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Ogawa S, Yamamoto A, Jogo A, Kageyama K, Sohgawa E, Ohira G, Kimura K, Tanaka S, Amano R, Takemura S, Ishizawa T, Miki Y. Embolization with or without portal vein stenting for bleeding ectopic jejunal varices in hepatopetal portal collaterals due to extrahepatic portal vein occlusion or stenosis after hepatobiliary and pancreatic surgery. Jpn J Radiol 2024:10.1007/s11604-024-01616-1. [PMID: 38935221 DOI: 10.1007/s11604-024-01616-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 06/17/2024] [Indexed: 06/28/2024]
Abstract
PURPOSE To evaluate the efficacy and safety of embolization with or without portal vein stenting for bleeding ectopic jejunal varices in the hepatopetal portal collateral due to extrahepatic portal vein occlusion or stenosis after hepatobiliary and pancreatic surgery. MATERIALS AND METHODS This study included consecutive patients who underwent embolization for bleeding ectopic jejunal varices in the hepatopetal collateral due to extrahepatic portal vein occlusion or stenosis after hepatobiliary and pancreatic surgery between September 2012 and December 2020. The safety, technical and clinical success rates (no re-bleeding within 1 month) and re-bleeding-free survival after the first therapy and overall survival were assessed. RESULTS Fourteen sessions in 11 patients were included. Four patients (7 sessions) underwent variceal embolization only, and the remaining seven patients (7 sessions) underwent portal vein stenting and variceal embolization. Technical success was achieved in all 14 sessions (100%). Clinical success was achieved in 13 of 14 sessions (92.9%). No treatment-related serious complications including liver failure were observed. One-year and 2-year re-bleeding-free survival rate after the first endovascular therapy in all 11 patients was 90.9 and 60.6%, respectively. Two patients who experienced re-bleeding had repeat embolization treatment. There was no significant difference in re-bleeding-free survival after endovascular therapy between the combination with stenting and embolization group and the embolization-only group (p = 0.13). CONCLUSION Embolization with or without portal vein stenting of bleeding ectopic jejunal varices in the hepatopetal portal collateral due to extrahepatic portal vein occlusion or stenosis after hepatobiliary and pancreatic surgery can be considered a safe, effective, and repeatable therapy for long-term hemostasis of uncontrollable bleeding.
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Affiliation(s)
- Satoyuki Ogawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
- Department of Diagnostic Radiology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-Ku, Osaka, 530-0012, Japan
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan.
| | - Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
| | - Ken Kageyama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
| | - Etsuji Sohgawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
| | - Go Ohira
- Department of Hepato-Biliary-Pancreatic Surgery Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Kenjiro Kimura
- Department of Hepato-Biliary-Pancreatic Surgery Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Shogo Tanaka
- Department of Hepato-Biliary-Pancreatic Surgery Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Ryosuke Amano
- Department of Hepato-Biliary-Pancreatic Surgery Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Shigekazu Takemura
- Department of Hepato-Biliary-Pancreatic Surgery Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Takeaki Ishizawa
- Department of Hepato-Biliary-Pancreatic Surgery Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
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2
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Ghadimi DJ, Ghorani H, Moradi Z, Golezar MH, Nouri S, Irilouzadian R, Zare Dehnavi A, Ebrahimi P, Ghasemi Rad M. Management of ectopic variceal bleeding with transjugular intrahepatic portosystemic shunt: a systematic review of case reports. Emerg Radiol 2024:10.1007/s10140-024-02258-6. [PMID: 38935315 DOI: 10.1007/s10140-024-02258-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024]
Abstract
Ectopic varices account for 5% of variceal bleedings and occur outside the gastro-esophageal region. This review evaluates the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) for ectopic variceal management. A comprehensive search through PubMed, Scopus, Web of Science, and Embase was conducted until January 16, 2023, using relevant keywords. Case reports and case series with fewer than 10 patients on TIPS for ectopic variceal management were included. The quality assessment followed the Joanna Briggs Institute checklist for case reports. This systematic review evaluated 43 studies involving 50 patients with ectopic varices undergoing TIPS. Patients had a mean age of 54.3 years, half were female, and two were pregnant. Alcoholic liver disease (48%) and hepatitis C infection (26%) were common causes of portal hypertension. Ascites and splenomegaly were reported in 32% and 28% of the patients, respectively. Rectal, oral, and stomal variceal bleeding accounted for 62%, 16%, and 22% of the patients, respectively. Ectopic varices were mainly located in the duodenum (28%) and rectum (26%) regions. Complications affected 42% of the patients, re-bleeding in eleven and hepatic encephalopathy in seven. The follow-up lasted 12 months on average, and finally, 5 received a liver transplant. Mortality post-TIPS was 18%. Despite complications and a notable mortality rate, favorable outcomes were observed in almost half of the patients with ectopic variceal bleeding managed with TIPS. Further research is warranted to refine strategies and improve patient outcomes.
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Affiliation(s)
- Delaram J Ghadimi
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamed Ghorani
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Science, Tehran, Iran
| | - Zahra Moradi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Hossein Golezar
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Science, Tehran, Iran
- Student Research Committee, Faculty of Medicine, Shahed University, Tehran, Iran
| | - Shadi Nouri
- Department of Radiology, School of Medicine Arak, University of Medical Sciences, Arak, Iran
| | - Rana Irilouzadian
- Burn Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Zare Dehnavi
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine and Science, Rochester, MN, 55905, USA
| | - Pouya Ebrahimi
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ghasemi Rad
- Department of Interventional Radiology, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA.
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3
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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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4
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Munechika T, Shiokawa K, Takeshita I, Shimokobe H, Sahara K, Matsumoto Y, Aisu N, Yoshimatsu G, Hasegawa S. Laparoscopic sigmoid colectomy for transverse colonic varices due to an inferior mesenteric arteriovenous fistula. Surg Case Rep 2024; 10:112. [PMID: 38700649 PMCID: PMC11068706 DOI: 10.1186/s40792-024-01911-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/25/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Colonic varices are a rare gastrointestinal anomaly often associated with portal hypertension. Arteriovenous fistula (AVF) in the inferior mesenteric artery (IMA) region is even rarer. Diagnosis and treatment of these entities present unique challenges, especially when the IMA is involved. CASE PRESENTATION A 48-year-old man with a history of cholecystectomy presented with after a positive fecal occult blood test. Investigations revealed varices from the splenic flexure to the transverse colon and suspected AVF in the IMA region. Given the high risk and low efficacy of endoscopic and radiological interventions, laparoscopic sigmoidectomy was performed. This surgical approach successfully addressed both the AVF and the associated varices. CONCLUSION This case underscores the importance of surgical intervention for AVF and colonic varices in the IMA region, particularly when other treatment options pose high risks and have limited efficacy. The favorable postoperative outcome in this case highlights the effectiveness of carefully chosen surgical methods when managing such complex and rare conditions.
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Affiliation(s)
- Taro Munechika
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma, Jonan-Ku, Fukuoka City, Fukuoka, 814-0180, Japan.
| | - Keiichi Shiokawa
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma, Jonan-Ku, Fukuoka City, Fukuoka, 814-0180, Japan
| | - Issei Takeshita
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma, Jonan-Ku, Fukuoka City, Fukuoka, 814-0180, Japan
| | - Hisaaki Shimokobe
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma, Jonan-Ku, Fukuoka City, Fukuoka, 814-0180, Japan
| | - Kurumi Sahara
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma, Jonan-Ku, Fukuoka City, Fukuoka, 814-0180, Japan
| | - Yoshiko Matsumoto
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma, Jonan-Ku, Fukuoka City, Fukuoka, 814-0180, Japan
| | - Naoya Aisu
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma, Jonan-Ku, Fukuoka City, Fukuoka, 814-0180, Japan
| | - Gumpei Yoshimatsu
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma, Jonan-Ku, Fukuoka City, Fukuoka, 814-0180, Japan
| | - Suguru Hasegawa
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma, Jonan-Ku, Fukuoka City, Fukuoka, 814-0180, Japan
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5
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Liu J, Wang P, Wang LM, Guo J, Zhong N. Outcomes of endoscopic sclerotherapy for jejunal varices at the site of choledochojejunostomy (with video): Three case reports. World J Gastroenterol 2024; 30:2059-2067. [PMID: 38681128 PMCID: PMC11045488 DOI: 10.3748/wjg.v30.i14.2059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/09/2024] [Accepted: 03/26/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Hemorrhage associated with varices at the site of choledochojejunostomy is an unusual, difficult to treat, and often fatal manifestation of portal hypertension. So far, no treatment guidelines have been established. CASE SUMMARY We reported three patients with jejunal varices at the site of choledochojejunostomy managed by endoscopic sclerotherapy with lauromacrogol/α-butyl cyanoacrylate injection at our institution between June 2021 and August 2023. We reviewed all patient records, clinical presentation, endoscopic findings and treatment, outcomes and follow-up. Three patients who underwent pancreaticoduodenectomy with a Whipple anastomosis were examined using conventional upper gastrointestinal endoscopy for suspected hemorrhage from the afferent jejunal loop. Varices with stigmata of recent hemorrhage or active hemorrhage were observed around the choledochojejunostomy site in all three patients. Endoscopic injection of lauromacrogol/α-butyl cyanoacrylate was carried out at jejunal varices for all three patients. The bleeding ceased and patency was observed for 26 and 2 months in two patients. In one patient with multiorgan failure and internal environment disturbance, rebleeding occurred 1 month after endoscopic sclerotherapy, and despite a second endoscopic sclerotherapy, repeated episodes of bleeding and multiorgan failure resulted in eventual death. CONCLUSION We conclude that endoscopic sclerotherapy with lauromacrogol/α-butyl cyanoacrylate injection can be an easy, effective, safe and low-cost treatment option for jejunal varicose bleeding at the site of choledochojejunostomy.
