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Okasha HH, Gadour E, Atalla H, AbdEl-Hameed OA, Ezzat R, Alzamzamy AE, Ghoneem E, Matar RA, Hassan Z, Miutescu B, Qawasmi A, Pawlak KM, Elmeligui A. Practical approach to linear endoscopic ultrasound examination of the gallbladder. World J Radiol 2024; 16:184-195. [PMID: 38983839 PMCID: PMC11229944 DOI: 10.4329/wjr.v16.i6.184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 04/03/2024] [Accepted: 05/28/2024] [Indexed: 06/26/2024] Open
Abstract
The gallbladder (GB) is a susceptible organ, prone to various pathologies that can be identified using different imaging techniques. Transabdominal ultrasound (TUS) is typically the initial diagnostic method due to its numerous well-established advantages. However, in cases of uncertainty or when a definitive diagnosis cannot be established, computed tomography (CT) or magnetic resonance imaging may be employed to provide more detailed information. Nevertheless, CT scans may sometimes offer inadequate spatial resolution, which can limit the differentiation of GB lesions, particularly when smaller yet clinically relevant abnormalities are involved. Conversely, endoscopic ultrasound (EUS) provides higher frequency compared to TUS, superior spatial resolution, and the option for contrast-enhanced harmonic imaging, enabling a more comprehensive examination. Thus, EUS can serve as a supplementary tool when conventional imaging methods are insufficient. This review will describe the standard EUS examination of the GB, focusing on its endosonographic characteristics in various GB pathologies.
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Affiliation(s)
- Hussein Hassan Okasha
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kasr Al-Aini School of Medicine, Cairo University, Cairo 11562, Egypt
| | - Eyad Gadour
- Department of Gastroenterology and Hepatology, King Abdulaziz Hospital-National Guard, Ahsa 31982, Saudi Arabia
- Department of Medicine, School of Medicine, Zamzam University College, Khartoum 11113, Sudan
| | - Hassan Atalla
- Department of Internal Medicine, Hepatology and Gastroenterology Unit, Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt
| | - Omar AbdAllah AbdEl-Hameed
- Department of Internal Medicine, Hepatology and Gastroenterology Unit, Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt
| | - Reem Ezzat
- Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut 71511, Egypt
| | - Ahmed Elsayed Alzamzamy
- Department of Gastroenterology and Heptology, Maadi Armed Forces Medical Complex, Military Medical Academy, Cairo 11728, Egypt
| | - Elsayed Ghoneem
- Department of Internal Medicine, Hepatology and Gastroenterology Unit, Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt
| | - Rasha Ahmad Matar
- Department of Gastroenterology and Advance Endoscopy, Sultant Qaboos Comprehensive Cancer Care and Research Centre, Muscat 0961, Oman
| | - Zeinab Hassan
- Department of Internal Medicine, Stockport Hospitals NHS Foundation Trust, Manchester SK2 7JE, United Kingdom
| | - Bogdan Miutescu
- Department of Gastroenterology and Hepatology, Victor Babes University of Medicine and Pharmacy, Timisoara 300041, Romania
- Advanced Regional Research Centre in Gastroenterology and Hepatology, Victor Babes University of Medicine and Pharmacy, Timisoara 30041, Romania
| | - Ayman Qawasmi
- Department of Gastroenterology, Al-Makassed Islamic Charitable Society Hospital, Cairo 11124, Egypt
| | - Katarzyna M Pawlak
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto M5B 1W8, Canada
| | - Ahmed Elmeligui
- Department of Gastroenterology, Southend University Hospital, Essex SS2 6XT, United Kingdom
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2
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Santiago LE, Alvi AT, Hong AM, Pasarin A, Aneja P. Ileocecal Mesentery Arteriovenous Malformation as a Rare Cause of Ectopic Variceal Bleeding in a 58-Year-Old Male With Cirrhosis. Cureus 2023; 15:e45785. [PMID: 37872923 PMCID: PMC10590625 DOI: 10.7759/cureus.45785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2023] [Indexed: 10/25/2023] Open
Abstract
Ectopic varices can be defined as dilated portosystemic venous collaterals that are located at a site other than the esophagus or stomach. These varices can be seen in patients with underlying portal hypertension, but bleeding from them is quite rare. The bleeding usually occurs in patients with a history of intra-abdominal surgery and adhesions. These varices are commonly found in the duodenum or rectum, but they can be present anywhere along the gastrointestinal tract. Currently, there are no well-established guidelines regarding the diagnosis and management of these variceal bleeds, and further investigations with randomized controlled or large-scale trials are required. Here, we report an unusual case of ectopic variceal bleeding from an ileal arteriovenous malformation (AVM), which presented as syncope associated with an acute abdomen in a patient with no prior history of intra-abdominal surgery.
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Affiliation(s)
- Luis E Santiago
- Internal Medicine, HCA Florida Westside Hospital, Plantation, USA
- Internal Medicine, HCA Florida Northwest Hospital, Margate, USA
| | - Ali Tariq Alvi
- Internal Medicine, HCA Florida Westside Hospital, Plantation, USA
- Internal Medicine, HCA Florida Northwest Hospital, Margate, USA
| | - Angelina M Hong
- Internal Medicine, HCA Florida Westside Hospital, Plantation, USA
- Internal Medicine, HCA Florida Northwest Hospital, Margate, USA
| | - Anthony Pasarin
- General Surgery, HCA Florida Westside Hospital, Plantation, USA
- General Surgery, HCA Florida Northwest Hospital, Margate, USA
| | - Pallavi Aneja
- Internal Medicine, HCA Florida Westside Hospital, Plantation, USA
- Internal Medicine, HCA Florida Northwest Hospital, Margate, USA
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An Uncommon Cause of Biliary Obstruction in a Patient With Budd-Chiari Syndrome. ACG Case Rep J 2021; 8:e00597. [PMID: 34549066 PMCID: PMC8443805 DOI: 10.14309/crj.0000000000000597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 02/16/2021] [Indexed: 11/17/2022] Open
Abstract
Biliary varices (BVs) are an infrequent complication of chronic portal hypertension. Most cases of BVs are asymptomatic and are likely underdiagnosed. We present a case of a 34-year-old woman with Budd-Chiari syndrome who was found to have BVs caused by a significant inferior vena cava (IVC) stenosis. This case demonstrates that preprocedure imaging for variceal screening should be considered before biliary tract procedures to prevent complications.
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Suda T, Omizo T, Yoshida R, Seike T, Oishi N, Matsushita E. Diagnosis of biliary varices using digital cholangioscopy. Endosc Int Open 2020; 8:E1437-E1438. [PMID: 33015349 PMCID: PMC7508654 DOI: 10.1055/a-1236-3421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Tsuyoshi Suda
- Department of Gastroenterology, Kanazawa Municipal Hospital, Kanazawa, Ishikawa, Japan.
| | - Tomohide Omizo
- Department of Gastroenterology, Kanazawa Municipal Hospital, Kanazawa, Ishikawa, Japan.
| | - Ryota Yoshida
- Department of Gastroenterology, Kanazawa Municipal Hospital, Kanazawa, Ishikawa, Japan.
| | - Takuya Seike
- Department of Gastroenterology, Kanazawa Municipal Hospital, Kanazawa, Ishikawa, Japan.
| | - Naoki Oishi
- Department of Gastroenterology, Kanazawa Municipal Hospital, Kanazawa, Ishikawa, Japan.
| | - Eiki Matsushita
- Department of Gastroenterology, Kanazawa Municipal Hospital, Kanazawa, Ishikawa, Japan.
