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He K, Pang K, Yan X, Wang Q, Wu D. New sights in ectopic varices in portal hypertension. QJM 2024; 117:397-412. [PMID: 38321102 DOI: 10.1093/qjmed/hcae026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/31/2024] [Indexed: 02/08/2024] Open
Abstract
Ectopic varices and associated bleeding, although rare, pose a significant risk to patients with portal hypertension, carrying a relatively high mortality rate. These varices can occur in various anatomical regions, excluding the gastroesophageal region, which is typically associated with portal vein drainage. The limited data available in the literature, derived mostly from case reports and series, make the diagnosis and treatment of ectopic variceal bleeding particularly challenging. Furthermore, it is crucial to recognize that ectopic varices in different sites can exhibit variations in key decision-making factors such as aetiology and vascular anatomy, severity and bleeding risk and hepatic reserve. These factors significantly influence treatment strategies and underscore the importance of adopting individualized management approaches. Therefore, the objective of this review is to provide a comprehensive overview of the fundamental knowledge surrounding ectopic varices and to propose site-oriented, stepwise diagnosis and treatment algorithms for this complex clinical issue. A multidisciplinary treatment approach is strongly recommended in managing ectopic varices. In addition, to enhance clinical reference, we have included typical case reports of ectopic varices in various sites in our review, while being mindful of potential publication bias.
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Affiliation(s)
- K He
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - K Pang
- Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - X Yan
- Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Q Wang
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - D Wu
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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2
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Parikh A, Leon D, Ghasemi Rad M, Wynne D, Amaresh A. Percutaneous Transhepatic Embolization of a Bleeding Colic Vein in a Cirrhotic Patient With Massive Hematochezia: A Case Report and Literature Review. Cureus 2022; 14:e25736. [PMID: 35812565 PMCID: PMC9262639 DOI: 10.7759/cureus.25736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2022] [Indexed: 11/15/2022] Open
Abstract
Ectopic varices are an uncommon cause of gastrointestinal bleeding in patients with portal hypertension. A 43-year-old female with alcoholic cirrhosis developed massive hematochezia and hemorrhagic shock, requiring emergent angiography and image-guided intervention. Angiography revealed active extravasation from a branch of the right colic vein. The patient underwent percutaneous transhepatic embolization of the bleeding colic vein with technical success demonstrated on post-embolization angiography. Treatment of bleeding ectopic varices may require endoscopic, image-guided, or surgical approaches.
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3
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MacFarlane KE, Fischer NJ. A case report of an endoscopic approach to life‐threatening cecal variceal hemorrhage. JGH OPEN 2022; 6:277-279. [PMID: 35475196 PMCID: PMC9021714 DOI: 10.1002/jgh3.12733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/15/2022] [Accepted: 03/20/2022] [Indexed: 11/28/2022]
Abstract
Cecal varices are a rare cause of gastrointestinal bleeding in patients with cirrhosis. We describe a 29‐year‐old man with decompensated alcoholic cirrhosis who developed gastrointestinal bleeding in the hospital. A computed tomography mesenteric angiogram showed bleeding cecal varices, which were successfully treated by glue injection therapy at colonoscopy. The procedure appeared to be complicated by bacteremia due to Escherichia coli.