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Affiliation(s)
- Jun Liu
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Peng Wang
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Li-Mei Wang
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Jing Guo
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Ning Zhong
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
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6
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Inomata Y, Naito T, Hiratsuka T, Shimoyama Y, Moroi R, Shiga H, Kakuta Y, Kayada K, Ohara Y, Asano N, Aoki S, Unno M, Masamune A. Rupture of ectopic varices of the ascending colon occurring after pancreatic cancer surgery: A case report and literature review. DEN OPEN 2024; 4:e255. [PMID: 37441155 PMCID: PMC10333722 DOI: 10.1002/deo2.255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/22/2023] [Accepted: 05/31/2023] [Indexed: 07/15/2023]
Abstract
A 69-year-old woman, a long-term survivor of subtotal stomach-preserving pancreatoduodenectomy with the splenic vein resection for pancreatic cancer, visited our hospital with a chief complaint of bloody stools. Previously, she was diagnosed with varices in the ascending colon due to left-sided portal hypertension after pancreatoduodenectomy by computed tomography and colonoscopy. After emergency hospitalization, she went into shock, and blood tests showed acute progression of severe anemia. Computed tomography showed a mosaic-like fluid accumulation from the ascending colon to the rectum. She was diagnosed with ruptured varices in the ascending colon. Emergency colonoscopy was performed, and treatment with endoscopic injection sclerotherapy using N-butyl-2-cyanoacrylate was successful. Ectopic varices occur at any location other than the esophagus and stomach, and colonic varices are rare among them. They are mostly caused by portal hypertension due to liver cirrhosis. However, with the trend of improving the prognosis for patients with pancreatic cancer, we should occasionally pay attention to the development of ectopic varices including colonic varices in patients who have undergone pancreatoduodenectomy with superior mesenteric and splenic veins resection. Treatment methods for colonic varices varied from case to case, including conservative therapy, interventional radiology, and endoscopic procedure. In this case, endoscopic injection sclerotherapy was successfully performed without any complications. To the best of our knowledge, this is the first study to report successful treatment with endoscopic injection sclerotherapy for varices in the ascending colon caused by left-sided portal hypertension after pancreatoduodenectomy. Colonic varices should be considered in patients with obscure gastrointestinal bleeding after pancreatoduodenectomy.
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Affiliation(s)
- Yushi Inomata
- Division of GastroenterologyTohoku University Graduate School of MedicineMiyagiJapan
| | - Takeo Naito
- Division of GastroenterologyTohoku University Graduate School of MedicineMiyagiJapan
| | - Takashi Hiratsuka
- Division of GastroenterologyTohoku University Graduate School of MedicineMiyagiJapan
| | - Yusuke Shimoyama
- Division of GastroenterologyTohoku University Graduate School of MedicineMiyagiJapan
| | - Rintaro Moroi
- Division of GastroenterologyTohoku University Graduate School of MedicineMiyagiJapan
| | - Hisashi Shiga
- Division of GastroenterologyTohoku University Graduate School of MedicineMiyagiJapan
| | - Yoichi Kakuta
- Division of GastroenterologyTohoku University Graduate School of MedicineMiyagiJapan
| | - Kimiko Kayada
- Division of GastroenterologyTohoku University Graduate School of MedicineMiyagiJapan
| | - Yuki Ohara
- Division of GastroenterologyTohoku University Graduate School of MedicineMiyagiJapan
| | - Naoki Asano
- Division of GastroenterologyTohoku University Graduate School of MedicineMiyagiJapan
| | - Shuichi Aoki
- Department of SurgeryTohoku University Graduate School of MedicineMiyagiJapan
| | - Michiaki Unno
- Department of SurgeryTohoku University Graduate School of MedicineMiyagiJapan
| | - Atsushi Masamune
- Division of GastroenterologyTohoku University Graduate School of MedicineMiyagiJapan
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7
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Pas M, Jogo A, Yamamoto A, Kageyama K, Sohgawa E, Oura T, Terayama E, Asano K, Matsushita K, Sakai Y, Ozaki M, Yonezawa H, Okazaki M, Nota T, Murai K, Kita R, Kaminou T, Miki Y. Transparaumbilical Intravariceal Sclerotherapy for Duodenal Varices Using Outflow Embolization. Intern Med 2024; 63:803-807. [PMID: 37495529 PMCID: PMC11008987 DOI: 10.2169/internalmedicine.2274-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/12/2023] [Indexed: 07/28/2023] Open
Abstract
A 55-year-old patient was admitted for variceal treatment, a complication of chronic portal hypertension and liver cirrhosis. Imaging studies revealed prominent duodenal varices, the pancreaticoduodenal vein as its afferent pathway, a drainer vessel into the inferior vena cava, and a paraumbilical vein. We successfully performed complete obliteration of the varix, including its afferent and efferent vessels, via the paraumbilical vein approach.
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Affiliation(s)
- Maciej Pas
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Ken Kageyama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Etsuji Sohgawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Tatsushi Oura
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Eisaku Terayama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Kazuo Asano
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Kazuki Matsushita
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Yuki Sakai
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Masanori Ozaki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Hiroki Yonezawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Masahiro Okazaki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Takehito Nota
- Advanced Imaging and Minimally Invasive Therapy Center, Tsukazaki Hospital, Japan
| | - Kazuki Murai
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Ryuichi Kita
- Department of Gastroenterology, Osaka Red Cross Hospital, Japan
| | - Toshio Kaminou
- Advanced Imaging and Minimally Invasive Therapy Center, Tsukazaki Hospital, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
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8
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Tranah TH, Nayagam JS, Gregory S, Hughes S, Patch D, Tripathi D, Shawcross DL, Joshi D. Diagnosis and management of ectopic varices in portal hypertension. Lancet Gastroenterol Hepatol 2023; 8:1046-1056. [PMID: 37683687 DOI: 10.1016/s2468-1253(23)00209-1] [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: 05/25/2023] [Revised: 06/29/2023] [Accepted: 07/03/2023] [Indexed: 09/10/2023]
Abstract
Ectopic variceal bleeding is a rare cause of gastrointestinal bleeding that can occur in settings of cirrhotic and non-cirrhotic portal hypertension and is characterised by its development at locations remote from the oesophagus and stomach. Ectopic varices can be difficult to identify and access, and, although a relatively uncommon cause of portal hypertensive bleeding, can represent a difficult diagnostic and therapeutic challenge associated with considerable mortality. Low incidence and variance in variceal anatomy preclude large randomised controlled trials, and clinical practice is based on experience from case reports, case series, and specialist centre expertise. Optimisation of survival outcomes relies on understanding a patient's portal venous anatomy and functional hepatic reserve to guide timely and targeted endoscopic and endovascular interventions to facilitate the rapid control of ectopic variceal bleeding.
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Affiliation(s)
- Thomas H Tranah
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Institute of Liver Studies, King's College Hospital, London, UK.
| | - Jeremy S Nayagam
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Institute of Liver Studies, King's College Hospital, London, UK
| | - Stephen Gregory
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Sarah Hughes
- Department of Gastroenterology and Hepatology, St George's Healthcare NHS Trust, London, UK
| | - David Patch
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and University College London, London, UK
| | - Dhiraj Tripathi
- Department of Liver and Hepato-Pancreato-Biliary Unit, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Debbie L Shawcross
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Institute of Liver Studies, King's College Hospital, London, UK
| | - Deepak Joshi
- Institute of Liver Studies, King's College Hospital, London, UK
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9
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Michielan A, Vieceli F, Pravadelli C, Moser L, Agugiaro F, Luppi G, Gatti FL, Costa L, Rozzanigo UM. Combination of transjugular intrahepatic portosystemic shunt and antegrade through-the-TIPS coil embolization for bleeding mixed-type ectopic ileal varices. Clin J Gastroenterol 2023; 16:668-672. [PMID: 37452994 PMCID: PMC10539418 DOI: 10.1007/s12328-023-01830-w] [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: 04/16/2023] [Accepted: 07/03/2023] [Indexed: 07/18/2023]
Abstract
A 61-year-old man with alcoholic cirrhosis and a history of severe cholecystitis leading to secondary thrombosis of the recanalized paraumbilical vein was admitted to our hospital for recurrent gastrointestinal bleeding and severe anemia. Capsule endoscopy and CT angiography detected profuse bleeding in the proximal ileum from ectopic ileal varices. Hepatic venous-portal gradient (HVPG) measurement was consistent with severe portal hypertension. Persistent bleeding despite transjugular intrahepatic portosystemic shunt (TIPS) placement required a combined approach with antegrade through-the-TIPS coil embolization of the ileal varices.
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Affiliation(s)
- Andrea Michielan
- Department of Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, APSS Trento, Trento, Italy
| | - Filippo Vieceli
- Department of Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, APSS Trento, Trento, Italy
| | - Cecilia Pravadelli
- Department of Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, APSS Trento, Trento, Italy
| | - Luisa Moser
- Department of Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, APSS Trento, Trento, Italy
| | - Flora Agugiaro
- Department of Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, APSS Trento, Trento, Italy
| | - Giacomo Luppi
- Department of Radiology, Santa Chiara Hospital, APSS Trento, Largo Medaglie D'Oro 9, 38122, Trento, Italy
| | - Francesco Lorenzo Gatti
- Department of Radiology, Santa Chiara Hospital, APSS Trento, Largo Medaglie D'Oro 9, 38122, Trento, Italy
| | - Lorenzo Costa
- Department of Radiology, Santa Chiara Hospital, APSS Trento, Largo Medaglie D'Oro 9, 38122, Trento, Italy
| | - Umberto Maria Rozzanigo
- Department of Radiology, Santa Chiara Hospital, APSS Trento, Largo Medaglie D'Oro 9, 38122, Trento, Italy.
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy.
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10
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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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11
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Füssel LM, Müller-Wille R, Dinkhauser P, Schauer W, Hofer H. Treatment of colonic varices and gastrointestinal bleeding by recanalization and stenting of splenic-vein-thrombosis: A case report and literature review. World J Gastroenterol 2023; 29:3922-3931. [PMID: 37426315 PMCID: PMC10324528 DOI: 10.3748/wjg.v29.i24.3922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/27/2023] [Accepted: 05/30/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Splenic vein thrombosis is a known complication of pancreatitis. It can lead to increased blood flow through mesenteric collaterals. This segmental hypertension may result in the development of colonic varices (CV) with a high risk of severe gastrointestinal bleeding. While clear guidelines for treatment are lacking, splenectomy or splenic artery embolization are often used to treat bleeding. Splenic vein stenting has been shown to be a safe option.