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Rana SS, Sharma RK, Gupta R. Contrast-Enhanced Endoscopic Ultrasound for Evaluation of Common Bile Duct in Presence of Portal Cavernoma. JOURNAL OF DIGESTIVE ENDOSCOPY 2020. [DOI: 10.1055/s-0040-1716790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
AbstractEndoscopic ultrasound (EUS) is an excellent imaging modality for the evaluation of common bile duct (CBD) because of its close proximity to the transducer placed in duodenum. However, in the presence of portal cavernoma, identification and proper evaluation of CBD become difficult because of presence of numerous venous collaterals. In these circumstances, the evaluation of CBD is more difficult if it is nondilated. In these difficult situations, contrast-enhanced EUS can provide better and clear images of CBD and therefore seems to be an excellent modality to evaluate nondilated CBD in the presence of portal cavernoma.
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Affiliation(s)
- Surinder Singh Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ravi Kumar Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Ma Y, Cai R, Zhuang D, Tang Y, Cao Y, Wang X, Qiao Z. Whole clinical process in a patient with portal hypertensive biliopathy: a case report. J Int Med Res 2020; 48:300060520914834. [PMID: 32228333 PMCID: PMC7132790 DOI: 10.1177/0300060520914834] [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] [Indexed: 11/15/2022] Open
Abstract
Portal hypertensive biliopathy is characterized by abnormalities in the biliary tract secondary to portal hypertension, especially extrahepatic portal vein obstruction. Most patients are asymptomatic; only about 20% have clinical symptoms. We herein report a case of portal hypertensive biliopathy caused by cavernous transformation of the portal vein with the development of recurrent cholangitis with common bile duct stones and stricture. This patient underwent endoscopic retrograde cholangiopancreatography, a surgical operation, and a transvenous intrahepatic portosystemic shunt procedure during the whole clinical process. Finally, we found the recurrent plastic stent insertion at endoscopic retrograde cholangiopancreatography was the best option for him at present. In addition, we also discussed the diagnosis and management of this disease.
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Affiliation(s)
- Yimin Ma
- Department of Gastroenterology, Gaochun People's Hospital of Nanjing, Gaochun Branch of Nanjing Drum Tower Hospital, Nanjing, China
| | - Rencheng Cai
- Department of Gastroenterology, Gaochun People's Hospital of Nanjing, Gaochun Branch of Nanjing Drum Tower Hospital, Nanjing, China
| | - Duanming Zhuang
- Department of Gastroenterology, Gaochun People's Hospital of Nanjing, Gaochun Branch of Nanjing Drum Tower Hospital, Nanjing, China
| | - Yuehua Tang
- Department of Gastroenterology, Gaochun People's Hospital of Nanjing, Gaochun Branch of Nanjing Drum Tower Hospital, Nanjing, China
| | - Youhong Cao
- Department of Gastroenterology, Gaochun People's Hospital of Nanjing, Gaochun Branch of Nanjing Drum Tower Hospital, Nanjing, China
| | - Xiaoping Wang
- Department of Gastroenterology, Gaochun People's Hospital of Nanjing, Gaochun Branch of Nanjing Drum Tower Hospital, Nanjing, China
| | - Zhenguo Qiao
- Department of Gastroenterology, Suzhou Ninth People's Hospital (Affiliated Wujiang Hospital of Nantong University), Suzhou, China
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Bhangui P, Lim C, Levesque E, Salloum C, Lahat E, Feray C, Azoulay D. Novel classification of non-malignant portal vein thrombosis: A guide to surgical decision-making during liver transplantation. J Hepatol 2019; 71:1038-1050. [PMID: 31442476 DOI: 10.1016/j.jhep.2019.08.012] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 07/25/2019] [Accepted: 08/12/2019] [Indexed: 02/07/2023]
Abstract
Non-tumoral portal vein thrombosis (PVT) is present at liver transplantation in 5% to 26% of cirrhotic patients, and the prevalence of complex PVT as defined here (grade 4 Yerdel, and grade 3,4 Jamieson and Charco) has been reported in 0% to 2.2%. Adequate portal inflow is mandatory to ensure graft and patient survival after liver transplantation. With time, the proposed classifications of non-tumoral chronic PVT have evolved from being anatomy-based, to also incorporating functional parameters. However, none of the currently proposed classifications are directed towards decision-making, regarding the choice of inflow to the graft during transplantation and the outcomes thereof. The present scoping review i) addresses the limits of the currently available classifications in terms of surgical decisiveness, ii) clarifies the concept of physiological or non-physiological portal inflow reconstruction, and subsequently, iii) proposes a new classification of non-tumoral PVT in candidates for liver transplantation; to help tailor the surgical strategy to an individual patient, in order to provide portal inflow to the graft together with control of prehepatic portal hypertension whenever feasible.
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Affiliation(s)
- Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, New Delhi, India
| | - Chetana Lim
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Pitié-Salpêtrière Hospital, Paris, France
| | - Eric Levesque
- Liver Intensive Care Unit, Henri Mondor Hospital, Créteil, France
| | - Chady Salloum
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Paul Brousse Hospital, Villejuif, France
| | - Eylon Lahat
- Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine Tel Aviv University, Israel
| | - Cyrille Feray
- Department of Hepatology, Paul Brousse Hospital, Villejuif, France
| | - Daniel Azoulay
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Paul Brousse Hospital, Villejuif, France; Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine Tel Aviv University, Israel.
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Abdalla AO, Abdallah MA, Calvo LA. Successful Treatment of a Case of Ectopic Jejunal Varices with Portal Venous Stenting. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:948-952. [PMID: 31266933 PMCID: PMC6621934 DOI: 10.12659/ajcr.916003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patient: Female, 77 Final Diagnosis: Ectopic variceal bleeding of the jejunum Symptoms: Abdominal pain • hematemesis • melena Medication: — Clinical Procedure: Portal vein stenting Specialty: Gastroenterology and Hepatology
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Affiliation(s)
- Abubaker O Abdalla
- Department to Internal Medicine, University of Nevada, School of Medicine, Reno, NV, USA
| | - Mohamed A Abdallah
- Department to Internal Medicine, University of South Dakota, Sioux Falls, SD, USA
| | - Lisa A Calvo
- Department to Internal Medicine, University of Nevada, School of Medicine, Reno, NV, USA
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Al Saeed M, Al-Jiffry B, Younes A, Badr S, Abdel-Rahman T, Hatem M, El-Meteini M. Risk factors, pattern of presentation, methods of diagnosis, and results of treatment of acute portal vein thrombosis: A multicenter study. SAUDI JOURNAL FOR HEALTH SCIENCES 2019. [DOI: 10.4103/sjhs.sjhs_77_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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10
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Saied Abdelgawad M, Abouyoussef RA. Portal biliopathy; multidetector CT (MDCT) imaging features. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2018. [DOI: 10.1016/j.ejrnm.2018.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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11
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An Unusual Case of Gastrointestinal Bleeding from Isolated Gallbladder Varices in a Patient with Pancreatic Cancer Complicated by Portal Biliopathy. Case Rep Gastrointest Med 2016; 2016:8602378. [PMID: 27800195 PMCID: PMC5069357 DOI: 10.1155/2016/8602378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 09/05/2016] [Indexed: 11/28/2022] Open
Abstract
Portal biliopathy is the complex of abnormalities of extrahepatic and intrahepatic bile ducts, cystic duct, and gallbladder, arising as a result of extrahepatic portal vein obstruction and noncirrhotic portal fibrosis, which can be caused by coagulopathies, tumors, inflammation, postoperative complications, dehydration, and neonatal umbilical vein catheterization. We report a case of a 55-year-old male patient with the history of pancreatic cancer and cholecystoenteric anastomosis presenting with gastrointestinal bleeding from gallbladder varices via the anastomosis.