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Affiliation(s)
| | - Nicholas J Fischer
- Auckland Hospital Auckland District Health Board Auckland New Zealand
- Department of surgery Basingstoke and North Hampshire Hospitals Basingstoke UK
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4
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Ozaka S, Gotoh Y, Honda S, Iwao T, Kawahara Y, Kinoshita K, Nakaya T, Noguchi C, Kagawa K, Murakami K. Rectal varix treated with endoscopic cyanoacrylate injection therapy. Clin J Gastroenterol 2021; 14:791-795. [PMID: 33389695 DOI: 10.1007/s12328-020-01305-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 11/18/2020] [Indexed: 11/30/2022]
Abstract
There is no established treatment for rectal varices. Although endoscopic cyanoacrylate (N-butyl 2-cyanoacrylate) injection therapy is the standard treatment for gastric varices, there are few reports of its use for rectal varices. We present a case of rectal varix that was successfully treated with endoscopic cyanoacrylate injection therapy. An 80-year-old man with cirrhosis was treated for rectal varices with interventional radiology 2 years earlier. At his current presentation, he underwent colonoscopy for hematochezia and anemia, which showed recurrence of rectal varix. We performed endoscopic cyanoacrylate injection therapy for the lesion. However, since we observed bleeding from the treated varix the next day, additional cyanoacrylate was injected. Thereafter, there was no re-bleeding and no recurrence was observed at the 3-year follow-up. According to the previous reports, interventional radiology (IVR), endoscopic sclerotherapy (EIS), and endoscopic variceal ligation (EVL) have been mainly used to treat rectal varices; however, there are few reports of endoscopic cyanoacrylate injection therapy. Our case suggests that endoscopic cyanoacrylate injection therapy might be a useful and safe treatment option for rectal varices.
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Affiliation(s)
- Sotaro Ozaka
- Department of Gastroenterology, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama, Yufu, Oita, 879-5593, Japan. .,Department of Gastroenterology, Shin Beppu Hospital, 3898 Tsurumi, Beppu, Oita, 874-8538, Japan.
| | - Yasuhiko Gotoh
- Department of Gastroenterology, Shin Beppu Hospital, 3898 Tsurumi, Beppu, Oita, 874-8538, Japan
| | - Shunichiro Honda
- Department of Gastroenterology, Oita Medical Center, 11 Yokota, Oita, Oita, 870-0263, Japan
| | - Toshiaki Iwao
- Department of Gastroenterology, Takada Central Hospital, 1176-1 Shinchi, Bungotakada, Oita, 879-0627, Japan
| | - Yoshinari Kawahara
- Department of Gastroenterology, Shin Beppu Hospital, 3898 Tsurumi, Beppu, Oita, 874-8538, Japan
| | - Keisuke Kinoshita
- Department of Gastroenterology, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama, Yufu, Oita, 879-5593, Japan
| | - Tomohisa Nakaya
- Department of Gastroenterology, Shin Beppu Hospital, 3898 Tsurumi, Beppu, Oita, 874-8538, Japan
| | - Chishio Noguchi
- Department of Gastroenterology, Shin Beppu Hospital, 3898 Tsurumi, Beppu, Oita, 874-8538, Japan
| | - Koichi Kagawa
- Department of Gastroenterology, Shin Beppu Hospital, 3898 Tsurumi, Beppu, Oita, 874-8538, Japan
| | - Kazunari Murakami
- Department of Gastroenterology, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama, Yufu, Oita, 879-5593, Japan
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5
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Murakami M, Fujimori N, Nagao Y, Yoshizumi T, Matsumoto K, Yasumori S, Teramatsu K, Takamatsu Y, Oono T, Ogawa Y. Colonic varices: a rare complication of pancreatic cancer. Clin J Gastroenterol 2020; 13:1355-1359. [PMID: 32897498 DOI: 10.1007/s12328-020-01225-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/27/2020] [Indexed: 10/23/2022]
Abstract
A 55-year-old man was diagnosed with pancreatic cancer of the uncus and received chemotherapy (modified FOLFIRINOX). Ten months later, he was admitted to our hospital with massive lower gastrointestinal bleeding. Contrast-enhanced CT showed ascending colon varices caused by the occlusion of the superior mesenteric vein (SMV) due to pancreatic cancer invasion. Colonoscopy revealed tortuous varices with red spots in the ascending colon. The patient received blood transfusions and was discharged; however, he was hospitalized for recurrent massive lower gastrointestinal bleeding 3 months later. During this readmission, we performed the transileocolic vein obliteration method due to SMV stenosis and the absence of an obvious shunt. He experienced an uneventful post-operative recovery, and contrast-enhanced CT after 2 months revealed no recurrence of colonic varices. Ectopic varices are portosystemic venous collaterals resulting from portal hypertension occurring in any locations other than the esophagogastric region. Colonic varices have rarely been reported before. Patients with pancreatic cancer may present with gastrointestinal bleeding caused by tumor bleeding or esophagogastric varices; however, ectopic varices such as colon varices, a rare complication of pancreatic cancer, should be considered in patients with obscure gastrointestinal bleeding.
