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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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Yokoyama S, Ishizu Y, Honda T, Imai N, Ito T, Yamamoto K, Komada T, Hayashi M, Ishigami M. Pipeline Esophagogastric Varices Secondary to Extrahepatic Portal Vein Obstruction Treated Endoscopically with the Assistance of Transileocolic Obliteration. Intern Med 2022; 61:3503-3511. [PMID: 35491134 PMCID: PMC9790781 DOI: 10.2169/internalmedicine.9404-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Endoscopic injection sclerotherapy (EIS) for esophagogastric varices (EGV) was attempted for a 29-year-old man with extrahepatic portal vein obstruction. However, pipeline varices characterized by a large blood flow volume were present, and the sclerosant did not accumulate sufficiently in them. Transileocolic obliteration (TIO) using coils was performed, but some EGVs and palisading veins remained. Thus, EIS was performed once again immediately after TIO. Since a reduction in the intravariceal blood flow was achieved by preceding TIO, effective injection of sclerosant into the vessels was possible. For pipeline varices difficult to treat endoscopically, combination therapy with TIO may be effective.
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Affiliation(s)
- Shinya Yokoyama
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Japan
| | - Yoji Ishizu
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Japan
| | - Takashi Honda
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Japan
| | - Norihiro Imai
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Japan
| | - Takanori Ito
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Japan
| | - Kenta Yamamoto
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Japan
| | - Tomohiro Komada
- Department of Radiology, Nagoya University Graduate School of Medicine, Japan
| | - Masamichi Hayashi
- Department of Gastroenterological Surgery 2, Nagoya University Graduate School of Medicine, Japan
| | - Masatoshi Ishigami
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Japan
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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: 4] [Impact Index Per Article: 1.0] [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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Masuda K, Takenaga S, Ashida H, Ojiri H. Variceal bleeding in the small intestine successfully treated with balloon-occluded retrograde transvenous obliteration using N-butyl-2-cyanoacrylate: A case report. Radiol Case Rep 2018; 13:400-403. [PMID: 29904482 PMCID: PMC6000062 DOI: 10.1016/j.radcr.2018.01.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 01/15/2018] [Indexed: 02/07/2023] Open
Abstract
Rupture of small intestinal varices associated with portal hypertension can be a serious condition that is difficult to diagnose early and to manage. Moreover, optimal guidelines for the treatment of small intestinal varices have not yet been established. We herein report a case of a 73-year-old man with small intestinal varices. The man presented with bleeding from a stoma in the small intestine, which subsequently led to hemorrhagic shock. We successfully treated the patient with balloon-occluded retrograde transvenous obliteration via the right inferior epigastric vein using N-butyl-2-cyanoacrylate.
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Affiliation(s)
- Koichi Masuda
- Department of Radiology, The Jikei University Katsushika Medical Center, 6-41-2, Aoto, Katsushika-ku, Tokyo, 125-8506, Japan
| | - Shinsuke Takenaga
- Department of Radiology, The Jikei University Katsushika Medical Center, 6-41-2, Aoto, Katsushika-ku, Tokyo, 125-8506, Japan
| | - Hirokazu Ashida
- Department of Radiology, The Jikei Medical University Hospital, Minato-ku, Tokyo, Japan
| | - Hiroya Ojiri
- Department of Radiology, The Jikei Medical University Hospital, Minato-ku, Tokyo, Japan
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Ishikawa T, Imai M, Ko M, Sato H, Nozawa Y, Sano T, Iwanaga A, Seki K, Honma T, Yoshida T. Percutaneous transhepatic obliteration and percutaneous transhepatic sclerotherapy for intractable hepatic encephalopathy and gastric varices improves the hepatic function reserve. Biomed Rep 2017; 6:99-102. [PMID: 28123716 PMCID: PMC5244787 DOI: 10.3892/br.2016.811] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 10/27/2016] [Indexed: 02/06/2023] Open
Abstract