CASE SUMMARY A 45-year-old female patient was admitted due to recurrent gastrointestinal bleeding. She was anemic with a hemoglobin of 8.0 g/dL. As a source of bleeding, CV were identified. Computed tomography scans revealed thrombotic occlusion of the splenic vein, presumably as a result of a severe acute pancreatitis 8 years prior. In a selective angiography, a dilated mesenterial collateral leading from the spleen to enlarged vessels in the right colonic flexure and draining into the superior mesenteric vein could be confirmed. The hepatic venous pressure gradient was within normal range. In an interdisciplinary board, transhepatic recanalization of the splenic vein via balloon dilatation and consecutive stenting, as well as coiling of the aberrant veins was discussed and successfully performed. Consecutive evaluation revealed complete regression of CV and splenomegaly as well as normalization of the red blood cell count during follow-up.
CONCLUSION Recanalization and stenting of splenic vein thrombosis might be considered in patients with gastrointestinal bleeding due to CV. However, a multidisciplinary approach with a thorough workup and discussion of individualized therapeutic strategies is crucial in these difficult to treat patients.
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Affiliation(s)
- Lisa-Michaela Füssel
- Department of Internal Medicine I, Gastroenterology and Hepatology, Klinikum Wels-Grieskirchen, Wels 4600, Austria
| | - Rene Müller-Wille
- Department of Radiology, Klinikum Wels-Grieskirchen, Wels 4600, Austria
| | - Patrick Dinkhauser
- Department of Internal Medicine I, Gastroenterology and Hepatology, Klinikum Wels-Grieskirchen, Wels 4600, Austria
| | - Walter Schauer
- Department of Abdominal Surgery, Klinikum Wels-Grieskirchen, Wels 4600, Austria
| | - Harald Hofer
- Department of Internal Medicine I, Gastroenterology and Hepatology, Klinikum Wels-Grieskirchen, Wels 4600, Austria
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12
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Dhar J, Samanta J. Endoscopic ultrasound-guided vascular interventions: An expanding paradigm. World J Gastrointest Endosc 2023; 15:216-239. [PMID: 37138933 PMCID: PMC10150286 DOI: 10.4253/wjge.v15.i4.216] [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: 11/17/2022] [Revised: 01/09/2023] [Accepted: 03/15/2023] [Indexed: 04/14/2023] Open
Abstract
Endoscopic ultrasound (EUS) has expanded its arena from a mere diagnostic modality to an essential therapeutic tool in managing gastrointestinal (GI) diseases. The proximity of the GI tract to the vascular structures in the mediastinum and the abdomen has facilitated the growth of EUS in the field of vascular interventions. EUS provides important clinical and anatomical information related to the vessels' size, appearance and location. Its excellent spatial resolution, use of colour doppler with or without contrast enhancement and ability to provide images “real-time” helps in precision while intervening vascular structures. Additionally, structures such as venous collaterals or varices can be dealt with optimally using EUS. EUS-guided vascular therapy with coil and glue combination has revolutionized the management of portal hypertension. It also helps to avoid radiation exposure in addition to being minimally invasive. These advantages have led EUS to become an upcoming modality to complement traditional interventional radiology in the field of vascular interventions. EUS-guided portal vein (PV) access and therapy is a new kid on the block. EUS-guided portal pressure gradient measurement, injecting chemotherapy in PV and intrahepatic portosystemic shunt has expanded the horizons of endo-hepatology. Lastly, EUS has also forayed into cardiac interventions allowing pericardial fluid aspiration and tumour biopsy with experimental data on access to valvular apparatus. Herein, we provide a comprehensive review of the expanding paradigm of EUS-guided vascular interventions in GI bleeding, portal vein access and its related therapeutic interventions, cardiac access, and therapy. A synopsis of all the technical details involving each procedure and the available data has been tabulated, and the future trends in this area have been highlighted.
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Affiliation(s)
- Jahnvi Dhar
- Gastroenterology, Sohana Multispeciality Hospital, Mohali 140308, India
| | - Jayanta Samanta
- Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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13
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Zhu Y, Li X, He S. Identification and Treatment of an Unusual Cause of Gastrointestinal Bleeding. Gastroenterology 2023; 164:e17-e20. [PMID: 36162591 DOI: 10.1053/j.gastro.2022.08.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 08/29/2022] [Accepted: 08/31/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Yongjun Zhu
- Department of Gastroenterology and Hepatology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xia Li
- Department of Gastroenterology and Hepatology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Song He
- Department of Gastroenterology and Hepatology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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14
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Shafiq S, Devarbhavi H, Patil M. Endoscopic Cyanoacrylate Glue Injection for Duodenal Varices—A Single-Center Study. JOURNAL OF DIGESTIVE ENDOSCOPY 2022. [DOI: 10.1055/s-0042-1757469] [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: 12/23/2022] Open
Abstract
Abstract
Aim/Objectives Duodenal varices (DVs), although rare, can present with massive, potentially fatal upper gastrointestinal bleeding; however, there are no randomized trials regarding management of this relatively uncommon presentation. We aim to report our experience with endoscopic cyanoacrylate glue injection in patients with DVs.
Materials and Methods We retrospectively evaluated the medical records of all patients with portal hypertension at our center between January 2010 and December 2021. Demographic characteristics along with the etiology, location, and effectiveness of cyanoacrylate glue injection for bleeding DVs were collected and analyzed.
Results A total of 5,892 patients with portal hypertension underwent endoscopy during the study period, of whom 41 patients (M:F = 29:12) with mean age of 38 years were noted to have DVs. While extrahepatic portal vein obstruction was the commonest etiology (n = 26), the most common site of DVs was the duodenal bulb (n = 21). Twenty-one (51%) out of these 41 patients presented primarily with DV bleeding and underwent endoscopic cyanoacrylate glue injection with successful hemostasis achieved of the index bleed; however, four of these 21 patients had rebleeding between 2 weeks and 12 months of follow-up requiring repeat endotherapy.. While three patients underwent successful repeat glue injections, one patient had recurrent massive bleedings, not amenable to endotherapy and was subjected to duodenal resection with surgical shunt procedure.
Conclusion While the prevalence of DVs in portal hypertension patients was 0.7% (41/5892), DVs accounted for 0.42% (21/4889) of portal hypertension-related bleedings. Endotherapy with cyanoacrylate glue appears to be a safe and cost-effective treatment for acute DV bleeding in a resource-limited setting.
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Affiliation(s)
- Syed Shafiq
- Department of Gastroenterology, St. John's Medical College Hospital, Bengaluru, Karnataka, India
| | - Harshad Devarbhavi
- Department of Gastroenterology, St. John's Medical College Hospital, Bengaluru, Karnataka, India
| | - Mallikarjun Patil
- Department of Gastroenterology, St. John's Medical College Hospital, Bengaluru, Karnataka, India
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15
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Pas M, Jogo A, Yamamoto A, Nishida N, Jogo E, Kageyama K, Sohgawa E, Miki Y. Successful treatment of rectal varices with antegrade transvenous sclerotherapy via the splenorenal shunt from the transjugular approach. Radiol Case Rep 2022; 17:4679-4684. [PMID: 36204409 PMCID: PMC9530408 DOI: 10.1016/j.radcr.2022.08.096] [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] [Received: 08/21/2022] [Accepted: 08/25/2022] [Indexed: 02/07/2023] Open
Abstract
A 74-year-old patient presented with hematochezia and a history of liver cirrhosis with repeated bleeding from esophageal and rectal varices. Endoscopic examination revealed multiple rectal varices with positive red color signs. Ascites, severe portosystemic thrombosis and a splenorenal shunt were diagnosed on a contrast-enhanced dynamic computed tomography examination. From a transjugular approach, we circumvented thrombosed regions by maneuvering double balloon catheters through the shunt and dilated left colic marginal vein. We managed to successfully obliterate the varices.
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16
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Ohta M, Murashima N, Ohyama T, Yoshida T, Hirota S, Kawanaka H, Hashizume M, Nakamura S, Chikamori F, Eguchi S, Tajiri T, Obara K, Kokubu S. The skill qualification system for portal hypertension in Japan. DEN OPEN 2022; 2:e74. [PMID: 35310701 PMCID: PMC8828245 DOI: 10.1002/deo2.74] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/01/2021] [Accepted: 10/24/2021] [Indexed: 11/23/2022]
Abstract
Objectives The diverse treatments available for portal hypertension require specialized knowledge of hemodynamics and include endoscopic treatments, interventional radiology (IVR), and surgery. The Japan Society for Portal Hypertension has developed the skill qualification system (SQS) for portal hypertension and began examination in 2014. Here, the status and validity of the judgment of the SQS examination were evaluated. Methods From 2014 to 2020, 79 applicants were evaluated by the SQS for portal hypertension. Each unedited video submitted as a candidate procedure was evaluated by two judges, and a grade of greater than 70% for the scoring items assessed by the judges was required to pass the examination. Inter‐rater agreement of success/failure between the two judges was investigated by the AC1 coefficient. Results The results of two judges differed for 11 of the 79 videos (13.9%), and five applicants (6.3%) ultimately failed the examination. The percentages of total points received by the applicants with endoscopic treatments, IVR, and surgery were 87.3%, 79.4%, and 80.8%, respectively. There were significant differences in the percentages between endoscopic treatments and IVR (P = 0.0015). The AC1 coefficients were 0.84 for the applicants overall, 0.93 for endoscopic treatments, 0.66 for IVR, and 0.72 for surgery. Similarly, there were significant differences in the AC1 coefficient between endoscopic treatments and IVR (P = 0.021). Conclusions The SQS for portal hypertension of the Japan Society for Portal Hypertension showed high reliability for video assessments by the judges. This system may contribute to the spread and further development of safe and effective treatments for portal hypertension in Japan.