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Affiliation(s)
- Masatoshi Murakami
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Nao Fujimori
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Yoshihiro Nagao
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazuhide Matsumoto
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Sho Yasumori
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Katsuhito Teramatsu
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yu Takamatsu
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takamasa Oono
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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6
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Kim CL, Kim T, Lee WH, Seo JW, Park SH, Choi JH, Heo NY. [Ascending Colon Variceal Bleeding in Cirrhotic Patient with Emergent Endoscopic Variceal Obturation with N-butyl-2-cyanoacrylate]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2018; 72:37-41. [PMID: 30049177 DOI: 10.4166/kjg.2018.72.1.37] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Ectopic varices are rare among patients with portal hypertension, especially in the ascending colon. It is difficult to evaluate massive lower gastrointestinal bleeding in patients with liver cirrhosis by colonoscopy due to hemodynamic instability and poor bowel preparation. In Korea, there has only been one case report about ascending colon variceal bleeding, in which hemostasis was performed by venous coil embolization. We report another rare case of ascending colon variceal bleeding in a patient with alcoholic cirrhosis, who was successfully treated via two sessions of N-butyl-2-cyanoacrylate injection through colonoscopy. This case suggests that the careful endoscopic approach and hemostasis with glue injection might be an option for treating massive bleeding in the lower gastrointestinal varix.
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Affiliation(s)
- Chang Lae Kim
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Taehong Kim
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Won Hyuk Lee
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Joo Wan Seo
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Seung Ha Park
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Joon Hyuk Choi
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Nae Yun Heo
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
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7
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Matsumoto K, Imai Y, Takano M, Nakazawa M, Ando S, Sugawara K, Nakayama N, Tomiya T, Mochida S. A case of colonic varices complicated by alcoholic cirrhosis treated using balloon-occluded retrograde transvenous obliteration. Clin J Gastroenterol 2018; 11:343-347. [PMID: 29696582 DOI: 10.1007/s12328-018-0857-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 03/30/2018] [Indexed: 02/07/2023]
Abstract
A 44-year-old man with cirrhosis arising from alcohol abuse manifested melena caused by the rupture of esophageal varices. He received endoscopic variceal ligation for the initial hemostasis, followed by endoscopic injection sclerotherapy as an additional consolidation therapy. A CT examination performed at the time of admission revealed collateral veins developing around the ascending colon, in which the feeding and draining vessels were identified as the superior mesenteric vein and the right testicular vein, respectively. Moreover, large nodular varices were observed in the ascending colon during a colonoscopy. To prevent the rupture of the colonic varices, balloon-occluded retrograde transvenous obliteration (B-RTO) was performed through the right testicular vein using a microballoon catheter. A CT examination performed 4 days after the B-RTO procedure revealed the disappearance of blood flow with thrombosis formation in both the colonic varices and the feeding vein. The varices in the ascending colon had completely disappeared when examined during a colonoscopy performed 4 months after the B-RTO procedure. B-RTO is a useful and minimally invasive procedure for the treatment of colonic varices to prevent bleeding.
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Affiliation(s)
- Keisuke Matsumoto
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-gun, Saitama, 350-0495, Japan
| | - Yukinori Imai
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-gun, Saitama, 350-0495, Japan
| | - Masashi Takano
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-gun, Saitama, 350-0495, Japan
| | - Manabu Nakazawa
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-gun, Saitama, 350-0495, Japan
| | - Satsuki Ando
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-gun, Saitama, 350-0495, Japan
| | - Kayoko Sugawara
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-gun, Saitama, 350-0495, Japan
| | - Nobuaki Nakayama
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-gun, Saitama, 350-0495, Japan
| | - Tomoaki Tomiya
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-gun, Saitama, 350-0495, Japan
| | - Satoshi Mochida
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-gun, Saitama, 350-0495, Japan.