Percutaneous transhepatic obliteration (PTO) and percutaneous transhepatic sclerotherapy (PTS) are widely performed as an emergency measure in cases of variceal hemorrhage and intractable hepatic encephalopathy. The PTO/PTS technique is capable of directly blocking the blood supply in cases in which balloon-occluded retrograde transvenous obliteration (B-RTO) is not effective, or in cases with complicated collateral flow. Although PTO/PTS is not currently the first choice due to the invasiveness of transhepatic puncture, this procedure can modify the blood flow in an antegrade manner. The present study examined the changes in hepatic function reserve following PTO/PTS for intractable hepatic encephalopathy and/or gastric varices. In total, the study included 37 patients (mean age, 61.75±12.77 years; age range, 32-88 years; male to female ratio, 23:14) with a variety of gastrorenal shunts, or B-RTO-intractable hepatic encephalopathy and gastric varices without gastrorenal shunts. The patients underwent PTO/PTS by embolizing a microcoil or injection of a sclerosing agent (5% ethanolamine oleate iopamidol). Alterations in hepatic function reserve prior to and following the procedure were compared. The patients were treated for hepatic encephalopathy in 11 patients, gastric varices in 19 patients, and both conditions in 7 patients. The results indicated that the blood ammonia level improved from 135.76±75.23 mg/dl to 88.00±42.16 and 61.81±33.75 mg/dl at 3 and 6 months after therapy, respectively. In addition, the Child-Pugh score improved from 8.48±2.01 prior to therapy to 7.70±1.84 and 7.22±2.01 at 3 and 6 months after the procedure, respectively. Although there was a concern that PTO/PTS may cause complications due to an increase in portal venous pressure (PVP) arising from shunt occlusion, no severe complications were observed. In conclusion, for patients with various gastrorenal shunts or those with B-RTO-intractable hepatic encephalopathy and gastric varices without gastrorenal shunts, PTO/PTS can improve the antegrade blood flow to the liver, as demonstrated by improvement in the hepatic function reserve.
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Affiliation(s)
- Toru Ishikawa
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Daini Hospital, Niigata 950-1104, Japan
| | - Michitaka Imai
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Daini Hospital, Niigata 950-1104, Japan
| | - Masayoshi Ko
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Daini Hospital, Niigata 950-1104, Japan
| | - Hiroki Sato
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Daini Hospital, Niigata 950-1104, Japan
| | - Yujiro Nozawa
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Daini Hospital, Niigata 950-1104, Japan
| | - Tomoe Sano
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Daini Hospital, Niigata 950-1104, Japan
| | - Akito Iwanaga
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Daini Hospital, Niigata 950-1104, Japan
| | - Keiichi Seki
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Daini Hospital, Niigata 950-1104, Japan
| | - Terasu Honma
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Daini Hospital, Niigata 950-1104, Japan
| | - Toshiaki Yoshida
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Daini Hospital, Niigata 950-1104, Japan
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Copelan A, Chehab M, Dixit P, Cappell MS. Safety and efficacy of angiographic occlusion of duodenal varices as an alternative to TIPS: review of 32 cases. Ann Hepatol 2015; 14:369-379. [PMID: 25864218 DOI: 10.1016/s1665-2681(19)31277-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED BACKGROUND/RATIONALE OF STUDY: Analyze safety and efficacy of angiographic-occlusion-with-sclerotherapy/embolotherapy-without-transjugular-intrahepatic-portosystemic-shunt (TIPS) for duodenal varices. Although TIPS is considered the best intermediate-to-long term therapy after failed endoscopic therapy for bleeding varices, the options are not well-defined when TIPS is relatively contraindicated, with scant data on alternative therapies due to relative rarity of duodenal varices. Prior cases were identified by computerized literature search, supplemented by one illustrative case. Favorable clinical outcome after angiography defined as no rebleeding during follow-up, without major procedural complications. RESULTS Thirty-two cases of duodenal varices treated by angiographic-occlusion-with-sclerotherapy/embolotherapy- without-TIPS were analyzed. Patients averaged 59.5 ± 12.2 years old (female = 59%). Patients presented with melena-16, hematemesis & melena-5, large varices-5, growing varices-2, ruptured varices-1, and other- 3. Twenty-nine patients had cirrhosis; etiologies included: alcoholism-11, hepatitis C-11, primary biliary cirrhosis- 3, hepatitis B-2, Budd-Chiari-1, and idiopathic-1. Three patients did not have cirrhosis, including hepatic metastases from rectal cancer-1, Wilson's disease-1, and chronic liver dysfunction-1. Thirty-one patients underwent esophagogastroduodenoscopy before therapeutic angiography, including fifteen undergoing endoscopic variceal therapy. Therapeutic angiographic techniques included balloon-occluded retrograde-transvenous-obliteration (BRTO) with sclerotherapy and/or embolization-21, DBOE (double-balloon-occluded-embolotherapy)-5, and other-6. Twenty-eight patients (87.5%; 95%-confidence interval: 69-100%) had favorable clinical outcomes after therapeutic angiography. Three patients were therapeutic failures: rebleeding at 0, 5, or 10 days after therapy. One major complication (Enterobacter sepsis) and one minor complication occurred. CONCLUSIONS This work suggests that angiographic-occlusion-with sclerotherapy/ embolotherapy-without-TIPS is relatively effective (~90% hemostasis-rate), and relatively safe (3% major-complication-rate). This therapy may be a useful treatment option for duodenal varices when endoscopic therapy fails and TIPS is relatively contraindicated.
