A rare case of bleeding duodenal varices from superior mesenteric vein obstruction -treated with transhepatic recanalization and stent placement

An Unusual Case of Isolated Duodenal Varices With Superior Mesenteric Vein Thrombosis

Duodenal varices usually occur due to portal hypertension and are rare causes of gastrointestinal tract bleeding. We report a unique case of a previously fit patient who presented with melena and was found to have isolated duodenal varices (DV) in the third part on esophagogastroduodenoscopy. No esophageal or gastric varices were noticed. The duodenal varices were successfully managed by endoscopic banding. A computerized tomography scan of the abdomen to further investigate the cause confirmed duodenal varices and revealed superior mesenteric vein thrombosis. The liver was normal with patent hepatic and portal veins. No evidence of thrombophilia was found. Apixaban was prescribed for superior mesenteric vein thrombosis and on follow-up. no further bleeding was reported.

Treatment of colonic varices and gastrointestinal bleeding by recanalization and stenting of splenic-vein-thrombosis: A case report and literature review

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.

Percutaneous transhepatic stent for chronic intestinal bleeding from jejunal varices in primary idiophatic superior mesenteric vein stenosis: A case report

Jejunal varices are a rare cause of gastrointestinal bleeding. In most cases, they are due to portal hypertension related to liver cirrhosis, less frequently to superior mesenteric vein stenosis (SMV). In this article we describe an unusual case of a 61 year-old male patient who arrived at our emergency department with intermittent variceal bleeding due to jejunal varices causing melena and subsequent chronic anaemia. Patient was indeed discovered to have primary idiopathic superior mesenteric vein stenosis. We managed to treat this patient via SMV stenting through percutaneous transhepatic approach. In cases of upper-GI bleed with negative endoscopy for active bleeding, a contrast-enhanced CT scan should be performed to diagnose jejunal varices and their underlying cause, such as SMV stenosis which is best treated with percutaneous phlebography.

Mesenteric Variceal Haemorrhage and Ectopic Cushing's Syndrome as Presenting Features of a Pancreatic Neuroendocrine Tumour Recurrence

Pancreatic neuroendocrine tumours can have varied and complex presentations. Whilst hormone hypersecretion often induces characteristic clinical syndromes, non-specific symptoms may arise due to localized tumour effects. Malignant invasion of local vasculature is an increasingly recognized complication of these neoplasms and can be associated with significant morbidity. Herein, we present the case of a 47-year-old male with a recurrence of a pancreatic neuroendocrine tumour who presented with unusual upper gastrointestinal bleeding. The tumour had recurred within the superior mesenteric vein, replacing the vessel and invading its branches. This resulted in porto-mesenteric hypertension and the formation of bleeding mesenteric varices. The patient subsequently developed progressive metabolic disturbances and was diagnosed with ectopic Cushing's syndrome, despite his primary tumour having been non-functional. This case demonstrates not only a rare pattern of tumour recurrence but also the potential for pancreatic neuroendocrine tumours to de-differentiate and change from non-functional to hormone secreting, a phenomenon which may complicate diagnosis and management.

Extraosseous Ewing's Sarcoma: Pictorial Review of Imaging Findings, Differential Diagnosis, and Pathologic Correlation

Extraosseous Ewing's sarcoma (EES), first described in 1969, is a malignant mesenchymal tumor just like its intraosseous counterpart. Although Ewing's sarcomas are common bone tumors in young children, EESs are rarer and more commonly found in older children/adults, often carrying a poorer prognosis. We discuss the multimodality imaging features of EES and the differential diagnosis of an aggressive appearing mass in proximity to skeletal structures, with pathologic correlates. This review highlights the need to recognize the variability of radiologic findings in EES such as the presence of hemorrhage, rich vascularity, and cystic or necrotic regions and its imaging similarity to other neoplasms that are closely related pathologically.