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9
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Tokodai K, Kawagishi N, Miyagi S, Nakanishi C, Hara Y, Nakanishi W, Kamei T, Ohuchi N. Splenectomy for Severe Intestinal Bleeding Caused by Portal Hypertensive Enteropathy After Pediatric Living-Donor Liver Transplantation: A Report of Three Cases. Transplant Proc 2017; 49:1129-1132. [DOI: 10.1016/j.transproceed.2017.03.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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10
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Diagnosis and treatment guidelines for aberrant portal hemodynamics: The Aberrant Portal Hemodynamics Study Group supported by the Ministry of Health, Labor and Welfare of Japan. Hepatol Res 2017; 47:373-386. [PMID: 28058764 DOI: 10.1111/hepr.12862] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 12/29/2016] [Accepted: 01/04/2017] [Indexed: 12/18/2022]
Abstract
Idiopathic portal hypertension (IPH), causing aberrant portal hemodynamics, is a disease with an as yet unidentified cause and no established treatment protocol. The Japanese research group on IPH in Japan was set up in 1975 by the Ministry of Health, Labor and Welfare. Extrahepatic portal obstruction and Budd-Chiari syndrome (BCS) have since been added to the group's research subjects. The aims of the research group are to accurately evaluate the current status of the three diseases in Japan, elucidate their etiology and pathogenesis, and develop new treatments. Due to the long-term efforts of the Japanese research group, aberrant portal hemodynamics has been investigated in a variety of aspects, from epidemiological and pathological studies to molecular biology analyses. As a result, it has been shown that there are abnormal genes in the liver, specific for IPH. In addition, pathological findings of BCS were internationally compared and the difference in findings between Japan and Europe (or North America) has been clarified. Furthermore, it was found that complication rates of hepatocellular carcinoma in BCS were higher in Japan. Based on the research, "Diagnosis and treatment of aberrant portal hemodynamics (2001)", including diagnostic criteria for aberrant portal hemodynamics, was published in 2001. In 2013, it was revised to "Diagnosis and treatment guidelines for aberrant portal hemodynamics (2013)" after the incorporation of diagnosis and treatment in accordance with its current status.
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11
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12
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Enteroscopic Management of Ectopic Varices in a Patient with Liver Cirrhosis and Portal Hypertension. Case Reports Hepatol 2016; 2016:2018642. [PMID: 27595025 PMCID: PMC4995326 DOI: 10.1155/2016/2018642] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 07/19/2016] [Indexed: 12/12/2022] Open
Abstract
Portal hypertension and liver cirrhosis may predispose patients to varices, which have a propensity to bleed and cause significant morbidity and mortality. These varices are most commonly located in the gastroesophageal area; however, rarely ectopic varices may develop in unusual locations outside of this region. Haemorrhage from these sites can be massive and difficult to control; thus early detection and management may be lifesaving. We present a case of occult gastrointestinal bleeding in a patient with underlying alcoholic liver disease where an ectopic varix was ultimately detected with push enteroscopy.
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13
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Colonic Varices Due to Chronic Pancreatitis: A Rare Cause of Lower Gastrointestinal Bleeding. ACG Case Rep J 2015; 2:168-70. [PMID: 26157952 PMCID: PMC4435410 DOI: 10.14309/crj.2015.43] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Accepted: 02/23/2015] [Indexed: 11/24/2022] Open
Abstract
A 75-year-old man with chronic pancreatitis presented with painless bloody stool. Computed tomography revealed a splenic vein occlusion with several collaterals towards the descending colon. Colonoscopy showed tortuous varices in the descending colon, which suggested recent bleeding. Sinistral portal hypertension (SPH) due to chronic pancreatitis was diagnosed, so splenectomy and distal pancreatectomy were performed. Our case illustrates a rare complication of SPH.
