can lead to gastric varices. Subsequent upper gastrointestinal bleeding may ensue related to the change in venous outflow to the portal system. Vascular surgeons are infrequently asked to assist in the management of this entity. However, with many vascular surgeons providing diverse endovascular-based interventions, understanding catheter-based solutions is imperative. This report presents a case in which arterial embolization was used to treat gastric variceal bleeding.
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Affiliation(s)
- Patrick A Stone
- West Virginia University, Charleston Division, Charleston, WV.
| | - David Phang
- West Virginia University, Charleston Division, Charleston, WV
| | - Bryan Richmond
- West Virginia University, Charleston Division, Charleston, WV
| | - Gurpreet Gill
- West Virginia University, Charleston Division, Charleston, WV
| | - John E Campbell
- West Virginia University, Charleston Division, Charleston, WV
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47
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Balloon-occluded retrograde transvenous obliteration of gastric varices. Cardiovasc Intervent Radiol 2013; 37:299-315. [PMID: 24091750 DOI: 10.1007/s00270-013-0715-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Accepted: 06/28/2013] [Indexed: 02/07/2023]
Abstract
Balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices is an image-guided transcatheter procedure used to treat gastric varices with sclerosants rather than decompression of the portal venous system. The history of its development, relevant portal venous, and systemic venous anatomic considerations, techniques, indications, and early results will be reviewed. In addition, the status of the practice of BRTO in the United States will be discussed.
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48
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Successful treatment of bleeding gastric varices with splenectomy in a patient with splenic, portal, and mesenteric thromboses. Case Rep Surg 2013; 2013:273531. [PMID: 24078893 PMCID: PMC3776550 DOI: 10.1155/2013/273531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Accepted: 08/04/2013] [Indexed: 11/23/2022] Open
Abstract
A 59-year-old female with a history of multiple splanchnic and portal thromboses treated with warfarin underwent an esophagogastroduodenoscopy for cancer screening, and a polypoid mass was biopsied. One week later, she was admitted with upper gastrointestinal hemorrhage. Her therapeutic coagulopathy was reversed with fresh frozen plasma, and she was transfused with packed red blood cells. An esophagogastroduodenoscopy demonstrated an erosion of a gastric varix without evidence of recent bleeding. Conservative measures failed, and she continued to bleed during her stay. She was not considered a candidate for a shunt procedure; therefore, a splenectomy was performed. Postoperative esophagogastroduodenoscopy demonstrated near complete resolution of gastric varices. One year after discharge on warfarin, there has been no recurrence of hemorrhage. Gastric varices often arise from either portal hypertension or splenic vein thrombosis. Treatment of gastric variceal hemorrhage can be challenging. Transjugular intrahepatic portosystemic shunt is often effective for emergency control in varices secondary to portal hypertension. Splenectomy is the treatment for varices that arise from splenic vein thrombosis. However, treatment of gastric variceal hemorrhage in the context of multiple splanchnic and portal vein thromboses is more complicated. We report splenectomy as a successful treatment of gastric varices in a patient with multiple extrahepatic thromboses.
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49
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Park EJ, Jang JY, Lee JE, Jeong SW, Lee SH, Kim SG, Cha SW, Kim YS, Cho YD, Cho JY, Kim HS, Kim BS, Kim YJ. The risk factors for bleeding of fundal varices in patients with liver cirrhosis. Gut Liver 2013; 7:704-11. [PMID: 24312712 PMCID: PMC3848544 DOI: 10.5009/gnl.2013.7.6.704] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 01/26/2013] [Accepted: 03/21/2013] [Indexed: 12/15/2022] Open
Abstract
Background/Aims The relationship between portal hemodynamics and fundal varices has not been well documented. The purpose of this study was to understand the pathophysiology of fundal varices and to investigate bleeding risk factors related to the presence of spontaneous portosystemic shunts, and to examine the hepatic venous pressure gradient (HVPG) between fundal varices and other varices. Methods In total, 85 patients with cirrhosis who underwent HVPG and gastroscopic examination between July 2009 and March 2011 were included in this study. The interrelationship between HVPG and the types of varices or the presence of spontaneous portosystemic shunts was studied. Results There was no significant difference in the HVPG between fundal varices (n=12) and esophageal varices and gastroesophageal varices type 1 (GOV1) groups (n=73) (17.1±7.7 mm Hg vs 19.7±5.3 mm Hg). Additionally, there was no significant difference in the HVPG between varices with spontaneous portosystemic shunts (n=28) and varices without these shunts (n=57) (18.3±5.8 mm Hg vs 17.0±8.1 mm Hg). Spontaneous portosystemic shunts increased in fundal varices compared with esophageal varices and GOV1 (8/12 patients [66.7%] vs 20/73 patients [27.4%]; p=0.016). Conclusions Fundal varices had a high prevalence of spontaneous portosystemic shunts compared with other varices. However, the portal pressure in fundal varices was not different from the pressure in esophageal varices and GOV1.
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Affiliation(s)
- Eui Ju Park
- Institution for Digestive Research, Digestive Disease Center, Department of Internal Medicine, Seoul, Korea
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Variceal bleeding in cirrhotic patients: risk factors, evolution, treatment. CLUJUL MEDICAL (1957) 2013; 86:107-10. [PMID: 26527928 PMCID: PMC4462429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 04/12/2013] [Accepted: 05/15/2013] [Indexed: 11/05/2022]
Abstract
OBJECTIVES The aim of this study was to monitor the risk factors that trigger variceal bleeding in cirrhotic patients, assess the severity of the bleeding and the efficacy of the endoscopic hemostasis techniques, as well as the recurrence of bleeding episodes and the mortality rate. MATERIALS AND METHODS The current study was a prospective one, and it was conducted in the period November 2004 - December 2006 in the "O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca. It included 273 patients with upper gastrointestinal bleeding because of variceal rupture, assessed by emergency endoscopy. The patients included in the study met the clinical, biochemical, endoscopic and ultrasound criteria for liver cirrhosis. Its etiology and staging were documented from the patients' observation charts. RESULTS Out of the 273 cases of variceal bleeding there were 255 (93.4%) cases of bleeding from esophageal varices and 18 (6.6%) from gastric varices. Variceal bleeding episodes were more frequent in patients with alcoholic liver cirrhosis (51.28%). Most patients with variceal bleeding were in Child class B or C (77%). Mortality because of variceal hemorrhage was 2.93% in the study group. A number of 148 patients were treated by sclerotherapy and 125 patients with elastic ligatures. Bleeding relapses occurred in 65 (23.8%) patients within the study group, 43 men and 22 women. Variceal bleeding relapses were more frequent after sclerotherapy than after elastic ligatures. CONCLUSIONS Variceal bleeding occurred more frequently in patients with alcoholic cirrhosis stage Child C. In the current study mortality was relatively low. The treatment of bleeding recurrence is more difficult, hence variceal rupture prevention and application of elastic ligatures represent a therapeutic necessity.
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