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12
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Barresi L, Ligresti D, Traina M. A Challenging Diagnosis for a Biliary Stricture. Gastroenterology 2016; 150:1537-1539. [PMID: 27140491 DOI: 10.1053/j.gastro.2016.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 02/11/2016] [Indexed: 12/02/2022]
Affiliation(s)
- Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS - ISMETT), Palermo, Italy
| | - Dario Ligresti
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS - ISMETT), Palermo, Italy
| | - Mario Traina
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS - ISMETT), Palermo, Italy
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13
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Subtypes and clinical significance of common bile duct varices in portal vein thrombosis: diagnosis and follow-up by Doppler US and EUS. Abdom Radiol (NY) 2016; 41:476-84. [PMID: 27039318 DOI: 10.1007/s00261-015-0596-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE To investigate (1) diagnostic performance of transabdominal color doppler ultrasound (US) and endoscopic ultrasound (EUS) for detection and sub-classification of common bile duct varices (CBDV) in patients with portal vein thrombosis (PVT), and (2) clinical significance and natural history of CBDV subtypes. PATIENTS AND METHODS During a 4-year period, 56 patients with PVT underwent US and EUS for the presence and subtypes of CBDV. Natural history was analyzed for patients who attended control visits. RESULTS CBDV were diagnosed in 57 and 59 % of patients with US and EUS, respectively. In 19 % of patients, EUS revealed different CBDV subtypes than previously seen by US. The most common were paracholedochal (PCV), while the least common were epicholedochal (ECV) and Submucosal varices (SMV). Nine patients had obstructive jaundice and underwent ERCP which was complicated by hemobilia in two patients with SMV. Among eight patients who underwent control EUS (median follow-up 60 months), the form of CBDV remained unchanged. Two patients bled from esophageal varices, both with ECV. CONCLUSION While abdominal US and EUS are equally sensitive for detection of CBDV, EUS allows more precise determination of CBDV subtype. Patients with SMV might be at increased risk of bleeding upon ERCP.
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Bhatia V, Shasthry SM, Mukund A. Intraductal Sonography in Patients With Portal Cavernoma Cholangiopathy. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:651-659. [PMID: 26903662 DOI: 10.7863/ultra.15.05013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 07/09/2015] [Indexed: 06/05/2023]
Abstract
Intraductal sonography generates high-resolution images of the entire length of the biliary tree and peribiliary tissues, including 3-dimensional dual- and muti-plane reconstructions to depict complex anatomy. Portal cavernoma cholangiopathy (previously called portal biliopathy) can have multiple etiologies of obstructive cholestasis in the same patient, which can be difficult to define even with advanced imaging techniques.We describe 2 difficult cases of portal cavernoma cholangiopathy in which intraductal sonography helped in clinical management decisions. We think that intraductal sonography should be part of the standard management algorithm for patients with portal cavernoma cholangiopathy and describe the intraductal sonographic correlates of the cholangiographic changes in this condition.
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Affiliation(s)
- Vikram Bhatia
- Departments of Hepatology (V.B., S.M.S.) and Radiology (A.M.), Institute of Liver and Biliary Sciences, New Delhi, India.
| | - Saggere Muralikrishna Shasthry
- Departments of Hepatology (V.B., S.M.S.) and Radiology (A.M.), Institute of Liver and Biliary Sciences, New Delhi, India
| | - Amar Mukund
- Departments of Hepatology (V.B., S.M.S.) and Radiology (A.M.), Institute of Liver and Biliary Sciences, New Delhi, India
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15
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Rai GP, Nijhawan S, Madhu MP, Sharma SS, Pokharna R. Comparative evaluation of magnetic resonance cholangiopancreatography/magnetic resonance splenoportovenography and endoscopic ultrasound in the diagnosis of portal cavernoma cholangiopathy. Indian J Gastroenterol 2015; 34:442-7. [PMID: 26743101 DOI: 10.1007/s12664-015-0610-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Accepted: 11/03/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Magnetic resonance cholangiopancreatography/magnetic resonance splenoportovenography (MRCP/MRSPV) is now the investigation of choice for the diagnosis of portal cavernoma cholangiopathy (PCC). Endoscopic ultrasound (EUS) is an emerging diagnostic modality for the diagnosis of PCC and may be better than MRCP/MRSPV to see the layer-wise localization of varices and to differentiate between varices, stone, and malignancy. METHODS Retrospective data of 50 patients of extrahepatic portal vein obstruction (EHPVO) were collected, and comparison between MRCP/MRSPV and EUS was done for the diagnosis of PCC. RESULTS Out of 50 patients, 56 % (28) were males, 44 % (22) females, and 24 % (12) symptomatic. Biliary changes were seen in 40 patients (80 %). Epicholedochal collateral (EPEC) was detected in 48 % and 20 % in MRCP/MRSPV and EUS, respectively. Perforators (PER) and intracholedochal collateral (ICC) were better seen with EUS (72 % and 48 %) as compared to MRCP/MRSPV (0 % and 8 %), and p-values were significant (<0.05). EUS has a sensitivity of 33.33 % and a specificity of 92.31 % for EPEC. Portal cavernoma (PC) and collateral at porta (CP), paracholedochal collateral (PAC), perisplenic (PS) and peripancreatic collateral (PPC), pericholedochal collateral (PEC), intrahepatic biliary radical dilatation (IHBRD), perigallbladder collateral (PG), common bile duct dilatation (CBDD) and common hepatic duct dilatation (CHDD), common bile duct stricture (CBDS), and retropancreatic collateral (RPC) were comparable between the two modalities. CONCLUSIONS EUS detected PER and ICC better than MRCP/MRSPV, while MRCP/MRSPV was more sensitive for detecting EPEC.
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Affiliation(s)
- Gyan Prakash Rai
- Department of Gastroenterology, Sawai Man Singh Medical College, Jawaharlal Nehru Marg, Gangawal Park, Jaipur, 302 004, India
| | - Sandeep Nijhawan
- Department of Gastroenterology, Sawai Man Singh Medical College, Jawaharlal Nehru Marg, Gangawal Park, Jaipur, 302 004, India.
| | - M P Madhu
- Department of Gastroenterology, Sawai Man Singh Medical College, Jawaharlal Nehru Marg, Gangawal Park, Jaipur, 302 004, India
| | - Shyam Sundar Sharma
- Department of Gastroenterology, Sawai Man Singh Medical College, Jawaharlal Nehru Marg, Gangawal Park, Jaipur, 302 004, India
| | - Rupesh Pokharna
- Department of Gastroenterology, Sawai Man Singh Medical College, Jawaharlal Nehru Marg, Gangawal Park, Jaipur, 302 004, India
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16
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Takagi T, Irisawa A, Shibukawa G, Hikichi T, Obara K, Ohira H. Intraductal ultrasonographic anatomy of biliary varices in patients with portal hypertension. Endosc Ultrasound 2015; 4:44-51. [PMID: 25789284 PMCID: PMC4362004 DOI: 10.4103/2303-9027.151346] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Accepted: 05/10/2014] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The term, portal biliopathy, denotes various biliary abnormalities, such as stenosis and/or dilatation of the bile duct, in patients with portal hypertension. These vascular abnormalities sometimes bring on an obstructive jaundice, but they are not clear which vessels participated in obstructive jaundice. The aim of present study was clear the bile ductal changes in patients with portal hypertension in hopes of establishing a therapeutic strategy for obstructive jaundice caused by biliary varices. MATERIALS AND METHODS Three hundred and thirty-seven patients who underwent intraductal ultrasound (IDUS) during endoscopic retrograde cholangiography for biliary abnormalities were enrolled. Portal biliopathy was analyzed using IDUS. RESULTS Biliary varices were identified in 11 (2.7%) patients. IDUS revealed biliary varices as multiple, hypoechoic features surrounding the bile duct wall. These varices could be categorized into one of two groups according to their location in the sectional image of bile duct: epicholedochal and paracholedochal. Epicholedochal varices were identified in all patients, but paracholedochal varices were observed only in patients with extrahepatic portal obstruction. CONCLUSION IDUS was useful to characterize the anatomy of portal biliopathy in detail.