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Affiliation(s)
- Masayuki Ohta
- Global Oita Medical Advanced Research Center for Health Oita University Oita Japan
- Department of Gastroenterological and Pediatric Surgery Oita University Faculty of Medicine Oita Japan
| | | | | | | | - Shozo Hirota
- Department of Radiology Konan Medical Center Hyogo Japan
| | - Hirofumi Kawanaka
- Clinical Research Institute and Department of Surgery National Hospital Organization Beppu Medical Center Oita Japan
| | | | - Shinichi Nakamura
- Institute of Gastroenterology Department of Internal Medicine Tokyo Women's Medical University Tokyo Japan
| | - Fumio Chikamori
- Department of Surgery Japanese Red Cross Kochi Hospital Kochi Japan
| | - Susumu Eguchi
- Department of Surgery Nagasaki University Graduate School of Biomedical Sciences Nagasaki Japan
| | | | - Katsutoshi Obara
- Fukushima Preservative Service Association of Health Fukushima Japan
| | - Shigehiro Kokubu
- Center for Liver Disease Minimal Invasive Treatment Shin‐Yurigaoka General Hospital Kanagawa Japan
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17
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Long-term outcomes of hemostatic therapy for variceal bleeding and the challenge pending in the post-direct-acting antivirals era. Acta Gastroenterol Belg 2022; 85:7-14. [PMID: 35304988 DOI: 10.51821/85.1.9276] [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] [Indexed: 11/21/2022]
Abstract
Background and study aims This study evaluated the longterm outcomes of mainly endoscopic hemostatic therapy for gastrointestinal variceal bleeding and of the transition of hemostatic therapy. Patients and methods Among 1,163 patients treated for gastrointestinal varices between April 2006 and June 2020, a total of 125 patients who underwent emergency hemostatic therapy were enrolled. Survival rates and secondary evaluation points were analyzed. Additionally, patients were classified into two groups: the previous and latter term. Patients' background, therapeutic method, and treatment results were compared between the groups. Results 94.4% had cirrhosis. The average Child-Pugh score was 8.90. Successful primary hemostasis rate was 98.4%, and 5.6% died within 2 weeks, all with a Child-Pugh score ≥9. The respective 1- and 5-year survival rates for Child-Pugh grade A/B were 81.3% and 55.4%, while those for Child-Pugh grade C were 58.1% and 17.8%. Child-Pugh grade C or hepatocellular carcinoma was significantly associated with poor prognosis. In total, 21.6% experienced variceal re-bleeding; 62.9% of these cases were triggered by continued alcohol consumption. There was no significant difference in survival between patients with and without variceal re-bleeding and in post-treatment survival between the previous and latter terms. In the latter term, the number of cases caused by continued alcohol consumption significantly increased. Conclusions Multidisciplinary treatment and continuation of proper management after hemostatic therapy for variceal bleeding are crucial. Continued alcohol consumption leads to variceal bleeding and re-bleeding; its proper management, including alcohol abstinence, is one of the major challenges left in the post-directacting antivirals era.
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18
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Haddad A, Beji H, Chaker Y, Maghrebi H, Jouini M, Kacem M. Surgical treatment for bleeding ileal varices: A case report. Int J Surg Case Rep 2021; 88:106573. [PMID: 34753100 PMCID: PMC8585655 DOI: 10.1016/j.ijscr.2021.106573] [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] [Received: 08/24/2021] [Revised: 10/31/2021] [Accepted: 10/31/2021] [Indexed: 11/28/2022] Open
Abstract
Introduction and importance Bleeding from ileal varices is a rare and a life-threatening situation. Its management is difficult and includes endoscopic, surgical and interventional radiology treatment. Here we report a successful emergency surgery for bleeding ileal varices in a patient with cirrhosis due to autoimmune hepatitis. Presentation of a case A 60-year-old woman was admitted for rectal bleeding. She had a history of autoimmune hepatitis. She was treated by endoscopic ligation for oesophageal varices. Eso-gastro-duodenal fibroscopy and colonoscopy failed to reveal the bleeding site. CT scan was then performed showing ileal varices due to a portocaval shunt, there was a communication between the superior mesenteric vein and the right internal iliac vein. As the embolization was not feasible and the bleeding did not stop, an exploratory laparotomy was performed showing two dilated veins on the surface of the ileal wall, communicating with the right internal iliac vein. We performed a ligation of the vessels. Postoperative course was uneventful. Discussion Ectopic varices are a rare case of gastrointestinal bleeding. Most of those patients have portal hypertension and liver cirrhosis. Diagnosing bleeding ileal varices is difficult because endoscopic examination can't always reveal the bleeding site. Interventional radiology is a good option for patients having bleeding ileal varices knowing that they often have advanced liver cirrhosis making them poor candidates for surgery. Haemostasis by endoscopy is often temporary and bleeding frequently recurs. Surgery should be considered if non-invasive treatments failed to ensure the haemostasis. Conclusion Bleeding ileal varices is a rare situation. Interventional radiology and endoscopy can be good options. If not feasible, surgical treatment should not be delayed. Ectopic varices are a rare case of gastrointestinal bleeding. Diagnosing bleeding ileal varices is difficult. Surgical treatment is the best option to stop the bleeding.
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Affiliation(s)
- Anis Haddad
- Department of General Surgery A Hospital La Rabta Tunis, Tunisia.
| | - Hazem Beji
- Department of General Surgery A Hospital La Rabta Tunis, Tunisia.
| | - Youssef Chaker
- Department of General Surgery A Hospital La Rabta Tunis, Tunisia
| | - Houcine Maghrebi
- Department of General Surgery A Hospital La Rabta Tunis, Tunisia
| | - Mohamed Jouini
- Department of General Surgery A Hospital La Rabta Tunis, Tunisia
| | - Montassar Kacem
- Department of General Surgery A Hospital La Rabta Tunis, Tunisia
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19
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Solanki S, Jena SS, Das SAP, Yadav A, Mehta NN, Nundy S. Isolated ectopic jejunal varices in a patient with extrahepatic portal vein obstruction - A case report. Int J Surg Case Rep 2021; 86:106299. [PMID: 34419724 PMCID: PMC8379621 DOI: 10.1016/j.ijscr.2021.106299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/06/2021] [Accepted: 08/07/2021] [Indexed: 01/17/2023] Open
Abstract
Introduction and importance Among the various causes for lower gastrointestinal bleeding, ectopic varices constitute a small chunk. Though rare, these can pose a diagnostic challenge with recurrent bleed leading to multiple admission and blood transfusions. Case presentation A 41-year-old male presented to our department with multiple episodes of melena. On further evaluation with CT angiography, a diagnosis of extrahepatic portal vein obstruction with moderate splenomegaly and ectopic jejunal varix was made. He underwent splenectomy with resection of involved jejunal segment with side to side anastomosis. Clinical discussion The diagnosis of ectopic varices remains elusive in a large number of cases in view of the varied etiology. Various newer endoscopic and imaging modalities can play a diagnostic as well as therapeutic role but this also further complicates the management as there is a lack of substantial guidelines directing the treatment protocol. As a result, we have to resort to a case by case approach for the optimal management in these cases. Conclusion The main modality of management for bleeding ectopic varices is percutaneous or endoscopic. Surgery is reserved for refractory cases, with decompressive shunts combined with segmental resection of involved intestine being at the forefront of surgical options. Ectopic varices are an unusual cause of lower GI bleeding caused by porto-systemic collaterals. Ectopic varices most commonly occur at jejuno-ileum, but duodenal varices are more prone to bleed. The optimal management varies with each case due to paucity of treatment guidelines. Decompressive shunt with splenectomy and segmental resection of intestine effectively prevents rebleeding.
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Affiliation(s)
- Sanket Solanki
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, Delhi 110060, India.
| | - Suvendu Sekhar Jena
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, Delhi 110060, India
| | - Sri Aurobindo Prasad Das
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, Delhi 110060, India
| | - Amitabh Yadav
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, Delhi 110060, India
| | - Naimish N Mehta
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, Delhi 110060, India
| | - Samiran Nundy
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, Delhi 110060, India
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Helavar RV, Ramappa V, Wali PP. Imaging of Portal Gastroduodenopathy. JOURNAL OF GASTROINTESTINAL AND ABDOMINAL RADIOLOGY 2021. [DOI: 10.1055/s-0041-1728235] [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: 10/20/2022] Open
Abstract
AbstractPortal hypertension is characterized by elevated pressure in portal venous system due to portal resistance due to various causes. The etiologies are either pre-hepatic, hepatic, or post-hepatic. Elevated portal pressure results in varices at various sites some of which are difficult to identify on endoscopy alone. Other manifestations of elevated portal pressure include portal gastropathy, enteropathy, colopathy, gastric antral vascular ectasia, and ascites. Imaging plays an essential role in diagnosis and imaging of various manifestations of portal hypertension by determining the locations of varices and plan the management for same. Endoscopy helps in visualizing mucosal varices but newer imaging modalities give a panoramic extent of the disease in the entire gastrointestinal tract with great specificity and sensitivity. Initially, Barium study was used to determine esophageal or gastric varices, computed tomography provides detailed anatomic information which can be used to plan management. Due to advancement in imaging and interventional techniques, treatment for varices has seen advent of multiple minimally invasive interventional radiological techniques. A brief outlook on anatomical aspect of varices and various recent advances in management of the same has been provided. Overall knowledge of the various imaging manifestations of portal hypertension can be helpful to evaluate prognosis and plan proper management.
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Affiliation(s)
- Rajesh V. Helavar
- Department of Diagnostic and Interventional Radiology, Columbia Asia Radiology Group, Bengaluru, Karnataka, India
| | - Vidyasagar Ramappa
- Department of Gastroenterology and Hepatology, Columbia Asia Referral Hospital, Bengaluru, Karnataka, India
| | - Praveen P. Wali
- Department of Diagnostic Radiology, Columbia Asia Radiology Group, Bengaluru, Karnataka, India
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21
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Barath S, Kheradia D, Gopalkrishnan SP, R. RK, K. MRP. Review of Applied Anatomy, Hemodynamics, and Endovascular Management of Ectopic Varices. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2021. [DOI: 10.1055/s-0041-1730868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
AbstractPortal hypertension leads to the opening up of collateral pathways to bypass the occlusion or resistance in the portal system. Ectopic varices are formed by such collaterals at many various sites along the gastrointestinal tract other than the usual location, that is, gastroesophageal region. Early diagnosis of ectopic varices needs strong clinical suspicion and contrast-enhanced computed tomography scan as endoscopy may often fail to pinpoint a source. In contrast to gastric varices where the understanding of the disease, as well as endovascular management, is widely studied and documented, the same is not true for ectopic varices due to low incidence. Understanding the applied anatomy and hemodynamic classification is important to decide the most suitable therapy. Interventional radiological procedures are aimed at either decompressing the varices or obliterating them and depend on the patency of the portal system, underlying etiology, and local expertise.