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14
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Abstract
Although often considered together, gastric and ectopic varices represent complications of a heterogeneous group of underlying diseases. Commonly, these are known to arise in patients with cirrhosis secondary to portal hypertension; however, they also arise in patients with noncirrhotic portal hypertension, most often secondary to venous thrombosis of the portal venous system. One of the key initial assessments is to define the underlying condition leading to the formation of these portal-collateral pathways to guide management. In the authors' experience, these patients can be grouped into distinct although sometimes overlapping conditions, which can provide a helpful conceptual basis of management.
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Affiliation(s)
- Zachary Henry
- Division of Gastroenterology and Hepatology, University of Virginia Health System, PO Box 800708, Charlottesville, VA 22908-0708, USA
| | - Dushant Uppal
- Division of Gastroenterology and Hepatology, University of Virginia Health System, PO Box 800708, Charlottesville, VA 22908-0708, USA
| | - Wael Saad
- Division of Vascular and Interventional Radiology, University of Virginia Health System, PO Box 800170, Charlottesville, VA 22908, USA
| | - Stephen Caldwell
- Division of Gastroenterology and Hepatology, University of Virginia Health System, PO Box 800708, Charlottesville, VA 22908-0708, USA.
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15
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Biecker E. Portal hypertension and gastrointestinal bleeding: Diagnosis, prevention and management. World J Gastroenterol 2013; 19:5035-5050. [PMID: 23964137 PMCID: PMC3746375 DOI: 10.3748/wjg.v19.i31.5035] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Revised: 03/20/2013] [Accepted: 05/17/2013] [Indexed: 02/06/2023] Open
Abstract
Bleeding from esophageal varices is a life threatening complication of portal hypertension. Primary prevention of bleeding in patients at risk for a first bleeding episode is therefore a major goal. Medical prophylaxis consists of non-selective beta-blockers like propranolol or carvedilol. Variceal endoscopic band ligation is equally effective but procedure related morbidity is a drawback of the method. Therapy of acute bleeding is based on three strategies: vasopressor drugs like terlipressin, antibiotics and endoscopic therapy. In refractory bleeding, self-expandable stents offer an option for bridging to definite treatments like transjugular intrahepatic portosystemic shunt (TIPS). Treatment of bleeding from gastric varices depends on vasopressor drugs and on injection of varices with cyanoacrylate. Strategies for primary or secondary prevention are based on non-selective beta-blockers but data from large clinical trials is lacking. Therapy of refractory bleeding relies on shunt-procedures like TIPS. Bleeding from ectopic varices, portal hypertensive gastropathy and gastric antral vascular ectasia-syndrome is less common. Possible medical and endoscopic treatment options are discussed.
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16
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Gastrointestinal Bleeding in Cirrhotic Patients with Portal Hypertension. ISRN HEPATOLOGY 2013; 2013:541836. [PMID: 27335828 PMCID: PMC4890899 DOI: 10.1155/2013/541836] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 06/29/2013] [Indexed: 02/06/2023]
Abstract
Gastrointestinal bleeding related to portal hypertension is a serious complication in patients with liver cirrhosis. Most patients bleed from esophageal or gastric varices, but bleeding from ectopic varices or portal hypertensive gastropathy is also possible. The management of acute bleeding has changed over the last years. Patients are managed with a combination of endoscopic and pharmacologic treatment. The endoscopic treatment of choice for esophageal variceal bleeding is variceal band ligation. Bleeding from gastric varices is treated by injection with cyanoacrylate. Treatment with vasoactive drugs as well as antibiotic treatment is started before or at the time point of endoscopy. The first-line treatment for primary prophylaxis of esophageal variceal bleeding is nonselective beta blockers. Pharmacologic therapy is recommended for most patients; band ligation is an alternative in patients with contraindications for or intolerability of beta blockers. Treatment options for secondary prophylaxis include variceal band ligation, beta blockers, a combination of nitrates and beta blockers, and combination of band ligation and pharmacologic treatment. A clear superiority of one treatment over the other has not been shown. Bleeding from portal hypertensive gastropathy or ectopic varices is less common. Treatment options include beta blocker therapy, injection therapy, and interventional radiology.