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Affiliation(s)
- Tadayuki Takagi
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Atsushi Irisawa
- Department of Gastroenterology, Fukushima Medical University Aizu Medical Center, Aizuwakamatsu, Japan
| | - Goro Shibukawa
- Department of Gastroenterology, Fukushima Medical University Aizu Medical Center, Aizuwakamatsu, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Katsutoshi Obara
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
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Abstract
Portal vein thrombosis is an important cause of portal hypertension. PVT occurs in association with cirrhosis or as a result of malignant invasion by hepatocellular carcinoma or even in the absence of associated liver disease. With the current research into its genesis, majority now have an underlying prothrombotic state detectable. Endothelial activation and stagnant portal blood flow also contribute to formation of the thrombus. Acute non-cirrhotic PVT, chronic PVT (EHPVO), and portal vein thrombosis in cirrhosis are the three main variants of portal vein thrombosis with varying etiological factors and variability in presentation and management. Procoagulant state should be actively investigated. Anticoagulation is the mainstay of therapy for acute non-cirrhotic PVT, with supporting evidence for its use in cirrhotic population as well. Chronic PVT (EHPVO) on the other hand requires the management of portal hypertension as such and with role for anticoagulation in the setting of underlying prothrombotic state, however data is awaited in those with no underlying prothrombotic states. TIPS and liver transplant may be feasible even in the setting of PVT however proper selection of candidates and type of surgery is warranted. Thrombolysis and thrombectomy have some role. TARE is a new modality for management of HCC with portal vein invasion.
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Key Words
- ACLA, anti-cardiolipin antibody
- AFP, alpha feto protein
- BCS, Budd-Chiari syndrome
- CDUS, color doppler ultrasonography
- CT, computed tomography
- CTP, Child Turcotte Pugh
- EHPVO, extra hepatic portal venous obstruction
- EST, endoscopic sclerotherapy
- HCC, hepatocellular carcinoma
- HVPG, hepatic venous pressure gradient
- IGF-1, insulin like growth factor-1
- IGFBP-3, insulin like growth factor binding protein-3
- INR, international normalized ratio
- JAK-2, Janus kinase 2
- LA, lupus anticoagulant
- LMWH, low molecular weight heparin
- MELD, model for end stage liver disease
- MPD, myeloproliferative disorder
- MRI, magnetic resonance imaging
- MTHFR, methylenetetrahydrofolate reductase
- MVT, mesenteric vein thrombosis
- OCPs, oral contraceptive pills
- PAI-1 4G-4G, plasminogen activator inhibitor type 1- 4G/4G genotype
- PNH, paroxysmal nocturnal hemoglobinuria
- PV, portal vein
- PVT
- PVT, portal vein thrombosis
- PWUS, Pulsed Wave ultrasonography
- RFA, radio frequency ablation
- SMA, superior mesenteric artery
- SMV, superior mesenteric vein
- TAFI, thrombin activatable fibrinolysis inhibitor
- TARE, Trans arterial radioembolization
- TB, tuberculosis
- TIPS, transjugular intrahepatic portosystemic shunt
- UFH, unfractionated heparin
- acute and chronic
- anticoagulation
- imaging
- prothrombotic
- rtPA, recombinant tissue plasminogen activator
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Affiliation(s)
- Yogesh K. Chawla
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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Rameshbabu CS, Wani ZA, Rai P, Abdulqader A, Garg S, Sharma M. Standard imaging techniques for assessment of portal venous system and its tributaries by linear endoscopic ultrasound: a pictorial essay. Endosc Ultrasound 2014. [PMID: 24949362 DOI: 10.4103/2303-9027.117724] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Linear Endosonography has been used to image the Portal Venous System but no established standard guidelines exist. This article presents techniques to visualize the portal venous system and its tributaries by linear endosonography. Attempt has been made to show most of the first order tributaries and some second order tributaries of splenic vein, superior mesenteric vein and portal vein.
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Affiliation(s)
- C S Rameshbabu
- Department of Anatomy, L.L.R.M., Medical College, Meerut 250001, U.P., India
| | - Zeeshn Ahamad Wani
- Department of Anatomy, Jaswant Rai Speciality Hospital, Saket, Meerut 250001, Uttar Pradesh, India
| | | | - Almessabi Abdulqader
- Department of Anatomy, Jaswant Rai Speciality Hospital, Saket, Meerut 250001, Uttar Pradesh, India
| | - Shubham Garg
- Department of Anatomy, Jaswant Rai Speciality Hospital, Saket, Meerut 250001, Uttar Pradesh, India
| | - Malay Sharma
- Department of Anatomy, Jaswant Rai Speciality Hospital, Saket, Meerut 250001, Uttar Pradesh, India
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Rana SS, Bhasin DK, Rao C, Singh K. Portal hypertensive biliopathy developing after acute severe pancreatitis. Endosc Ultrasound 2014; 2:228-9. [PMID: 24949402 PMCID: PMC4062273 DOI: 10.4103/2303-9027.121244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Accepted: 03/10/2013] [Indexed: 11/04/2022] Open
Affiliation(s)
- Surinder Singh Rana
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepak Kumar Bhasin
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Chalapathi Rao
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kartar Singh
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Rameshbabu CS, Wani ZA, Rai P, Abdulqader A, Garg S, Sharma M. Standard imaging techniques for assessment of portal venous system and its tributaries by linear endoscopic ultrasound: a pictorial essay. Endosc Ultrasound 2014; 2:16-34. [PMID: 24949362 PMCID: PMC4062237 DOI: 10.7178/eus.04.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Accepted: 01/08/2013] [Indexed: 12/12/2022] Open
Abstract
Linear Endosonography has been used to image the Portal Venous System but no established standard guidelines exist. This article presents techniques to visualize the portal venous system and its tributaries by linear endosonography. Attempt has been made to show most of the first order tributaries and some second order tributaries of splenic vein, superior mesenteric vein and portal vein.
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Affiliation(s)
- C S Rameshbabu
- Department of Anatomy, L.L.R.M., Medical College, Meerut 250001, U.P., India
| | - Zeeshn Ahamad Wani
- Department of Anatomy, Jaswant Rai Speciality Hospital, Saket, Meerut 250001, Uttar Pradesh, India
| | | | - Almessabi Abdulqader
- Department of Anatomy, Jaswant Rai Speciality Hospital, Saket, Meerut 250001, Uttar Pradesh, India
| | - Shubham Garg
- Department of Anatomy, Jaswant Rai Speciality Hospital, Saket, Meerut 250001, Uttar Pradesh, India
| | - Malay Sharma
- Department of Anatomy, Jaswant Rai Speciality Hospital, Saket, Meerut 250001, Uttar Pradesh, India
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Role of single-operator per-oral cholangioscopy and intraductal US in assessment of portal biliopathy (with videos). Gastrointest Endosc 2014; 79:1015-9. [PMID: 24713306 DOI: 10.1016/j.gie.2014.01.042] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 01/23/2014] [Indexed: 02/08/2023]
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Portal cavernoma cholangiopathy: an endoscopic ultrasound based imaging approach. J Clin Exp Hepatol 2014; 4:S53-61. [PMID: 25755596 PMCID: PMC4244829 DOI: 10.1016/j.jceh.2013.08.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 08/28/2013] [Indexed: 02/06/2023] Open
Abstract
In patients with portal cavernoma cholangiopathy (PCC), appearance and location of collateral channels depends on extent and location of occlusive thrombus in the porto-mesenteric venous system. If the porto-mesenteric venous system is occluded near the formation of portal vein, blood tends to flow through collateral channels that form varices in and around the common bile duct. Though endoscopic ultrasound (EUS) is considered the investigative modality of choice for evaluating common bile duct obstruction, its role in evaluating collateral pathways in and around the common bile duct is poorly defined. This article reviews the anatomy, genesis and appearance of these collateral pathways in PCC. EUS identifies different layers of the common bile duct (CBD) wall and, in PCC, where varices are in close contact with or part of these different layers, can establish the relationship between them. Thus, EUS appears to be the investigation of choice for tracing the origin and course of collaterals in PCC. Careful study of varices in the common bile duct wall prior to ERCP for bile duct stones or biliary strictures may help to plan the procedure and to manage anticipated complications such as hemobilia.