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Affiliation(s)
- Sitaram Barath
- Interventional Radiology Subdivision, Department of Radiology, Geetanjali Medical College & Hospital, Udaipur, Rajasthan, India
| | | | | | - Rahul K. R.
- Government Medical College, Kozhikode, Kerala, India
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22
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Small Intestine Varices in Cirrhosis at a High-Volume Liver Transplant Center: A Retrospective Database Study and Literature Review. Am J Gastroenterol 2021; 116:1426-1436. [PMID: 33734116 DOI: 10.14309/ajg.0000000000001204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/22/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Esophageal varices are a well-characterized sequela of portal hypertension; however, less is known about varices arising in ectopic locations. We aimed to describe bleeding small intestine varices (SIV) in patients with cirrhosis and compare characteristics and outcomes to published case reports. METHODS We performed an institutional chart review using billing codes and natural language processing between 2008 and 2019. Inclusion criteria were adult patients with cirrhosis and SIV verified by endoscopy, video capsule, or imaging. Patients with noncirrhotic portal hypertension and stomal varices were excluded. We examined demographic and clinical factors, characteristics of SIV, bleeding, intervention, and outcomes in our series and collated data from published cases identified during a literature review. RESULTS We identified 71 patients with cirrhosis and SIV (18 bled). The literature search yielded 76 cases with bleeding SIV. Our series and published cases were matched for age, sex, liver disease etiology, and SIV location. Length of stay and transfusion requirements were similar. Aggregate initial treatments (number, hemostasis rate) included medical (n = 7, 57%), endoscopic (n = 48, 56%), interventional radiology (n = 31, 77%), and surgery (n = 8, 87%). Hospital and overall mortality rates were higher in our series (22% and 38%) compared with the published cases (5.3% and 18.4%), respectively (P = 0.02 and P = 0.07). DISCUSSION A quarter of patients with cirrhosis and SIV experience bleeding, with high transfusion requirements, frequent need for secondary interventions, and high mortality. These findings highlight the need for a multidisciplinary approach and second-line therapeutic modalities in the timely management of bleeding SIV in cirrhosis.
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23
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Systemic manifestations - do not forget the small bowel. Curr Opin Gastroenterol 2021; 37:234-244. [PMID: 33606400 DOI: 10.1097/mog.0000000000000717] [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: 12/10/2022]
Abstract
PURPOSE OF REVIEW Systemic diseases can afflict the small bowel (SB) but be challenging to diagnose. In this review, we aim to provide a broad overview of these conditions and to summarise their management. RECENT FINDINGS Small bowel capsule endoscopy (SBCE) is an important modality to investigate pathology in the SB. SB imaging can be complementary to SBCE for mural and extramural involvement and detection of multiorgan involvement or lymphadenopathy. Device assisted enteroscopy provides a therapeutic arm, to SBCE enabling histology and therapeutics to be carried out. SUMMARY SB endoscopy is essential in the diagnosis, management and monitoring of these multi-system conditions. Collaboration across SB centres to combine experience will help to improve the management of some of these rarer SB conditions.
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Robertson AR, Koulaouzidis A, Rondonotti E, Bruno M, Pennazio M. The Role of Video Capsule Endoscopy in Liver Disease. Gastrointest Endosc Clin N Am 2021; 31:363-376. [PMID: 33743931 DOI: 10.1016/j.giec.2020.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In the setting of chronic liver disease, capsule endoscopy is safe and well tolerated, making it an appealing diagnostic procedure. It is used mainly for the surveillance of esophageal varices, investigation of anemia, and exploration of the small bowel for complications of portal hypertension. Capsule endoscopy is recognized as a viable alternative in patients unable or unwilling to undergo upper gastrointestinal endoscopy for investigations of esophageal varices. In evaluating the small bowel of patients with liver disease and unexplained anemia, capsule endoscopy increases recognition of mucosal abnormalities, although their clinical significance is often unclear.
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Affiliation(s)
- Alexander Ross Robertson
- Department of Gastroenterology, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, Scotland. https://twitter.com/alexoscopy
| | - Anastasios Koulaouzidis
- Pomeranian Medical University, Department of Social Medicine & Public Health, Faculty of Health Sciences, Rybacka 1, Szczecin, West Pomeranian Voivodeship, Poland
| | - Emanuele Rondonotti
- Gastroenterology Unit, Valduce Hospital, Dante Alighieri Street, 11, Como 22100, Italy
| | - Mauro Bruno
- University Division of Gastroenterology, City of Health and Science University Hospital, Via Cavour 31, 10123 Turin, Italy
| | - Marco Pennazio
- University Division of Gastroenterology, City of Health and Science University Hospital, Via Cavour 31, 10123 Turin, Italy.
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Yipeng W, Cong L, Sizhe W, Chenkai H, Anjiang W, Xuan Z. Effectiveness and safety of endoscopic treatment for duodenal variceal bleeding: a systematic review. Eur J Gastroenterol Hepatol 2021; 33:461-469. [PMID: 32576766 PMCID: PMC7908861 DOI: 10.1097/meg.0000000000001819] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023]
Abstract
Duodenal varix is a rare condition that involves massive bleeding, diagnostic difficulties, and a high rate of rebleeding and mortality. The purpose of this study was to systematically review endoscopic treatment for duodenal variceal bleeding to evaluate its effectiveness and safety. We searched PubMed, Embase, Web of Science, and the Cochrane Library up to 21 November 2019. Ninety-two studies containing 156 patients were finally included, and individual data from 101 patients (mean age: 52.67 ± 13.82 years, male: 64.4%) were collected and further analyzed. We used an analysis of variance and χ2 or Fisher's exact tests to analyze individual data from 101 patients. The cause of duodenal variceal bleeding was cirrhosis-related intrahepatic portal hypertension (IPH) in 76.2% of patients. The overall rates of initial hemostasis and treatment success of endoscopic treatment for duodenal variceal bleeding were 89.1 and 81.2%, respectively. The median duration of follow-up was 4.5 (1.0, 12.0) months. The overall rates of rebleeding and mortality were 8.9 and 13.9%, respectively. Among a variety of endoscopic treatments available, only the initial hemostasis rate was significantly different between the endoscopic injection sclerotherapy and endoscopic tissue adhesive (ETA) groups (72.7 vs. 94.7%, P = 0.023); differences in treatment success, rebleeding, mortality, and adverse events were not statistically significant among the four groups. Endoscopic intervention is a feasible, well tolerated, and effective modality for the treatment of duodenal variceal bleeding. Among the variety of endoscopic treatments available, ETA with cyanoacrylate may be preferable for duodenal variceal bleeding.
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Affiliation(s)
- Wan Yipeng
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Liu Cong
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Wan Sizhe
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Huang Chenkai
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Wang Anjiang
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Zhu Xuan
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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Jejunal variceal rupture in a patient with myelofibrosis: a case report. Clin J Gastroenterol 2021; 14:542-545. [PMID: 33675010 DOI: 10.1007/s12328-021-01373-y] [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: 09/24/2020] [Accepted: 02/22/2021] [Indexed: 10/22/2022]
Abstract
An 80-year old man with myelofibrosis and chronic renal disease was admitted to our hospital because of severe anemia and gastrointestinal bleeding. Although no bleeding was observed by upper or lower endoscopy, contrast-enhanced computed tomography revealed an enhanced area in the small intestinal wall that was suspected of being the bleeding site, and was confirmed by double-balloon endoscopy. Based on endoscopic findings, it was difficult to differentiate between variceal rupture and collapse of a submucosal tumor. We performed segmental resection of the small intestine to make a definitive diagnosis and achieve reliable hemostasis. The gross findings confirmed a variceal rupture from the small intestine. His gastrointestinal bleeding stopped and his anemia improved following surgery. Although some cases of portal hypertension in association with myelofibrosis have been reported, we are aware of no prior reports of variceal rupture in the small intestine. To our knowledge, this is the first reported case of ectopic jejunal varices in a patient with myelofibrosis.
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Cai Y, Chen XB, Mai DH, Wu P, Chen YH, Chen H. Multidetector computed tomography three-dimensional and multiplanar reconstruction diagnosis of a rare cause of gastrointestinal bleeding: A case report. World J Gastrointest Surg 2021; 13:87-95. [PMID: 33552396 PMCID: PMC7830075 DOI: 10.4240/wjgs.v13.i1.87] [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: 09/17/2020] [Revised: 11/30/2020] [Accepted: 12/10/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Anastomosis of the testicular vein with the superior mesenteric vein rarely causes severe gastrointestinal bleeding. To date, there have been few studies describing its appearance on medical imaging. Here, we present multidetector computed tomography three-dimensional and multiplanar reconstruction (MPR) images of a typical digital subtraction angiography showing proven ectopic bleeding and provide the first review of the image performance.
CASE SUMMARY A 68-year-old man who had been rushed to the hospital with a four-day history of melena and fainting underwent multiple esophagogastroduodenoscopy procedures that failed to identify the source of bleeding. We used MPR combined with three-dimensional reconstruction images, and found that the testicular vein had anastomosed with the superior mesenteric vein, and they clustered together in the jejunal vessel wall, which caused severe gastrointestinal bleeding. Digital subtraction angiography confirmed the location of bleeding. After transfusion and embolization therapy, the patient’s condition improved.
CONCLUSION Computed tomography-MPR combined with three-dimensional images offers significant value in the localization and qualitative assessment of rare gastrointestinal hemorrhage. The features of multiphase spiral scanning can improve the accuracy of the diagnosis.