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Abstract
Blood loss has always been a sensitive issue in surgery. Traditional techniques, such as suturing and electrocautery, have drastically reduced operatory bleeding. Unfortunately, wound edges and point application devices are frequently characterized by bleeding and infections. Over the past 20 years, haemostatic agents and tissue sealants have been developed and now are currently used, along with classic suture in various surgical specialties. Their fluid nature allows management of blood loss along any point of the wound and tissue repair. This review presents an overview of the most diffused haemostatic sealants, focusing on their main use in surgery and their adverse effects.
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18
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Ko BS, Kim WT, Chang SS, Kim EH, Lee SW, Park WS, Kim YS, Nam SW, Lee DS, Kim JC, Kang SB. A case of ascending colon variceal bleeding treated with venous coil embolization. World J Gastroenterol 2013; 19:311-5. [PMID: 23345957 PMCID: PMC3547563 DOI: 10.3748/wjg.v19.i2.311] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 11/08/2012] [Accepted: 11/14/2012] [Indexed: 02/06/2023] Open
Abstract
A 38-year-old female with a history of alcoholic liver cirrhosis visited our hospital with a massive hematochezia. An esophagogastroduodenoscopy did not demonstrate any bleeding source, and a colonoscopy showed a massive hemorrhage in the ascending colon but without an obvious focus. The source of the bleeding could not be found with a mesenteric artery angiography. We performed an enhanced abdominal computed tomography, which revealed a distal ascending colonic varix, and assumed that the varix was the source of the bleeding. We performed a venous coil embolization and histoacryl injection to obliterate the colon varix. The intervention appeared to be successful because the vital signs and hemoglobin laboratory data remained stable and because the hematochezia was no longer observed. We report here on a rare case of colonic variceal bleeding that was treated with venous coil embolization.
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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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Affiliation(s)
- Ashish Kumar Jha
- Department of Gastroenterology, Apollo Gleneagles Hospital, Kolkata, India
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21
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Khaliq A, Dutta U, Kochhar R, Chalapathi A, Singh K. Massive lower gastrointestinal bleed due to rectal varix. Intern Emerg Med 2012; 7 Suppl 1:S57-9. [PMID: 22033787 DOI: 10.1007/s11739-011-0685-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Accepted: 07/22/2011] [Indexed: 12/31/2022]
Affiliation(s)
- Abdul Khaliq
- Department of Gastroenterology, PGIMER, Sector-12, Chandigarh, India.
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22
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Maranki JL, Haluszka O. Endoscopic therapies for small-bowel bleeding. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2012. [DOI: 10.1016/j.tgie.2012.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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23
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Almadi MA, Almessabi A, Wong P, Ghali PM, Barkun A. Ectopic varices. Gastrointest Endosc 2011; 74:380-8. [PMID: 21612777 DOI: 10.1016/j.gie.2011.03.1177] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Accepted: 03/14/2011] [Indexed: 12/13/2022]
Affiliation(s)
- Majid Abdulrahman Almadi
- Division of Gastroenterology, McGill University and the McGill University Health Centre, Montreal, Quebec, Canada
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24
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Malik A, Junglee N, Khan A, Sutton J, Gasem J, Ahmed W. Duodenal varices successfully treated with cyanoacrylate injection therapy. BMJ Case Rep 2011; 2011:bcr.02.2011.3913. [PMID: 22694885 DOI: 10.1136/bcr.02.2011.3913] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Duodenal varices are a rare complication of portal hypertension secondary to liver cirrhosis. Compared to oesophageal varices, they bleed less often but are also more difficult to diagnose and treat. There is no established treatment for bleeding duodenal varices and different treatment strategies have been employed with variable results. The authors present a case of 52-year-old male who was admitted with melaena. Upper gastrointestinal endoscopy was performed which identified bleeding varices in the second part of duodenum. The varices were injected with cyanoacrylate and the outcome was favourable. Subsequent endoscopies showed complete resolution of the varices. The authors conclude that cyanoacrylate injection is an effective first-line treatment for bleeding duodenal varices.