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Portal cavernoma cholangiopathy: consensus statement of a working party of the Indian national association for study of the liver. J Clin Exp Hepatol 2014; 4:S2-S14. [PMID: 25755591 PMCID: PMC4274351 DOI: 10.1016/j.jceh.2014.02.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 02/02/2014] [Indexed: 12/12/2022] Open
Abstract
Portal cavernoma cholangiopathy (PCC) is defined as abnormalities in the extrahepatic biliary system including the cystic duct and gallbladder with or without abnormalities in the 1st and 2nd generation biliary ducts in a patient with portal cavernoma. Presence of a portal cavernoma, typical cholangiographic changes on endoscopic or magnetic resonance cholangiography and the absence of other causes of these biliary changes like bile duct injury, primary sclerosing cholangitis, cholangiocarcinoma etc are mandatory to arrive a diagnosis. Compression by porto-portal collateral veins involving the paracholedochal and epicholedochal venous plexuses and cholecystic veins and ischemic insult due to deficient portal blood supply or prolonged compression by collaterals bring about biliary changes. While the former are reversible after porto-systemic shunt surgery, the latter are not. Majority of the patients with PCC are asymptomatic and approximately 21% are symptomatic. Symptoms in PCC could be in the form of long standing jaundice due to chronic cholestasis, or biliary pain with or without cholangitis due to biliary stones. Endoscopic retrograde cholangiography has no diagnostic role because it is invasive and is associated with risk of complications, hence it is reserved for therapeutic procedures. Magnetic resonance cholangiography and portovenography is a noninvasive and comprehensive imaging technique, and is the modality of choice for mapping of the biliary and vascular abnormalities in these patients. PCC is a progressive condition and symptoms develop late in the course of portal hypertension only in patients with severe or advanced changes of cholangiopathy. Asymptomatic patients with PCC do not require any treatment. Treatment of symptomatic PCC can be approached in a phased manner, coping first with biliary clearance by nasobiliary or biliary stent placement for acute cholangitis and endoscopic biliary sphincterotomy for biliary stone removal; second, with portal decompression by creating portosystemic shunt; and third, with persistent biliary obstruction by performing second-stage biliary drainage surgery such as hepaticojejunostomy or choledochoduodenostomy. Patients with symptomatic PCC have good prognosis after successful endoscopic biliary drainage and after successful shunt surgery.
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Key Words
- CBD, common bile duct
- CHD, common hepatic duct
- CT, computed tomography
- EHPVO, extrahepatic portal venous obstruction
- ERC, endoscopic retrograde cholangiography
- EUS, endoscopic ultrasound
- GRADE, Grading of Recommendations, Assessment, Development and Evaluation
- INASL, Indian National Association for Study of the Liver
- MRC, magnetic resonance cholangiography
- MRI, magnetic resonance imaging
- NCPF, non-cirrhotic portal fibrosis
- PSS, portosystemic shunt
- PVT, portal vein thrombosis
- UDCA, ursodeoxycholic acid
- USG, ultrasound
- cholestasis
- extrahepatic portal venous obstruction
- gallbladder varices
- obstructive jaundice
- portal hypertensive biliopathy
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Suárez V, Puerta A, Santos LF, Pérez JM, Varón A, Botero RC. Portal hypertensive biliopathy: A single center experience and literature review. World J Hepatol 2013; 5:137-44. [PMID: 23556047 PMCID: PMC3612573 DOI: 10.4254/wjh.v5.i3.137] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Revised: 09/25/2012] [Accepted: 11/14/2012] [Indexed: 02/06/2023] Open
Abstract
Portal hypertensive biliopathy (PHB) is characterized by anatomical and functional abnormalities of the intrahepatic, extrahepatic and pancreatic ducts, in patients with portal hypertension associated to extrahepatic portal vein obstruction and less frequently to cirrhosis. These morphological changes, consisting in dilatation and stenosis of the biliary tree, are due to extensive venous collaterals occurring in an attempt to decompress the portal venous blockage. It is usually asymptomatic until it progresses to more advanced stages with cholestasis, jaundice, biliary sludge, gallstones, cholangitis and finally biliary cirrhosis. Imaging modalities of the biliary tree such as Doppler ultrasound, computed tomography, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography are essential to establish the diagnosis and the need of therapeutical interventions. Once the diagnosis is established, treatment with ursodesoxycholic acid seems to be beneficial. Decompression of the biliary tree to dilate, remove stones or implant biliary prosthesis by endoscopic or surgical procedures (hepato-yeyunostomy) usually resolves the cholestatic picture and prevents septic complications. The ideal treatment is the decompression of the portal system, with transjugular intrahepatic porto-systemic shunt or a surgical porto-systemic shunt. Unfortunately, few patients will be candidates for these procedures due to the extension of the thrombotic process. The purpose of this paper is to report the first 3 cases of PHB seen in a Colombian center and to review the literature.
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Affiliation(s)
- Vanessa Suárez
- Vanessa Suárez, Luisa Fernanda Santos, Adriana Varón, Rafael Claudino Botero, Gastroenterology and Hepatology Service, Department of Internal Medicine, Fundación Cardioinfantil, Bogotá 110131, Colombia
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Akhter NM, Haskal ZJ. Diagnosis and management of ectopic varices. GASTROINTESTINAL INTERVENTION 2012. [DOI: 10.1016/j.gii.2012.08.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Abstract
Biliary ductal changes are a common radiological finding in patients with portal hypertension, however only a small percentage of patients (5%-30%) develop symptomatic bile duct obstruction. The exact pathogenesis is not clear, but an involvement of factors such as bile duct compression by venous collaterals, ischemia, and infection is accepted by most authors. Although endoscopic retrograde cholangiopancreatography was used to define and diagnose this condition, magnetic resonance cholangiopancreatography is currently the investigation of choice for diagnosing this condition. Treatment is indicated only for symptomatic cases. Portosystemic shunts are the treatment of choice for symptomatic portal biliopathy. In the majority of patients, the changes caused by biliopathy resolve after shunt surgery, however, 15%-20% patients require a subsequent bilio-enteric bypass or endoscopic management for persistent biliopathy. There is a role for endoscopic therapy in patients with bile duct stones, cholangitis or when portosystemic shunt surgery is not feasible.
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Affiliation(s)
- Jong Hwan Choi
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
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Justo LA, Olcina JRF, Tallón AG, Carbonell SP, Rivera JIG, Vicente VM. [Cholangiopathy associated with portal hypertension]. GASTROENTEROLOGIA Y HEPATOLOGIA 2011; 34:619-23. [PMID: 21862180 DOI: 10.1016/j.gastrohep.2011.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2011] [Revised: 05/18/2011] [Accepted: 05/26/2011] [Indexed: 11/28/2022]
Abstract
Portal cholangiopathy encompasses a group of abnormalities of the biliary system and gallbladder that occur secondary to chronic portal vein thrombosis and collateral venous circulation. Chronic obstruction of the portal vein is a frequent cause of gastrointestinal variceal bleeding, but data on biliary tract abnormalities are limited. We report the case of a male patient with obstructive jaundice secondary to portal cholangiopathy. We describe the pathogenesis of this entity, and the various diagnostic and therapeutic options available.