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Affiliation(s)
- Yong Cai
- Department of Diagnostic Imaging, Maoming People’s Hospital, Maoming 525000, Guangdong Province, China
| | - Xiao-Bo Chen
- Department of Diagnostic Imaging, Maoming People’s Hospital, Maoming 525000, Guangdong Province, China
| | - Da-Hai Mai
- Department of Oncology, Maoming People's Hospital, Maoming 525000, Guangdong Province, China
| | - Ping Wu
- Department of Gastroenterology, Maoming People's Hospital, Maoming 525000, Guangdong Province, China
| | - Yong-Hai Chen
- Department of Diagnostic Imaging, Maoming People’s Hospital, Maoming 525000, Guangdong Province, China
| | - Hua Chen
- Department of Oncology, Maoming People's Hospital, Maoming 525000, Guangdong Province, China
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Maeda H, Kageyama K, Yamamoto A, Jogo A, Sohgawa E, Matsushita K, Asano K, Yonezawa H, Nota T, Murai K, Ogawa S, Miki Y. Usefulness of coil-assisted retrograde transvenous obliteration II (CARTO-II) for the treatment of ascending colonic varix: a case report. CVIR Endovasc 2020; 3:90. [PMID: 33275189 PMCID: PMC7718362 DOI: 10.1186/s42155-020-00187-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/30/2020] [Indexed: 12/17/2022] Open
Abstract
Background Colonic varices are rare among ectopic varices. A previous report demonstrated that once bleeding from colonic varices occurs, it can be fatal. Several treatments for colonic varices exist, including surgical, endoscopic, and endovascular treatments; however, management of colonic varices has not been standardized. For colonic varices, minimally invasive therapies would be desirable. Balloon-occluded retrograde transvenous obliteration (B-RTO) is one of the treatment options for colonic varices to prevent their rupture. Two cases of successful conventional B-RTO for these varices have already been reported. However, B-RTO using coil-assisted retrograde transvenous obliteration II (CARTO-II) procedure for these varices has not been reported. Case presentation A 71-year-old male patient had liver cirrhosis caused by hepatitis C virus infection. A varix was located at the ascending colon, which was coincidentally found on colonic endoscopy. Contrast-enhanced computed tomography (CT) showed that the feeder vein was the ileocolic vein and that the main draining vein was the right renal vein. Physicians concluded that treatment was required to avoid the risk of death from massive bleeding due to varix rupture. However, endoscopic and surgical treatments were difficult due to the anatomical location of the varix and the high risk of operative compilations, respectively. This ascending colonic varix was treated by balloon-occluded retrograde transvenous obliteration (B-RTO) using coil-assisted retrograde transvenous obliteration II (CARTO-II) procedure via the right renal vein. There were no complications during the procedure and no recurrences for 36 months during long-term follow-up. Conclusions CARTO-II can be one of the effective treatment techniques for ascending colonic varices.
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Affiliation(s)
- Hiroyuki Maeda
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Ken Kageyama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan.
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Etsuji Sohgawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Kazuki Matsushita
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Kazuo Asano
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Hiroki Yonezawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Takehito Nota
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Kazuki Murai
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Satoyuki Ogawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
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Yipeng W, Anjiang W, Bimin L, Chenkai H, Size W, Xuan Z. Clinical characteristics and efficacy of endoscopic treatment of gastrointestinal ectopic varices: A single-center study. Saudi J Gastroenterol 2020; 27:35-43. [PMID: 33208560 PMCID: PMC8083249 DOI: 10.4103/sjg.sjg_50_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Ectopic varices (EcVs) may cause massive bleeding, which can be difficult to control, with a high rate of mortality. The purpose of this study was to analyze the clinical characteristics of EcVs and the efficacy of endoscopic treatment. METHODS From January 2008 to July 2017, the clinical data of 150 patients with EcVs in our center were retrospectively collected and analyzed. RESULTS One hundred and fifty patients with EcVs (male 74.7%), with a mean age of: 54.1 ± 14.6 years were included. The prevalence of EcVs was 0.92% in gastrointestinal varices. Cirrhosis was the most common cause of EcVs (67.0%). The rates of bleeding were 57.14%, 4.34%, 30.0%, 33.3%, and 100% in the duodenal varices rectal varices, colonic varices, anastomotic varices, and small bowel varices, respectively. An age under 55 years, varices in the duodenum, and erythema were considered risk factors for EcV bleeding. Endoscopic treatments were performed in 15 patients with EcV bleeding. The follow-up period of the patients who underwent endoscopic treatment ranged from 0.5 to 24 months. The overall rate of treatment success was 73.33% for endoscopic treatment of EcV bleeding. The overall rates of rebleeding and mortality during 2 years were as high as 53.3% and 26.7%, respectively. CONCLUSION Age, erythema, and the location of EcVs are considered risk factors for EcV bleeding, and the rate of bleeding is higher in patients with duodenal varices than in those with other EcVs. Endoscopic treatment is safe, effective, and feasible for controlling EcV bleeding.
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Affiliation(s)
- Wan Yipeng
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Hospital in Nanchang, China
| | - Wang Anjiang
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Hospital in Nanchang, China
| | - Li Bimin
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Hospital in Nanchang, China
| | - Huang Chenkai
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Hospital in Nanchang, China
| | - Wan Size
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Hospital in Nanchang, China
| | - Zhu Xuan
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Hospital in Nanchang, China,Address for correspondence: Dr. Zhu Xuan, Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Nanchang, China. E-mail:
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Ma HW, Zhang JH, Ding XP, Yu GW, Ma WJ, Yang J, Ma WL. Endoscopic treatment of esophagogastric variceal bleeding with rectal variceal bleeding: Report of two cases. Shijie Huaren Xiaohua Zazhi 2020; 28:1102-1106. [DOI: 10.11569/wcjd.v28.i21.1102] [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] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Esophagogastric variceal bleeding is one of the most common and serious complications of portal hypertension in patients with decompensated cirrhosis. However, esophagogastric variceal bleeding with rectal variceal bleeding is clinically rare. If not treated timely or properly, it will cause fatal consequences.
CASE SUMMARY This paper reports two cases of esophagogastric variceal bleeding complicated with rectal varices bleeding. The bleeding was stopped successfully using endoscopic sclerotherapy and ligation method on the basis of drug treatment.
CONCLUSION Clinicians should broaden their thinking and consider the occurrence of such a situation during the treatment of gastrointestinal bleeding.
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Affiliation(s)
- Hai-Wen Ma
- Medical Department of Northwest Minzu University, Lanzhou 730030, Gansu Province, China
| | - Jin-Hua Zhang
- Department of Gastroenterology, Affiliated Hospital of Northwest Minzu University and the second people's Hospital of Gansu Province, Lanzhou 730000, Gansu Province, China
| | - Xiang-Ping Ding
- Department of Gastroenterology, Affiliated Hospital of Northwest Minzu University and the second people's Hospital of Gansu Province, Lanzhou 730000, Gansu Province, China
| | - Guo-Wei Yu
- Medical Department of Northwest Minzu University, Lanzhou 730030, Gansu Province, China
| | - Wan-Jun Ma
- Medical Department of Northwest Minzu University, Lanzhou 730030, Gansu Province, China
| | - Jie Yang
- Medical Department of Northwest Minzu University, Lanzhou 730030, Gansu Province, China
| | - Wei-Lin Ma
- Medical Department of Northwest Minzu University, Lanzhou 730030, Gansu Province, China
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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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Bleeding from gastrointestinal ectopic varices is not associated with haemorrhage from oesophageal or gastric varices. GASTROENTEROLOGY REVIEW 2020; 15:60-64. [PMID: 32215130 PMCID: PMC7089859 DOI: 10.5114/pg.2020.93632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 05/27/2019] [Indexed: 11/21/2022]
Abstract
Introduction Ectopic varices are those that appear in a different region of the gastroesophageal junction. Bleeding from ectopic varices is rare but is usually massive and deadly. Aim To identify the possible factors that cause bleeding from ectopic varices in patients with portal hypertension. Material and methods A cross-sectional and retrospective study; the data were collected between January 2004 and June 2014. We included patients with portal hypertension and gastrointestinal ectopic varices diagnosed by endoscopy. Results We found 31 patients with gastrointestinal ectopic varices. Of these, 25 had liver cirrhosis, and six showed non-cirrhotic portal hypertension. There were 16 men and 15 women in the study. The median age of the patients was 60 years (range minimum–maximum of 27 to 80 years). Nineteen (61%) patients had rectal varices, 10 (32%) had duodenal varices, 1 (3%) had ileal varices, and 1 (3%) had colonic varices. We found bleeding in 4 (13%) of the 31 patients with ectopic varices; two belonged to the cirrhosis group, and the other two were from the non-cirrhotic portal hypertension group. Three of the 4 patients with bleeding from gastrointestinal ectopic varices had exhibited haemorrhage from oesophageal varices (odds ratio = 4.09, 95% CI: 0.37–44.78, p = 0.249), but none of them showed bleeding from gastric varices. Conclusions Bleeding from gastrointestinal ectopic varices is not necessarily associated with bleeding from oesophageal or gastric varices.
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Liu C, Srinivasan S, Babu SB, Chung R. Balloon-occluded retrograde transvenous obliteration of colonic varices: a case report. CVIR Endovasc 2020; 3:17. [PMID: 32173771 PMCID: PMC7073350 DOI: 10.1186/s42155-020-00108-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 02/12/2020] [Indexed: 02/07/2023] Open
Abstract
Background Ectopic varices are uncommon and typically due to underlying liver cirrhosis. They can be located in the duodenum, small intestines, colon or rectum, and may result in massive haemorrhage. While established guidelines exist for the management of oesophageal and gastric variceal bleeding, this is currently lacking for colonic varices. Beta-blockers, transjugular intrahepatic portosystemic shunt insertion and subtotal colectomy have been reported as management methods. However, there are only two other cases that have reported successfully treating colonic varices using balloon-occluded retrograde transvenous obliteration (BRTO), an endovascular procedure typically performed for gastric varices. Case presentation A 55-year-old man with background of alcoholic liver cirrhosis presented with per-rectal bleeding due to caecal varices. Grade 2–3 oesophageal varices were identified on oesophago-gastro-duodenoscopy, and computed tomography showed multiple right para-colic portosystemic collaterals around the hepatic flexure and ascending colon. Colonoscopy confirmed fresh blood in the colon up to the caecum, with a submucosal varix deemed the most likely source of haemorrhage. As transjugular intrahepatic portosystemic shunt insertion was potentially technically difficult, due to left portal vein thrombosis and a small right portal venous system, he underwent BRTO, which successfully embolised and thrombosed the colonic varices without complications. Conclusions Whilst further studies are required to conclude its effectiveness and efficacy, BRTO may be considered a viable solution in managing ectopic, colonic, variceal haemorrhage especially when traditional techniques are unsuccessful or contraindicated.