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Affiliation(s)
- Ahsan Malik
- Department of Gastroenterology, Ysbyty Gwynedd, Bangor, UK.
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25
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Fixot K, Cazeres C, Massoure MP, Bredin C, Aziz S, Sockeel P. [Colonic varices treated by right colectomy]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2009; 33:1018-1020. [PMID: 19477610 DOI: 10.1016/j.gcb.2009.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Revised: 02/27/2009] [Accepted: 03/03/2009] [Indexed: 05/27/2023]
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26
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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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27
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Transverse colonic varices successfully treated with endoscopic procedure. Clin J Gastroenterol 2008; 1:52-55. [PMID: 26193462 DOI: 10.1007/s12328-008-0010-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2008] [Accepted: 03/03/2008] [Indexed: 01/27/2023]
Abstract
A 75-year-old woman with hepatitis C virus antibody-positive liver cirrhosis was admitted to our hospital with anal bleeding. Colonoscopy revealed red color-positive tortuous transverse colonic varices near the splenic flexure. Colonic varices were considered to be the most probable cause of bleeding, although the precise site could not be determined. Endoscopic injection sclerotherapy was performed for colonic varices. Endoscopic clipping was performed for bilateral sites of varices as an additional treatment. Four months after endoscopic treatments, colonoscopy revealed ulcer scars in the transverse colon and shrinkage of the varices.
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28
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Park WG, Yeh RW, Triadafilopoulos G. Injection therapies for variceal bleeding disorders of the GI tract. Gastrointest Endosc 2008; 67:313-23. [PMID: 18226695 DOI: 10.1016/j.gie.2007.09.052] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2007] [Accepted: 09/27/2007] [Indexed: 02/07/2023]
Affiliation(s)
- Walter G Park
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California 94305, USA.
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29
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Abstract
Many advances have occurred in the management of varices over the years. Guidelines based on sound evidence have been developed to manage the esophageal variceal hemorrhage. Less is known about how best to manage some of the more difficult cases of bleeding related to portal hypertension. This article reviews evidence in the hypertensive gastropathy, ectopic varices, and management of patients who are intolerant of or have not responded to beta-blocker therapy. The goal of this article is to review the sparse available evidence and to suggest reasonable management options.
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Affiliation(s)
- Atif Zaman
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Mailcode PV310, Portland, OR 97210, USA.
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30
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Parvaiz A, Azeem S, Singh RK, Lamparelli M. Stapled hemorrhoidopexy: an alternative technique for the treatment of bleeding anorectal varices. Report of a case. Dis Colon Rectum 2006; 49:411-2. [PMID: 16322963 DOI: 10.1007/s10350-005-0255-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Amjad Parvaiz
- Department of Surgery, Dorset County Hospital, Williams Avenue, Dorchester, DTI 2JY, United Kingdom
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31
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Ryu SH, Ryu SH, Moon JS, Moon JS, Kim I, Kim YS, Kim YS, Lee JH, Lee JH. Endoscopic injection sclerotherapy with N-butyl-2-cyanoacrylate in a patient with massive rectal variceal bleeding: a case report. Gastrointest Endosc 2005; 62:632-5. [PMID: 16185988 DOI: 10.1016/j.gie.2005.05.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2005] [Accepted: 05/03/2005] [Indexed: 12/10/2022]
Affiliation(s)
- Soo Hyung Ryu
- Department of Internal Medicine, University of Inje College of Medicine, Seoul Paik Hospital, Seoul, Korea
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32
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Ho YP, Lin CJ, Su MY, Tseng JH, Chiu CT, Chen PC. Isolated varices over hepatic flexure colon indicating superior mesenteric venous thrombosis caused by uncinate pancreatic head cancer - a case report. World J Gastroenterol 2005; 11:1886-9. [PMID: 15793888 PMCID: PMC4305898 DOI: 10.3748/wjg.v11.i12.1886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Very rare cases of varices involving right side colon were reported. Most of them were due to cirrhotic portal hypertension or other primary causes. No report case contributed to pancreatic cancer. Here, we reported a case of uncinate pancreatic cancer with the initial finding of isolated hepatic flexure colon varices. Following studies confirmed isolated varices involving hepatic flexure colon due to pancreatic cancer with occlusion of superior mesenteric vein. From this report, superior mesenteric vein occlusion caused by uncinate pancreatic head cancer should be considered as a differential diagnosis of colon varices.