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Affiliation(s)
- Linette Achécar Justo
- Servicio de Gastroenterología, Hospital Universitario Ramón y Cajal, Madrid, España.
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29
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Bayraktar Y. Portal ductopathy: Clinical importance and nomenclature. World J Gastroenterol 2011; 17:1410-5. [PMID: 21472098 PMCID: PMC3070013 DOI: 10.3748/wjg.v17.i11.1410] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Revised: 12/09/2010] [Accepted: 12/16/2010] [Indexed: 02/06/2023] Open
Abstract
Non-cirrhotic portal hypertension (PHT) accounts for about 20% of all PHT cases, portal vein thrombosis (PVT) resulting in cavernous transformation being the most common cause. All known complications of PHT may be encountered in patients with chronic PVT. However, the effect of this entity on the biliary tree and pancreatic duct has not yet been fully established. Additionally, a dispute remains regarding the nomenclature of common bile duct abnormalities which occur as a result of chronic PVT. Although many clinical reports have focused on biliary abnormalities, only a few have evaluated both the biliary and pancreatic ductal systems. In this review the relevant literature evaluating the effect of PVT on both ductal systems is discussed, and findings are considered with reference to results of a prominent center in Turkey, from which the term “portal ductopathy” has been put forth to replace “portal biliopathy”.
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30
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Ng CH, Lai L, Lok KH, Li KK, Szeto ML. Choledochal varices bleeding: A case report. World J Gastrointest Endosc 2010; 2:190-2. [PMID: 21160747 PMCID: PMC2999127 DOI: 10.4253/wjge.v2.i5.190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2009] [Revised: 03/23/2010] [Accepted: 03/30/2010] [Indexed: 02/05/2023] Open
Abstract
Choledochal varices are a rare cause of hemobilia associated with chronic portal vein thrombosis. We present a case of chronic portal vein thrombosis complicated with bleeding from choledochal varices. The presentation, clinical manifestations and management are described.
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Affiliation(s)
- Chi Ho Ng
- Chi Ho Ng, Lawrence Lai, Ka Ho Lok, Kin Kong Li, Ming Leung Szeto, Department of Medicine and Geriatrics, Tuen Mun Hospital, Hong Kong, China
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Ginès A, Fernández-Esparrach G. Endoscopic ultrasonography for the evaluation of portal hypertension. Clin Liver Dis 2010; 14:221-9. [PMID: 20682231 DOI: 10.1016/j.cld.2010.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Since the 1980s, endoscopic ultrasonography (EUS) has been useful in the evaluation of portal hypertension, either for the diagnostic aspects or for the evaluation of therapy and risk of bleeding. More recently, it has been described as a method for guiding interventions such as variceal injection, portal vein catheterization, or even for creating an intrahepatic portosystemic shunt in the animal laboratory. The new generation of radial electronic echoendoscopes is equipped with color Doppler capability, allowing for measurement of any hemodynamic parameter of the portal circulation. This article summarizes the current knowledge on the role of EUS for the evaluation of portal hypertension.
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Affiliation(s)
- Angels Ginès
- Institut de Malalties Digestives i Metabòliques, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Spain.
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Abstract
BACKGROUND Portal vein thrombosis (PVT) is an important cause of portal hypertension. It may occur as such with or without associated cirrhosis and hepatocellular carcinoma. Information on its management is scanty. AIM To provide an update on the modern management of portal vein thrombosis. Information on portal vein thrombosis in patients with and without cirrhosis and hepatocellular carcinoma is also updated. METHODS A pubmed search was performed to identify the literature using search items portal vein thrombosis-aetiology and treatment and portal vein thrombosis in cirrhosis and hepatocellular carcinoma. RESULTS Portal vein thrombosis occurs because of local inflammatory conditions in the abdomen and prothrombotic factors. Acute portal vein thrombosis is usually symptomatic when associated with cirrhosis and/or superior mesenteric vein thrombosis. Anticoagulation should be given for 3-6 months if detected early. If prothrombotic factors are identified, anticoagulation should be given lifelong. Chronic portal vein thrombosis usually presents with well tolerated upper gastrointestinal bleed. It is diagnosed by imaging, which demonstrates a portal cavernoma in place of a portal vein. Anticoagulation does not have a definite role, but bleeds can be treated with endotherapy or shunt surgery. Rarely liver transplantation may be considered. CONCLUSION Role of anticoagulation in chronic portal vein thrombosis needs to be further studied.
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Affiliation(s)
- Y Chawla
- Department of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh, India.
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Sharma M, Pathak A. Perforators of common bile duct wall in portal hypertensive biliopathy (with videos). Gastrointest Endosc 2009; 70:1041-3. [PMID: 19631938 DOI: 10.1016/j.gie.2009.03.040] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Accepted: 03/17/2009] [Indexed: 12/19/2022]
Affiliation(s)
- Malay Sharma
- Department of Gastroenterology, Jaswant Rai Speciality Hospital, Meerut, India.
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Gallbladder wall variceal haemorrhage with associated rupture: a rare cause of mortality in the cirrhotic patient. Eur J Gastroenterol Hepatol 2009; 21:955-7. [PMID: 19598330 DOI: 10.1097/meg.0b013e328323aadd] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Gallbladder wall varices are unusual ectopic varices, which occur in the setting of portal hypertension, usually but not universally associated with portal vein thrombosis. Rupture of these varices may lead to life-threatening intra abdominal haemorrhage and is associated with a high mortality rate. We report a case of gallbladder wall variceal haemorrhage in a cirrhotic patient with patent transjugular intrahepatic portosystemic shunt, which resulted in death.
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Abstract
This guideline has been approved by the American Association for the Study of Liver Diseases (AASLD) and represents the position of the association.
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Affiliation(s)
- Laurie D DeLeve
- Division of Gastrointestinal and Liver Diseases and the Research Center for Liver Diseases, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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37
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Abstract
BACKGROUND AND METHODS Biliary obstruction as a consequence of portal biliopathy, because of extrahepatic portal vein occlusion is an uncommon cause of biliary disease in the western world. We reviewed all patients presenting to the Regional Liver Transplant Unit in Birmingham, UK with symptomatic portal biliopathy between 1992 and 2005 and report the presentation, investigation, management and outcome of these complex patients. RESULTS Thirteen patients with symptomatic portal biliopathy were followed up for a median of 2 years (range 1-18 years). Jaundice was the presenting feature in all cases and was associated with bile duct stones or debris in 77% (10 of 13) of cases. Successful treatment of biliary problems was achieved by biliary decompression in six cases (metallic stent=three, plastic stent=one, combined procedure=one and sphincterectomy=one) and portal decompression in three cases (transjugular intrahepatic portosystemic shunt=two, meso-caval shunt=one). Successful biliary drainage could not be achieved endoscopically or by portal decompression in one case that was accepted for combined liver and small bowel transplantation. Three patients had spontaneous resolution without recurrence over the follow-up period. Ten patients (77%) experienced gastrointestinal bleeding. Two deaths over the follow-up period occurred; both were associated with portal hypertensive bleeding. CONCLUSION Endoscopic management (sphincterectomy and stone extraction or stent insertion) is effective initial therapy for patients with symptomatic portal biliopathy. In the case of persistent biliary obstruction porto-systemic shunting (transjugular intrahepatic portosystemic shunt or surgical) should be considered, however, the extent of vascular thrombosis precludes this in most cases.