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Affiliation(s)
- Chantal Liu
- St George's Hospital Medical School, Cranmer Terrace, Tooting, London, SW17 0RE, UK.
| | - Sivasubramanian Srinivasan
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
| | - Suresh B Babu
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
| | - Raymond Chung
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
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Hemostasis With Endoscopic Band Ligation for Rupture of Jejunal Varices. ACG Case Rep J 2019; 6:e00211. [PMID: 31750379 PMCID: PMC6831151 DOI: 10.14309/crj.0000000000000211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 07/30/2019] [Indexed: 11/17/2022] Open
Abstract
Compared with the variceal rupture in the esophagus or stomach, rupture of ectopic varices including those in the jejunum is rare, and a definitive hemostatic method is not established. We report our case and review the literature regarding the pathophysiology and hemostatic methods of ectopic varices. A patient presented with hematemesis and cardiopulmonary arrest following hemorrhagic shock. After resuscitation, we performed emergency endoscopy and diagnosed ruptured jejunal varices that were subsequently treated by endoscopic band ligation.
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Despott EJ, May A, Lazaridis N, Vlachou E, Koukias N, Patch D, Planche K, Hayashi Y, Murino A. Double-balloon enteroscopy-facilitated cyanoacrylate-injection endotherapy of small-bowel varices: an international experience from 2 European tertiary centers (with videos). Gastrointest Endosc 2019; 90:302-306. [PMID: 30980796 DOI: 10.1016/j.gie.2019.03.1171] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 03/28/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Small-bowel varices (SBVs) are an uncommon consequence of portal hypertension. Radiologic intervention is usually considered for first-line management. When radiologic intervention is not possible, management options become very limited. The aim of this study was to evaluate the usefulness of double-balloon enteroscopy (DBE)-facilitated cyanoacrylate-injection endotherapy of SBVs. METHODS This was a retrospective review of DBE-facilitated cyanoacrylate-injection endotherapy of SBVs (December 2015 to October 2016). RESULTS Ten DBEs were performed in 6 patients (4 women; median age, 68.5 years). No radiologic or surgical options were deemed feasible. Thirteen nests of SBVs were identified and injected with cyanoacrylate glue without hemorrhagic or embolic adverse events. At the 30-day follow-up after therapy, only 1 patient had experienced a mild recurrence of mid-gut bleeding; this was managed conservatively. One patient presented with acute GI bleeding 7 months later, and a repeat DBE with cyanoacrylate-injection endotherapy was successfully performed. One patient succumbed to his underlying advanced cholangiocarcinoma after 2 months. The remaining patients had a median follow-up of 12 months without any recurrent GI bleeding. CONCLUSIONS DBE-facilitated cyanoacrylate-injection endotherapy of SBVs appears to be a safe and effective option when other first-line options are not feasible.
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Affiliation(s)
- Edward J Despott
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK
| | - Andrea May
- Department of Gastroenterology, Sana Klinikum Offenbach GmbH and University of Mainz, Germany
| | - Nikolaos Lazaridis
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK
| | - Erasmia Vlachou
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK; NIMTS Army Veterans Hospital, Athens, Greece
| | - Nikolaos Koukias
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK
| | - David Patch
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK
| | - Katie Planche
- Department of Radiology, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK
| | - Yoshikazu Hayashi
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK; Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
| | - Alberto Murino
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK
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36
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Shin DS, Kim AG, Ingraham CR. Balloon-occluded antegrade transvenous obliteration via transjugular intrahepatic access for bleeding rectal varices. Radiol Case Rep 2019; 14:805-808. [PMID: 31015887 PMCID: PMC6468156 DOI: 10.1016/j.radcr.2019.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 04/01/2019] [Accepted: 04/01/2019] [Indexed: 12/14/2022] Open
Abstract
Bleeding rectal varices in cirrhotic patients with portal hypertension can be difficult to treat endoscopically or surgically. Transjugular intrahepatic portosystemic shunt creation offers a minimally invasive method to effectively decompress the portal system but may be contraindicated in patients with poor hepatic reserve or hepatic encephalopathy. We present a case of a 44-year-old woman with persistent rectal variceal bleeding, who was a poor candidate for endoscopic intervention, surgery, or transjugular intrahepatic portosystemic shunt. We therefore performed balloon-occluded antegrade transvenous obliteration of the rectal varices via transjugular intrahepatic access, which effectively controlled her rectal bleeding.
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Affiliation(s)
- David S Shin
- Department of Radiology, University of Washington, Seattle, Washington, U.S.A. 1959 NE Pacific St, Box 357115, Seattle, WA 98195, USA
| | - Andrew G Kim
- Department of Radiology, University of Washington, Seattle, Washington, U.S.A. 1959 NE Pacific St, Box 357115, Seattle, WA 98195, USA
| | - Christopher R Ingraham
- Department of Radiology, University of Washington, Seattle, Washington, U.S.A. 1959 NE Pacific St, Box 357115, Seattle, WA 98195, USA
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37
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Rostambeigi N, Shrestha P, Dunn TB, Golzarian J, Khoshnoodi P, Rosenberg M, Talaie R. Recurrent Ectopic Variceal Bleed After Pancreas Transplantation With No Portal Hypertension: Case Report and Outcomes of Endovascular Onyx Embolization. Vasc Endovascular Surg 2019; 53:415-419. [PMID: 30929610 DOI: 10.1177/1538574419839255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A 57-year-old male presented with intermittent gastrointestinal bleeding (GIB) 1 year after a successful simultaneous pancreas and kidney transplant. No source could be found after 5 tagged red blood cell studies, 3 computed tomographies (CTs), 7 endoscopies, and 4 catheter angiograms. Review of CTs showed pathologically enlarged superior mesenteric vein branches near a jejunal segment near pancreas graft. Transhepatic superior mesenteric venogram showed varicosities near jejunum, which were obliterated with ethylene vinyl alcohol (Onyx). Follow-up CTs confirmed complete obliteration, but he had more GIBs and eventually underwent native jejunal and donor duodenal resection. He has remained GIB-free for 12 months.
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Affiliation(s)
- Nassir Rostambeigi
- 1 Department of Radiology, Division of Interventional Radiology, West Virginia University, Morgantown, WV, USA.,2 Department of Radiology, Division of Interventional Radiology, University of Minnesota, Minneapolis, MN, USA
| | - Prashant Shrestha
- 2 Department of Radiology, Division of Interventional Radiology, University of Minnesota, Minneapolis, MN, USA
| | - Ty B Dunn
- 3 Department of Surgery, Division of Transplantation, University of Pennsylvania, Philadelphia, PA, USA
| | - Jafar Golzarian
- 2 Department of Radiology, Division of Interventional Radiology, University of Minnesota, Minneapolis, MN, USA
| | - Pooria Khoshnoodi
- 4 Department of Laboratory Medicine & Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Michael Rosenberg
- 2 Department of Radiology, Division of Interventional Radiology, University of Minnesota, Minneapolis, MN, USA
| | - Reza Talaie
- 2 Department of Radiology, Division of Interventional Radiology, University of Minnesota, Minneapolis, MN, USA
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38
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Gheorghiu AC, Proserpio M, Regusci L, Pagnamenta A. Ectopic varices masquerading as lower gastrointestinal bleeding. BMJ Case Rep 2019; 12:12/1/e227469. [PMID: 30709832 DOI: 10.1136/bcr-2018-227469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A middle-aged woman previously in good health arrived to hospital with severe haemorrhagic shock. An abdominal and pelvic CT scan showed hepatomegaly, fluid in the sigmoid colon, perigastric and right sided pelvic varices without a clear source of bleeding. Urgent esophagogastroduodenoscopy excluded gastric varices and active upper gastrointestinal bleeding and the colonoscopy was inconclusive due to haemodynamic instability and massive bleeding which made it impossible to proceed with a full colonoscopy. An explorative laparotomy identified liver cirrhosis and bleeding from varices of the right fallopian tube which had formed a fistula with the caecum. A right hemicolectomy with a side to side anastomosis and a right sided salpingo-oophorectomy were carried out. The patient was thereafter transferred to the intensive care unit intubated, requiring massive fluid resuscitation and high doses of vasoactive agents. Nine days after hospital admission she was transferred to the surgical ward and followed up by a hepatologist.
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Affiliation(s)
- Alina Cristiana Gheorghiu
- Intensive Care Medicine, Ente Ospedaliero Cantonale, Ospedale Regionale di Mendrisio, Mendrisio, Switzerland
| | - Michele Proserpio
- Intensive Care Medicine, Ente Ospedaliero Cantonale, Ospedale Regionale di Mendrisio, Mendrisio, Switzerland
| | - Luca Regusci
- Department of Surgery, Ente Ospedaliero Cantonale, Ospedale Regionale di Mendrisio, Mendrisio, Switzerland
| | - Alberto Pagnamenta
- Intensive Care Medicine, Ente Ospedaliero Cantonale, Ospedale Regionale di Mendrisio, Mendrisio, Switzerland
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39
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Shiratori Y, Ikeya T, Ishii N, Takasu A, Honda H, Nakamura K, Fukuda K. Endoscopic Band Ligation for Acute Lower Gastrointestinal Bleeding. Intern Med 2019; 58:3505-3508. [PMID: 31839670 PMCID: PMC6949462 DOI: 10.2169/internalmedicine.3185-19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective Endoscopic band ligation (EBL) is commonly performed to treat colonic diverticular bleeding (CDB). However, EBL is not suitable for other disorders that cause acute lower gastrointestinal bleeding (ALGIB), and the safety and efficacy of the procedure are not well known. This study aimed to evaluate the efficacy and safety of EBL for non-colonic diverticular bleeding (non-CDB) and investigate the application of EBL to ALGIB. Methods This study was a retrospective evaluation of the success rate of EBL, the rate of early re-bleeding (within 30 days of the initial EBL), and complications such as perforation and abscess formation. Patients Thirty patients who presented with non-CDB and underwent EBL as the first-line treatment in our hospital from June 2009 to December 2017 were included in the present study. Results The success rate of EBL was 93% (28/30). The rate of early re-bleeding after EBL was 20% (6/30). Repeat EBL, endoscopic clipping, or conservative therapy was performed in the event of re-bleeding. No emergency surgery or interventional hemostatic treatments were required for hemostasis. No complications such as perforation or abscess formation were observed in any patient. Conclusion Our results suggest that EBL is an effective and safe endoscopic treatment for non-CDB.