Balloon assisted stent deployment in the cephalic arch (BASCA)

Cephalic arch stenosis causes repeated dysfunction and failure of arteriovenous access. Outcomes following balloon angioplasty alone in this location are unsatisfactory. Stent grafts have very good patency rates in this location. However, stent graft placement is technically challenging in this location due to the adverse angles and vectors of the cephalic arch. Stent graft deployment in this location is associated with a real risk of jailing the axillary vein, thereby precluding the use of that arm for future accesses and/or predisposes to venous edema. We describe a technique that was used to safely and effectively deploy a stent graft in the cephalic arch of a 65-year-old male patient.

Demystifying Sacral Masses: A Pictorial Review

The sacrum is a triangular shaped bone made up of five fused vertebral bodies. It is composed of bone, cartilage, marrow elements as well as notochord remnants and is a common site for both benign and malignant (primary and secondary) tumors. Familiarity with the imaging features and clinical presentations of sacral bone tumors could be helpful in narrowing the differential diagnosis. Magnetic resonance imaging and computed tomography are the preferred imaging modalities for evaluating sacral masses. This pictorial review will highlight imaging features of common sacral tumors with pathologic correlation. Additionally, this article will review some critical principles and helpful tips to successfully biopsy these lesions.

Risk Factors for Major Hemorrhage Following Percutaneous Image-Guided Renal Biopsy: What is the "core" of the Problem? A Retrospective Case-control Study

Objectives:

Percutaneous renal biopsy (PRB) plays a critical role in the work-up of renal parenchymal disease. Although it is considered a low-risk procedure, additional interventions may be required in about 7% of the cases following biopsy. The purpose of this study was to identify risk factors for major hemorrhage by microscopic analysis of the cores obtained following PRB, with an intent to enhance the sensitivity and specificity of the risk stratification process, especially in patients undergoing this procedure in an outpatient setting.

Material and Methods:

A retrospective review identified 17 of 179 patients (9.50%) with major hemorrhage following PRB between July 2014 and June 2019. Using propensity score matching, 26 controls (without major hemorrhage) were matched to 17 cases (with major hemorrhage). The biopsy cores obtained from the cases and controls were analyzed by a single pathologist for medullary, cortical, total (medullary + cortical) lengths, and the number of arcuate arteries (AAs). Medullary:cortical (M:C), cortical:total (C:T), and medullary:total (M:T) length ratios were then calculated.

Results:

A stratified version of logistic regression was used to test for an association between each of the variables identified on the cores and the probability of a major hemorrhage. The analysis revealed that there was a statistically significant association between the number of AAs per specimen with the risk of major hemorrhage (P = 0.0006). When 0, 1, or >2 AAs were identified, the frequency of major hemorrhage was 13.04%, 66.67%, and 75.00%, respectively. The odds of major hemorrhage were 6 times higher with one AA and (95% CI, 1.28–32.30) and 15 times higher with >2 AAs (95% CI, 1.41–169.57). No significant association was found between medullary length (P = 0.228), medulla:cortex (M:C) (P = 0.089), medulla:total (M:T) (P = 0.108), or cortex:total (C:T) (P = 0.112) length ratios and major hemorrhage.

Conclusion:

There was a strong and incremental correlation between major renal hemorrhage following PRB and the number of AAs per core specimen. Identification of AAs by the pathologist, while assessing for sample adequacy, in the US suite can help predict major hemorrhage in patients undergoing PRBs.

Chemorefractory liver metastasis from cervical cancer successfully treated with a combination of yttrium-90 and immunotherapy

Liver metastases in cervical cancer is rare and can be difficult-to-treat. The current guidelines established by the Gynecologic Oncology Group recommend platinum-based systemic chemotherapy in combination with an anti-angiogenic agent such as bevacizumab, however, overall survival remains poor following diagnosis and options for patients who fail chemotherapy are limited. Yttrium-90 (Y90) radioembolization (RE) has shown great promise in the treatment of chemo-refractory colorectal liver metastases. We describe a 30-year-old female with a history of stage IB endocervical adenocarcinoma who later developed metastases to the liver, that were unresponsive to multiple chemotherapeutics and chemoembolization, and was successfully treated with Y90 RE with concurrent systemic Pembrolizumab. The Y90 RE treatment resulted in positive clinical and imaging responses with improvement in her quality of life, all of which continue to persist at the time of writing this manuscript about 8-months into her RE treatment.