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Zhang XL, An JY. Advance in treatment and diagnosis of portal hypertensive biliopathy. Shijie Huaren Xiaohua Zazhi 2008; 16:3933-3936. [DOI: 10.11569/wcjd.v16.i35.3933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Portal hypertensive biliopathy (PHB) refers to abnormalities of the entire biliary tract including intrahepatic and extrahepatic bile ducts, cystic duct and gallbladder in patients with portal hypertension. The pathogenesis of PHB is not clearly known and it has been postulated that external pressure by dilated veins of portal cavernoma and/or ischaemic strictures of the bile duct may play a role. Approximately 20% of patients are with symptoms of biliary system, which is associated with higher age, longer duration of diseases, higher frequency of common bile duct (CBD) stones and gallbladder stones, and abnormal liver function. Magnetic resonance (MR) cholangiography and MR portography are the initial choice of investigation in the evaluation of PHB. Endoscopy or surgical method is optional to treat patients with symptoms, aiming at management of portal hypertension and relief of obstructive jaundice.
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Abstract
Ectopic varices (EcV) comprise large portosystemic venous collaterals located anywhere other than the gastro-oesophageal region. No large series or randomized-controlled trials address this subject, and therefore its management is based on available expertise and facilities, and may require a multidisciplinary team approach. EcV are common findings during endoscopy in portal hypertensive patients and their bleeding accounts for only 1–5% of all variceal bleeding. EcV develop secondary to portal hypertension (PHT), surgical procedures, anomalies in venous outflow, or abdominal vascular thrombosis and may be familial in origin. Bleeding EcV may present with anaemia, shock, haematemesis, melaena or haematochezia and should be considered in patients with PHT and gastrointestinal bleeding or anaemia of obscure origin. EcV may be discovered during panendoscopy, enteroscopy, endoscopic ultrasound, wireless capsule endoscopy, diagnostic angiography, multislice helical computed tomography, magnetic resonance angiography, colour Doppler-flow imaging, laparotomy, laparoscopy and occasionally during autopsy. Patients with suspected EcV bleeding need immediate assessment, resuscitation, haemodynamic stabilization and referral to specialist centres. Management of EcV involves medical, endoscopic, interventional radiological and surgical modalities depending on patients’ condition, site of varices, available expertise and patients’ subsequent management plan.
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Rai T, Irisawa A, Takagi T, Shibukawa G, Wakatsuki T, Imamura H, Takahashi Y, Sato A, Sato M, Hikichi T, Obara K, Ohira H. Intraductal sonography of biliary varices associated with extrahepatic portal vein obstruction. JOURNAL OF CLINICAL ULTRASOUND : JCU 2007; 35:527-30. [PMID: 17366553 DOI: 10.1002/jcu.20338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
We report a case of biliary varices associated with extrahepatic portal vein obstruction (EHPVO) that were identified via intraductal sonography during endoscopic retrograde cholangiography. A 35-year-old man was admitted to our hospital because of jaundice that had developed during an episode of EHPVO. Laboratory data showed obstructive jaundice. Endoscopic retrograde cholangiography showed some bile duct stenosis with smooth stricture along the extrahepatic biliary duct. Intraductal sonographic examination revealed numerous vessels around the lower and upper parts of the bile duct. Compression by these vessels was suspected as the cause of the biliary stricture.
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Affiliation(s)
- Tsuyoshi Rai
- Department of Internal Medicine 2, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima City, Japan
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41
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Kessler A, Graif M, Konikoff F, Mercer D, Oren R, Carmiel M, Blachar A. Vascular and biliary abnormalities mimicking cholangiocarcinoma in patients with cavernous transformation of the portal vein: role of color Doppler sonography. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2007; 26:1089-95. [PMID: 17646372 DOI: 10.7863/jum.2007.26.8.1089] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
OBJECTIVE The purpose of this study was to describe and evaluate the sonographic and color Doppler features of tumorlike biliary and venous changes in patients with cavernous transformation of the portal vein (CTPV). METHODS The sonographic studies of 24 patients with CTPV were reviewed. Sonographic evaluation of the biliary system included measurement of intrahepatic and extrahepatic biliary duct caliber changes and common bile duct (CBD) wall thickening and character. Color Doppler features of the portoportal collateral circulation at various locations (intrahepatic, periportal, gallbladder, pancreatic, and gastric regions) were carefully evaluated. RESULTS Biliary abnormalities were detected in 13 (54%) of 24 patients with CTPV. All 13 patients (100%) had intrahepatic biliary dilatation; 11 patients (85%) had CBD abnormalities: diffuse CBD wall thickening causing diffuse narrowing of the true lumen in 7 (54%) and CBD dilatation proximal to the focal area of narrowing due to pericholedochal compressing venous collaterals in 4 (30%). A tumorlike solid mass appeared on the gray scale images of 2 patients (8%): 1 at the porta hepatis and the other at the pancreatic head level. Color Doppler imaging evaluation showed venous-type flow, suggesting a bulk of varicosities. CONCLUSIONS Portoportal collaterals in patients with CTPV may alter the biliary and venous systems, causing biliary wall thickening, stenosis, intrahepatic and extrahepatic dilatation, and pseudotumors. Detailed sonographic and color Doppler imaging assessment can show and facilitate the correct diagnosis of those changes, thus avoiding the need for a more invasive modality such as endoscopic retrograde cholangiopancreatography or a more expensive investigation such as magnetic resonance cholangiopancreatography.
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Affiliation(s)
- Ada Kessler
- Division of Ultrasound, Department of Radiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
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42
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MESH Headings
- Acute Disease
- Adult
- Anticoagulants/therapeutic use
- Biopsy
- Carcinoma, Hepatocellular/complications
- Carcinoma, Hepatocellular/diagnosis
- Carcinoma, Hepatocellular/pathology
- Colonoscopy
- Hemangioma, Cavernous/diagnosis
- Hemangioma, Cavernous/diagnostic imaging
- Hemangioma, Cavernous/etiology
- Hemangioma, Cavernous/therapy
- Humans
- Liver/pathology
- Liver Cirrhosis/complications
- Liver Neoplasms/complications
- Liver Neoplasms/diagnosis
- Liver Neoplasms/pathology
- Liver Transplantation
- Mesenteric Vascular Occlusion/diagnostic imaging
- Mesenteric Veins
- Portal Vein/pathology
- Portal Vein/physiopathology
- Portasystemic Shunt, Transjugular Intrahepatic
- Prognosis
- Retrospective Studies
- Tomography, Spiral Computed
- Tomography, X-Ray Computed
- Vascular Neoplasms/diagnosis
- Vascular Neoplasms/diagnostic imaging
- Vascular Neoplasms/etiology
- Vascular Neoplasms/therapy
- Venous Thrombosis/complications
- Venous Thrombosis/diagnosis
- Venous Thrombosis/diagnostic imaging
- Venous Thrombosis/drug therapy
- Venous Thrombosis/etiology
- Venous Thrombosis/pathology
- Venous Thrombosis/physiopathology
- Venous Thrombosis/surgery
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Affiliation(s)
- Bertrand Condat
- Service d'Hépatogastroentérologie, Hôpital Saint Camille, Bry-sur-Marne.