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Affiliation(s)
| | - Takashi Ikeya
- Department of Gastroenterology, St. Luke's International Hospital, Japan
| | - Naoki Ishii
- Department of Gastroenterology, Tokyo Shinagawa Hospital, Japan
| | - Ayaka Takasu
- Department of Gastroenterology, St. Luke's International Hospital, Japan
| | - Hirokazu Honda
- Department of Gastroenterology, St. Luke's International Hospital, Japan
| | - Kenji Nakamura
- Department of Gastroenterology, St. Luke's International Hospital, Japan
| | - Katsuyuki Fukuda
- Department of Gastroenterology, St. Luke's International Hospital, Japan
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40
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Endoscopic Sclerotherapy with a Large Volume of High Concentration of Cyanoacrylate for Jejunal Variceal Bleeding bys Single-Balloon Enteroscopy. ACTA ACUST UNITED AC 2018; 54:medicina54050068. [PMID: 30344299 PMCID: PMC6262278 DOI: 10.3390/medicina54050068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 09/04/2018] [Accepted: 09/06/2018] [Indexed: 12/14/2022]
Abstract
Jejunal varices are a rare manifestation of portal hypertension, and they are associated with a high mortality and poor prognosis when bleeding occurs. A bleeding jejunal varix is much more challenging to diagnose and manage because of its anatomic location. Herein, we describe the case of a 62-year-old man with active jejunal variceal bleeding who presented with massive hematochezia and hypovolemic shock. He was treated successfully with a high volume and concentration of a glue mixture as endoscopic sclerotherapy using single-balloon enteroscopy in the intensive care unit. Enteroscopic sclerotherapy is an effective option for jejunal variceal bleeding.
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41
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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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42
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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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43
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Successful Embolization of Bleeding Ileal Varices with N-butyl Cyanoacrylate via a Recanalized Paraumbilical Vein. Cardiovasc Intervent Radiol 2018; 41:1291-1294. [PMID: 29687259 DOI: 10.1007/s00270-018-1970-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 04/17/2018] [Indexed: 12/11/2022]
Abstract
A 48-year-old woman with alcoholic liver cirrhosis was admitted to our hospital because of hematochezia and severe anemia. She had been hospitalized many times over the past year for hematochezia of unknown etiology. Contrast-enhanced CT demonstrated ileal varices, which were fed by several ileal veins. These feeding veins were selectively embolized with N-butyl cyanoacrylate (NBCA) via a recanalized paraumbilical vein. The paraumbilical vein instead of the portal vein was punctured to decrease the risk of bleeding complications because she had coagulopathy and ascites. We consider antegrade embolization of ileal varices with NBCA to be a feasible and effective treatment. Access via a paraumbilical vein is an alternative to the transhepatic approach.Level of Evidence Level V, case report.
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44
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Wu X, Xuan W, Song L. Transjugular intrahepatic portosystemic stent shunt placement and embolization for hemorrhage associated with rupture of anorectal varices. J Int Med Res 2018; 46:1666-1671. [PMID: 29338471 PMCID: PMC6091825 DOI: 10.1177/0300060517730720] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Portal hypertension can lead to ectopic varices, which occur most frequently in the rectum. Rectal variceal bleeding in patients with portal hypertension is rare but can be life-threatening if not diagnosed and treated in a timely manner. However, no specific treatment guidelines have been established for rectal variceal bleeding. We herein report a case involving a woman with portal hypertension due to autoimmune liver disease who was successfully treated with a transjugular intrahepatic portosystemic stent shunt and variceal embolization. We recommend treatment of refractory ectopic variceal bleeding with a transjugular intrahepatic portosystemic stent shunt in combination with embolization.
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Affiliation(s)
- Xiuyan Wu
- Department of Medical Oncology, The Second Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Wei Xuan
- Department of Medical Oncology, The Second Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Lei Song
- Department of Medical Oncology, The Second Hospital of Dalian Medical University, Dalian, Liaoning, China
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45
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46
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Sclerotherapy for Rectal Varices by a Small-Bore Needle Puncture Through the Greater Sciatic Foramen. Cardiovasc Intervent Radiol 2017; 41:317-322. [PMID: 29038875 DOI: 10.1007/s00270-017-1803-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 09/21/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE To report a sclerotherapy technique for rectal varices consisting of direct puncture of the superior rectal vein with a small-bore sheathed needle via the greater sciatic foramen without insertion of a sheath or catheter. MATERIALS AND METHODS The subjects of this retrospective study were three consecutive patients who underwent embolization of rectal varices, two for rupture of rectal varices and one for hepatic encephalopathy and hyperammonemia. A 5% solution of ethanolamine oleate with iodinated contrast agent (5% EOI) was injected through puncture of the superior rectal vein and carried in the blood flow, after which n-butyl cyanoacrylate mixed with lipiodol (NBCA-Lip) was immediately injected to stop the blood flow. RESULTS The 5% EOI and NBCA-Lip were successfully injected in all three patients. There was no movement of NBCA-Lip on plain radiographs or computed tomography (CT) immediately after injection, and the 5% EOI remained within the rectal varices. The mean procedure time was 53 min (42-60 min). On contrast-enhanced CT 1 month after the procedure, there was no contrast enhancement of the rectal varices that had been seen on preoperative CT in any of the three patients, confirming that the rectal varices had disappeared. CONCLUSION Sclerotherapy for rectal varices using an approach for puncture of the superior rectal vein with a small-bore sheathed needle via the greater sciatic foramen was technically feasible and clinically effective.
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47
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Soape MP, Lichliter A, Cura M, Lepe-Suastegui MR, Burdick JS. Rare Duodenal Varix Coil Erosion Post TIPS Creation and Coil Embolization of Mesenteric-Systemic Shunt. Dig Dis Sci 2017; 62:2601-2603. [PMID: 28687942 DOI: 10.1007/s10620-017-4663-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 06/23/2017] [Indexed: 12/24/2022]
Affiliation(s)
- Matthew P Soape
- Baylor University Medical Center, Baylor Scott and White, 3600 Gaston Ave, Wadley Tower Ste. 260, Dallas, TX, 75246, USA.
| | - Andrew Lichliter
- Baylor University Medical Center, Baylor Scott and White, 3600 Gaston Ave, Wadley Tower Ste. 260, Dallas, TX, 75246, USA
| | - Marco Cura
- Baylor University Medical Center, Baylor Scott and White, 3600 Gaston Ave, Wadley Tower Ste. 260, Dallas, TX, 75246, USA
| | - Maria R Lepe-Suastegui
- Baylor University Medical Center, Baylor Scott and White, 3600 Gaston Ave, Wadley Tower Ste. 260, Dallas, TX, 75246, USA
| | - J Steven Burdick
- Baylor University Medical Center, Baylor Scott and White, 3600 Gaston Ave, Wadley Tower Ste. 260, Dallas, TX, 75246, USA
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48
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Laparotomy-Assisted Endoscopic Injection of Jejunal Varices for Overt Small Bowel Bleeding. ACG Case Rep J 2017; 4:e79. [PMID: 28670593 PMCID: PMC5482908 DOI: 10.14309/crj.2017.79] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 05/05/2017] [Indexed: 12/22/2022] Open
Abstract
A 54-year old male liver transplant recipient with Roux-en-Y choledochojejunostomy was admitted for symptomatic anemia. Despite endoscopies and a bleeding scan, active bleeding was not visualized. Angiography and abdominal computed tomography demonstrated possible jejunal varices at the choledochojejunal anastomosis. Double-balloon enteroscopy demonstrated varices with overlying clots in the Roux limb at the anastomosis. Due to the extensive loop formation and unstable position of the endoscope, therapeutic intervention could not be performed. Operative enterotomy and intraoperative endoscopy were subsequently required. A varix in the jejunum with venous flow on Doppler was injected twice with cyanoacrylate and successfully obturated.
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49
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Sokhandon F, Al-katib S, Bahoura L, Copelan A, George D, Scola D. Multidetector CT enterography of focal small bowel lesions: a radiological-pathological correlation. Abdom Radiol (NY) 2017; 42:1319-1341. [PMID: 27999885 DOI: 10.1007/s00261-016-1015-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Focal small bowel lesions present a diagnostic challenge for both the radiologist and gastroenterologist. Both the detection and characterization of small bowel masses have greatly improved with the advent of multidetector CT enterography (MD-CTE). As such, MD-CTE is increasingly utilized in the workup of occult gastrointestinal bleeding. In this article, we review the spectrum of focal small bowel masses with pathologic correlation. Adenocarcinoma, the most common primary small bowel malignancy, presents as a focal irregular mass occasionally with circumferential extension leading to obstruction. Small bowel carcinoid tumors most commonly arise in the ileum and are characterized by avid enhancement and marked desmoplastic response of metastatic lesions. Aneurysmal dilatation of small bowel is pathognomonic for lymphoma and secondary findings of lymphadenopathy and splenomegaly should be sought. Benign small bowel masses such as leiomyoma and adenoma may be responsible for occult gastrointestinal bleeding. However, primary vascular lesions of the small bowel remain the most common cause for occult small bowel gastrointestinal bleeding. The arterial phase of contrast obtained with CTE aids in recognition of the vascular nature of these lesions. Systemic conditions such as Peutz-Jeghers syndrome and Crohn's disease may be suggested by the presence of multiple small bowel lesions. Lastly, potential pitfalls such as ingested material should be considered when faced with focal small bowel masses.
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50
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Kim YH, Lee YS, Yoon YS, Hong S, Kim WY, Kim JH, Park YC. Rectal ectopic variceal bleeding during liver transplantation -A case report-. Anesth Pain Med (Seoul) 2017. [DOI: 10.17085/apm.2017.12.2.165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Yun-hee Kim
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Yoon-Sook Lee
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Yong-sang Yoon
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Soonyoung Hong
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Woon Young Kim
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Jae Hwan Kim
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Young-cheol Park
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Ansan, Korea
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