Appendiceal diverticulosis in a patient with family history of Birt-Hogg-Dubé syndrome--a case report

Birt-Hogg-Dubé syndrome (BHD) is a rare autosomal dominant disorder that predisposes patients to cutaneous tumors, pulmonary cysts with recurrent spontaneous pneumothoraces, and a variety of renal neoplasms including hybrid oncocytic and chromophobe renal cell carcinomas. There has been much debate regarding the genetic link with the occurrence of colorectal cancer and other colonic anomalies. Associations between BHD and intestinal adenomatous polyposis and sigmoid diverticulosis have been described in the literature, but there have been no prior reports of appendiceal diverticulosis in patients with BHD. Here, we present a 40-year-old female patient with a known family history of BHD, who was found to have diverticulosis of the appendix and pulmonary blebs on computed tomography upon routine screening for renal and pulmonary abnormalities, suggesting additional focus be given to the gastrointestinal tract (including the appendix) at the time of CT assessment.

Metastatic retro-crural lymph nodes from transitional cell carcinoma of bladder successfully treated with single session cryoablation

Bladder cancer (BC) is a relatively common tumor, with a male preponderance. High-grade muscle invasive bladder cancer (MIBC) has a very high incidence of pelvic lymph node metastasis at presentation. Involvement of the retro-crural lymph nodes, although has been described in other pelvic tumors, is very uncommon for BC. Cryoablation in the retro-crural region is extremely challenging due to the proximity to the critical structures like inferior venacava and aorta and has not been extensively reported. We describe a 56-year old male patient with MIBC who underwent extensive treatments including radical cystoprostatectomy, chemoradiation and immunotherapy, ultimately with localized disease in the retro-crural region. Single session cryoablation of these lymph nodes was performed with a curative intent yielding a positive response that has persisted for more than 2 years.

Metalophagia: Splenic artery pseudoaneurysm after foreign body ingestion and retrieval

Persistent eating of non-nutritive, nonfood substances (Pica) is seen in children and adult patients with psychiatric problems. Ingestion of multiple metallic FBs with resultant bezoar formation is rare. While many FBs are passed without complication, mucosal injury, bleeding, obstruction or perforation can occur in some cases. Endoscopic FB removal is performed in 20% of patients following FB ingestion. Generally, these are safe procedures, and very effective in extracting ingested FBs. We report, a 25-year-old male patient with a metal ingestion predominant Pica, requiring multiple prior extraction procedures (including open gastrostomy). He developed a splenic artery pseudoaneurysm following his latest endoscopic FB removal, that was successfully treated with transarterial coil embolization. The unique circumstances leading to this rare complication and its successful endovascular management make this case worthy of report.

Spontaneous hemorrhage of an adrenal myelolipoma treated with transarterial embolization: A case report

Adrenal myelolipoma is a benign tumor of the adrenal cortex composed predominantly of fat and hematopoietic tissue. These lesions are usually asymptomatic, and most often incidentally detected on imaging. Uncommonly, they present with retroperitoneal hemorrhage, and these have been traditionally treated with emergent surgery. Although, transarterial embolization has been effectively and safely used in patients presenting with active hemorrhage from acute traumatic and nontraumatic causes, literature specifically pertaining to adrenal artery embolization is scant, perhaps due to smaller size and variability of adrenal arteries. With recent advances in endovascular techniques and imaging, there are emerging case reports and series of adrenal artery embolization in acute and nonacute settings. We report a case of spontaneous hemorrhage within an adrenal myelolipoma in a 43-year-old male patient, successfully treated with transarterial embolization, thereby avoiding major surgery. Our report adds to the growing body of literature pertaining to adrenal artery embolization.