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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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An Uncommon Cause of Biliary Obstruction in a Patient With Budd-Chiari Syndrome. ACG Case Rep J 2021; 8:e00597. [PMID: 34549066 PMCID: PMC8443805 DOI: 10.14309/crj.0000000000000597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 02/16/2021] [Indexed: 11/17/2022] Open
Abstract
Biliary varices (BVs) are an infrequent complication of chronic portal hypertension. Most cases of BVs are asymptomatic and are likely underdiagnosed. We present a case of a 34-year-old woman with Budd-Chiari syndrome who was found to have BVs caused by a significant inferior vena cava (IVC) stenosis. This case demonstrates that preprocedure imaging for variceal screening should be considered before biliary tract procedures to prevent complications.
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Suda T, Omizo T, Yoshida R, Seike T, Oishi N, Matsushita E. Diagnosis of biliary varices using digital cholangioscopy. Endosc Int Open 2020; 8:E1437-E1438. [PMID: 33015349 PMCID: PMC7508654 DOI: 10.1055/a-1236-3421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Tsuyoshi Suda
- Department of Gastroenterology, Kanazawa Municipal Hospital, Kanazawa, Ishikawa, Japan.
| | - Tomohide Omizo
- Department of Gastroenterology, Kanazawa Municipal Hospital, Kanazawa, Ishikawa, Japan.
| | - Ryota Yoshida
- Department of Gastroenterology, Kanazawa Municipal Hospital, Kanazawa, Ishikawa, Japan.
| | - Takuya Seike
- Department of Gastroenterology, Kanazawa Municipal Hospital, Kanazawa, Ishikawa, Japan.
| | - Naoki Oishi
- Department of Gastroenterology, Kanazawa Municipal Hospital, Kanazawa, Ishikawa, Japan.
| | - Eiki Matsushita
- Department of Gastroenterology, Kanazawa Municipal Hospital, Kanazawa, Ishikawa, Japan.
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Hytiroglou P, Wanless IR. The Interstitial Space Takes Shape. Hepatology 2019; 69:1830-1832. [PMID: 30215854 DOI: 10.1002/hep.30268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Affiliation(s)
- Prodromos Hytiroglou
- Department of Pathology, Aristotle University Medical School, Thessaloniki, Greece
| | - Ian R Wanless
- Department of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada
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Structure and Distribution of an Unrecognized Interstitium in Human Tissues. Sci Rep 2018; 8:4947. [PMID: 29588511 PMCID: PMC5869738 DOI: 10.1038/s41598-018-23062-6] [Citation(s) in RCA: 175] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 03/06/2018] [Indexed: 01/13/2023] Open
Abstract
Confocal laser endomicroscopy (pCLE) provides real-time histologic imaging of human tissues at a depth of 60-70 μm during endoscopy. pCLE of the extrahepatic bile duct after fluorescein injection demonstrated a reticular pattern within fluorescein-filled sinuses that had no known anatomical correlate. Freezing biopsy tissue before fixation preserved the anatomy of this structure, demonstrating that it is part of the submucosa and a previously unappreciated fluid-filled interstitial space, draining to lymph nodes and supported by a complex network of thick collagen bundles. These bundles are intermittently lined on one side by fibroblast-like cells that stain with endothelial markers and vimentin, although there is a highly unusual and extensive unlined interface between the matrix proteins of the bundles and the surrounding fluid. We observed similar structures in numerous tissues that are subject to intermittent or rhythmic compression, including the submucosae of the entire gastrointestinal tract and urinary bladder, the dermis, the peri-bronchial and peri-arterial soft tissues, and fascia. These anatomic structures may be important in cancer metastasis, edema, fibrosis, and mechanical functioning of many or all tissues and organs. In sum, we describe the anatomy and histology of a previously unrecognized, though widespread, macroscopic, fluid-filled space within and between tissues, a novel expansion and specification of the concept of the human interstitium.
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Khuroo MS, Rather AA, Khuroo NS, Khuroo MS. Portal biliopathy. World J Gastroenterol 2016; 22:7973-7982. [PMID: 27672292 PMCID: PMC5028811 DOI: 10.3748/wjg.v22.i35.7973] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/22/2016] [Accepted: 08/01/2016] [Indexed: 02/06/2023] Open
Abstract
Portal biliopathy refers to cholangiographic abnormalities which occur in patients with portal cavernoma. These changes occur as a result of pressure on bile ducts from bridging tortuous paracholedochal, epicholedochal and cholecystic veins. Bile duct ischemia may occur due prolonged venous pressure effect or result from insufficient blood supply. In addition, encasement of ducts may occur due fibrotic cavernoma. Majority of patients are asymptomatic. Portal biliopathy is a progressive disease and patients who have long standing disease and more severe bile duct abnormalities present with recurrent episodes of biliary pain, cholangitis and cholestasis. Serum chemistry, ultrasound with color Doppler imaging, magnetic resonance imaging with magnetic resonance cholangiopancreatography and magnetic resonance portovenography are modalities of choice for evaluation of portal biliopathy. Endoscopic retrograde cholangiography being an invasive procedure is indicated for endotherapy only. Management of portal biliopathy is done in a stepwise manner. First, endotherapy is done for dilation of biliary strictures, placement of biliary stents to facilitate drainage and removal of bile duct calculi. Next portal venous pressure is reduced by formation of surgical porto-systemic shunt or transjugular intrahepatic portosystemic shunt. This causes significant resolution of biliary changes. Patients who persist with biliary symptoms and bile duct changes may benefit from surgical biliary drainage procedures (hepaticojejunostomy or choledechoduodenostomy).