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Affiliation(s)
- Yu-Pin Ho
- Department of Gastroenterology, Radiology, Linkou Medical Center, Chang Gung Memorial Hospital, 5 Fushin Street, Kweishan, Taoyuan, Taiwan, China
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Shiraki M, Takagi S, Sugiyama K, Iwasaki T, Aihara H, Takahashi S, Kinouchi Y, Hiwatashi N, Shimosegawa T. Rupture of Rectal Varices Treated With Endoscopic Variceal Ligation. Surg Laparosc Endosc Percutan Tech 2004; 14:295-9. [PMID: 15492663 DOI: 10.1097/00129689-200410000-00015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We report here 3 cases of rectal varices treated with endoscopic variceal ligation and discuss the pathogenesis, treatment, and prognosis of rectal varices with referring to previous reports. Of the 3 patients, 2 had been diagnosed as liver cirrhosis and 1 as extrahepatic portal hypertension. All of the 3 patients had previously undergone treatment of esophagogastric varices. The rupture of rectal varices appeared to have some relationship with the treatment of esophageal varices. In previous reports, 73% of patients with ruptured rectal varices treated with endoscopic injection sclerotherapy or endoscopic variceal ligation had undergone treatments of esophageal varices. The endoscopic treatments resulted in a favorable prognosis in 2 patients. Although no fatality from endoscopic injection sclerotherapy or endoscopic variceal ligation has been reported, 1 of the present 3 cases died of liver failure.
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Affiliation(s)
- Manabu Shiraki
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan.
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34
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Silvain C. [How to prevent and to treat bleeding from gastric or ectopic or from portal hypertension gastropathy]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2004; 28 Spec No 2:B218-26. [PMID: 15150516 DOI: 10.1016/s0399-8320(04)95259-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- Christine Silvain
- Service d'Hépato-Gastroentérologie et Assistance Nutritive, CHU La Milétrie, 86021 Poitiers Cedex
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35
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Oberti F. Comment prévenir et traiter les hémorragies par varices gastriques, ou ectopiques ou par gastropathie congestive. ACTA ACUST UNITED AC 2004; 28 Spec No 2:B53-72. [PMID: 15150498 DOI: 10.1016/s0399-8320(04)95241-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Frédéric Oberti
- Service d'Hépato-Gastroentérologie, Centre Hospitalo-Universitaire Angers, 49100 Angers
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36
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Abstract
Urgent colonoscopy has emerged as the initial diagnostic and main therapeutic tool in the evaluation and treatment of colonic lower gastrointestinal bleeding. Endoscopic therapy can effectively treat most cases of colonic bleeding with a demonstrable improvement in clinical outcome parameters. The identification of high-risk stigmata of hemorrhage enables selective targeting of endoscopic therapy to lesions at high risk of rebleeding. Advances in technologies such as novel mechanical methods of hemostasis (eg, metallic clips), injection techniques (eg, cyanoacrylate injection), and the widening application of established endoscopic hemostatic techniques (eg, rubber-band ligation) to colonic lesions offers the possibility of further improvements in the efficacy of endoscopic hemostasis. Clinical trials are needed to compare these novel endoscopic techniques with more conventional approaches to establish the best form of endoscopic therapy for different bleeding lesions and finally to establish more definitively the optimal timing of colonoscopy.
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Affiliation(s)
- Umar Beejay
- Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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