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43
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Condat B, Valla D. Nonmalignant portal vein thrombosis in adults. NATURE CLINICAL PRACTICE. GASTROENTEROLOGY & HEPATOLOGY 2006; 3:505-15. [PMID: 16951667 DOI: 10.1038/ncpgasthep0577] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2005] [Accepted: 06/28/2006] [Indexed: 02/06/2023]
Abstract
Portal vein thrombosis (PVT) consists of two different entities: acute PVT and chronic PVT. Acute PVT usually presents as abdominal pain. When the thrombus extends to the mesenteric venous arches, intestinal infarction can occur. Chronic PVT is usually recognized after a fortuitous diagnosis of hypersplenism or portal hypertension, or when there are biliary symptoms related to portal cholangiopathy. Local risk factors for PVT, such as an abdominal inflammatory focus, can be identified in 30% of patients with acute PVT; 70% of patients with acute and chronic PVT have a general risk factor for PVT, most commonly myeloproliferative disease. Early initiation of anticoagulation therapy for acute PVT is associated with complete and partial success in 50% and 40% of patients, respectively. A minimum of 6 months' anticoagulation therapy is recommended for the treatment of acute PVT. For patients with either form of PVT, permanent anticoagulation therapy should be considered if they have a permanent risk factor. In patients with large varices, beta-adrenergic blockade or endoscopic therapy seems to prevent bleeding as a result of portal hypertension, even in patients on anticoagulation therapy. In patients with jaundice or recurrent biliary symptoms caused by cholangiopathy, insertion of a biliary endoprosthesis is the first treatment option. Overall, the long-term outcome for patients with PVT is good, but is jeopardized by cholangiopathy and transformation of underlying myeloproliferative disease into myelofibrosis or acute leukemia.
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Affiliation(s)
- Bertrand Condat
- Service d'Hépatologie, Hôpital Beaujon, 100 Boulevard du Général-Leclerc, 92118 Clichy Cedex, France
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44
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Aubert A, Palazzo L. [Diagnosis of gallbladder diseases by endoscopic ultrasound]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2005; 29:59-63. [PMID: 15738896 DOI: 10.1016/s0399-8320(05)80694-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Affiliation(s)
- Alain Aubert
- Service de Gastro-entérologie, Hôpital Beaujon, 100 boulevard du Général Leclerc, 92000 Clichy, France
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45
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Umphress JL, Pecha RE, Urayama S. Biliary stricture caused by portal biliopathy: diagnosis by EUS with Doppler US. Gastrointest Endosc 2004; 60:1021-4. [PMID: 15605028 DOI: 10.1016/s0016-5107(04)02216-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
MESH Headings
- Cholangiopancreatography, Endoscopic Retrograde
- Cholecystectomy
- Cholelithiasis/complications
- Cholelithiasis/diagnostic imaging
- Cholelithiasis/surgery
- Cholestasis, Extrahepatic/diagnostic imaging
- Cholestasis, Extrahepatic/etiology
- Cholestasis, Extrahepatic/surgery
- Cholestasis, Intrahepatic/diagnostic imaging
- Cholestasis, Intrahepatic/etiology
- Cholestasis, Intrahepatic/surgery
- Collateral Circulation/physiology
- Combined Modality Therapy
- Dilatation, Pathologic
- Endosonography
- Gallstones/complications
- Gallstones/diagnostic imaging
- Gallstones/surgery
- Humans
- Hypertension, Portal/complications
- Hypertension, Portal/diagnostic imaging
- Hypertension, Portal/surgery
- Liver Function Tests
- Male
- Middle Aged
- Portal Vein/diagnostic imaging
- Portal Vein/surgery
- Recurrence
- Reoperation
- Sphincterotomy, Endoscopic
- Stents
- Thrombosis/complications
- Thrombosis/diagnostic imaging
- Thrombosis/surgery
- Tissue Adhesions
- Ultrasonography, Doppler
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Affiliation(s)
- Jason L Umphress
- Department of Internal Medicine, Division of Gastroenterology, University of California-Davis, Medical Center, 4150 V Street, Sacramento, CA 95817, USA
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46
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Condat B, Vilgrain V, Asselah T, O'Toole D, Rufat P, Zappa M, Moreau R, Valla D. Portal cavernoma-associated cholangiopathy: a clinical and MR cholangiography coupled with MR portography imaging study. Hepatology 2003; 37:1302-8. [PMID: 12774008 DOI: 10.1053/jhep.2003.50232] [Citation(s) in RCA: 157] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Although biliary symptoms appear to be uncommon in patients with portal cavernoma, almost all of them have endoscopic retrograde cholangiographic abnormalities. The mechanisms underlying the biliary changes are explained poorly. This study in patients with portal cavernoma had 3 aims: (1) to assess the manifestations related to biliary involvement; (2) to evaluate with magnetic resonance (MR) imaging the aspect and frequency of cholangiographic changes; and (3) to clarify the mechanisms underlying biliary involvement. From December 1999 to July 2001, 25 consecutive adults with portal cavernoma without cancer or cirrhosis were studied with MR cholangiography coupled with MR portography. Seven patients presented with clinical manifestations of biliary disease. MR cholangiography findings were stenosis in 21 patients, with upstream dilatation in 16 and displacement in 13. MR cholangiography coupled with MR portography showed in all cases that the biliary abnormalities were secondary to a mass effect directly related to pressure by the cavernoma. In conclusion, in patients with portal cavernoma, clinical manifestations of biliary disease are most frequent; the cholangiographic abnormalities are very common and usually are caused by a mass effect by pressure from the veins composing the cavernoma. MR cholangiography coupled with MR portography is an effective noninvasive examination for simultaneous visualization of bile ducts and their relationship to the cavernoma.
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Affiliation(s)
- Bertrand Condat
- Service d'Hépatologie, Fédération Médico-Chirurgicale d'Hépatogastroentérologie, Hôpital Beaujon, AP-HP, Paris, France
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47
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Ponction guidée par échoendoscopie: Résultats d’une étude monocentrique portant sur 1 323 patients. ACTA ACUST UNITED AC 2003. [DOI: 10.1007/bf03023687] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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48
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Chu EC, Chick W, Hillebrand DJ, Hu KQ. Fatal spontaneous gallbladder variceal bleeding in a patient with alcoholic cirrhosis. Dig Dis Sci 2002; 47:2682-5. [PMID: 12498285 DOI: 10.1023/a:1021092719209] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Gallbladder varices are unusual ectopic varices that may develop in patients with portal hypertension, particularly in those with portal vein occlusion. In rare instances, these varices may cause hemobilia, life-threatening bleeding, or even rupture of the gallbladder. We report the first case of a 41-year-old man with alcoholic cirrhosis and patent portal vein who developed massive hemoperitoneum from spontaneous rupture of varices in the gallbladder fossa. The diagnosis of gallbladder varices eluded conventional imaging and was made only at autopsy. Gallbladder variceal hemorrhage is a rare, but potentially catastrophic complication of cirrhosis.
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Affiliation(s)
- Eric C Chu
- Division of Gastroenterology, Loma Linda University Medical Center, Loma Linda, California 92354, USA
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49
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Mutignani M, Shah SK, Bruni A, Perri V, Costamagna G. Endoscopic treatment of extrahepatic bile duct strictures in patients with portal biliopathy carries a high risk of haemobilia: report of 3 cases. Dig Liver Dis 2002; 34:587-91. [PMID: 12502216 DOI: 10.1016/s1590-8658(02)80093-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Extrahepatic portal venous obstruction can be associated with bile duct abnormalities, the entity being called portal biliopathy. Three cases are reported of extrahepatic bile duct strictures in patients with portal biliopathy who developed haemobilia during endotherapy. Although endoscopic therapy with stent placement can be successful in patients with portal biliopathy and could also lead to permanent stricture resolution, procedure-related haemobilia is not as uncommon as previously held. Shunt surgery could be a better option in fit patients, since it could provide definitive treatment in a young patient with an otherwise normal life expectancy.
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Affiliation(s)
- M Mutignani
- Digestive Endoscopy Unit, Catholic University Sacro Cuore, A. Gemelli University Hospital, Rome, Italy
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50
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Byrne MF, Mitchell RM, Baillie J. Uncommon biliary strictures. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2002. [DOI: 10.1053/tgie.2002.34137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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