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Barresi L, Ligresti D, Traina M. A Challenging Diagnosis for a Biliary Stricture. Gastroenterology 2016; 150:1537-1539. [PMID: 27140491 DOI: 10.1053/j.gastro.2016.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 02/11/2016] [Indexed: 12/02/2022]
Affiliation(s)
- Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS - ISMETT), Palermo, Italy
| | - Dario Ligresti
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS - ISMETT), Palermo, Italy
| | - Mario Traina
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS - ISMETT), Palermo, Italy
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Bhatia V, Shasthry SM, Mukund A. Intraductal Sonography in Patients With Portal Cavernoma Cholangiopathy. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:651-659. [PMID: 26903662 DOI: 10.7863/ultra.15.05013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 07/09/2015] [Indexed: 06/05/2023]
Abstract
Intraductal sonography generates high-resolution images of the entire length of the biliary tree and peribiliary tissues, including 3-dimensional dual- and muti-plane reconstructions to depict complex anatomy. Portal cavernoma cholangiopathy (previously called portal biliopathy) can have multiple etiologies of obstructive cholestasis in the same patient, which can be difficult to define even with advanced imaging techniques.We describe 2 difficult cases of portal cavernoma cholangiopathy in which intraductal sonography helped in clinical management decisions. We think that intraductal sonography should be part of the standard management algorithm for patients with portal cavernoma cholangiopathy and describe the intraductal sonographic correlates of the cholangiographic changes in this condition.
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Affiliation(s)
- Vikram Bhatia
- Departments of Hepatology (V.B., S.M.S.) and Radiology (A.M.), Institute of Liver and Biliary Sciences, New Delhi, India.
| | - Saggere Muralikrishna Shasthry
- Departments of Hepatology (V.B., S.M.S.) and Radiology (A.M.), Institute of Liver and Biliary Sciences, New Delhi, India
| | - Amar Mukund
- Departments of Hepatology (V.B., S.M.S.) and Radiology (A.M.), Institute of Liver and Biliary Sciences, New Delhi, India
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Park TY, Seo DW, Kang HJ, Cho MK, Song TJ, Park DH, Lee SS, Lee SK, Kim MH. Endoscopic ultrasonography-guided placement of a transhepatic portal vein stent in a live porcine model. Endosc Ultrasound 2016; 5:315-319. [PMID: 27803904 PMCID: PMC5070289 DOI: 10.4103/2303-9027.191611] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background and Objectives: Percutaneous portal vein (PV) stent placement is used to manage PV occlusion or stenosis caused by malignancy. The use of endoscopic ultrasonography (EUS) has expanded to include vascular interventions. The aim of this study was to examine the technical feasibility and safety of EUS-guided transhepatic PV stent placement in a live porcine model. Materials and Methods: EUS-guided transhepatic PV stent placement was performed in six male miniature pigs under general anesthesia using forward-viewing echoendoscope. Under EUS guidance, the left intrahepatic PV was punctured with a 19-gauge fine-needle aspiration (FNA) needle and a 0.025 inch guidewire inserted through the needle and into the main PV. The FNA needle was then withdrawn and a needle-knife inserted to dilate the tract. Under EUS and fluoroscopic guidance, a noncovered metal stent was inserted over the guidewire and released into the main PV. Results: A PV stent was placed successfully in all six pigs with no technical problems or complications. The patency of the stent in the main PV was confirmed using color Doppler EUS and transhepatic portal venography. Necropsy of the first three animals revealed no evidence of bleeding and damage to intra-abdominal organs or vessels. No complications occurred in the remaining three animals during the 8 weeks observation period. Conclusions: EUS-guided transhepatic PV stent placement can be both technically feasible and safe in a live animal model.
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Affiliation(s)
- Tae Young Park
- Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Dong Wan Seo
- Department of Internal Medicine, Division of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyeon-Ji Kang
- Department of Gastroenterology, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea
| | - Min Keun Cho
- Department of Internal Medicine, Division of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Jun Song
- Department of Internal Medicine, Division of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hyun Park
- Department of Internal Medicine, Division of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Soo Lee
- Department of Internal Medicine, Division of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Koo Lee
- Department of Internal Medicine, Division of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Myung-Hwan Kim
- Department of Internal Medicine, Division of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Abstract
Intraductal ultrasonography (IDUS) provides real-time, cross-sectional imaging of pancreatobiliary ducts and surrounding structures during endoscopic retrograde cholangiopancreatography using a high-frequency ultrasound (US) transducer. Hence, IDUS has been considered a sensitive tool in the evaluation of suspicious choledocholithiasis and neoplasms, to help distinguish between benign and malignant bile duct strictures or wall thickness, and to assess tumor extension and invasion depth. With the rapid development and enriched choices of sensitive diagnostic modalities include but are not limited to endoscopic US, peroral cholangioscopy, and confocal laser endomicroscopy, it is needed to systematically assess the role of IDUS in the investigation of pancreatobiliary diseases. Some new developments and innovative use of IDUS techniques will be discussed in this paper with the review of literature.
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Affiliation(s)
- Bo Sun
- Department of Gastroenterology, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Bing Hu
- Department of Gastroenterology, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
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