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Affiliation(s)
- Alexander Copelan
- Department of Radiology, William Beaumont Hospital, Royal Oak, MI, USA
| | - Monzer Chehab
- Department of Radiology, William Beaumont Hospital, Royal Oak, MI, USA
| | - Purushottam Dixit
- Department of Radiology, William Beaumont Hospital, Royal Oak, MI, USA; Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Mitchell S Cappell
- Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA; Division of Gastroenterology & Hepatology, William Beaumont Hospital, Royal Oak, MI, USA
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Successful emergency combined therapy with partial splenic arterial embolization and endoscopic injection therapy against a bleeding duodenal varix in a child. Clin J Gastroenterol 2015; 8:138-42. [PMID: 25851961 DOI: 10.1007/s12328-015-0563-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 03/17/2015] [Indexed: 01/15/2023]
Abstract
There is no consensus guidelines for treating duodenal variceal bleeding, which is a rare and life-threatening complication of portal hypertension. Here we report an exceedingly unusual case in a 9-year-old boy who had developed left-sided portal hypertension after surgical treatment for pancreatoblastoma followed by a duodenal variceal bleeding with massive melena, severe anemia (hemoglobin 4.5 g/dL) and hypovolemic shock. Emergency partial splenic arterial embolization (PSE) provided a reduction of variceal bleeding and improved blood pressure. Endoscopic injection sclerotherapy (EIS) was subsequently performed and stopped the duodenal variceal bleeding without the complication of portal vein thrombosis caused by injected sclerosant under hepatopetal flow. Our case demonstrates that emergency combined therapy with PSE and EIS can be considered as the therapeutic option for the management of left-sided portal hypertension-induced ectopic variceal bleedings in order to avoid the complication of portal embolization by EIS and provide effective hematostasis.
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8
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Hwang SW, Sohn JH, Kim TY, Kim JY, Yhi J, Kwak DS, Kim HS, Song SY. Long-term successful treatment of massive distal duodenal variceal bleeding with balloon-occluded retrograde transvenous obliteration. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2015; 63:248-52. [PMID: 24755751 DOI: 10.4166/kjg.2014.63.4.248] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Duodenal variceal bleeding in patients with portal hypertension due to cirrhosis or other causes is uncommon. We report on a case of a 55-year-old male with an ectopic variceal rupture at the distal fourth part of the duodenum who presented with massive hematochezia and shock. Shortly after achievement of hemodynamic stability, due to the limitation of an endoscopic procedure, we initially attempted to find the bleeding focus by abdominal computed tomography, which showed tortuous duodenal varices that drained into the left gonadal vein. He was treated with first-line balloon-occluded retrograde transvenous obliteration (BRTO), resulting in a favorable long-term outcome without rebleeding three years later. This case suggests that BRTO may be a first-line therapeutic option for control of ruptured duodenal varices, especially at a distal location.
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Affiliation(s)
- Soon Woo Hwang
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Joo Hyun Sohn
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Tae Yeob Kim
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Ji Yeoun Kim
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Jiyoung Yhi
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Dong Shin Kwak
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Hae Su Kim
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Soon-Young Song
- Department of Radiology, Hanyang University Seoul Hospital, Seoul, Korea
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Saad WEA, Lippert A, Saad NE, Caldwell S. Ectopic varices: anatomical classification, hemodynamic classification, and hemodynamic-based management. Tech Vasc Interv Radiol 2014; 16:158-75. [PMID: 23830673 DOI: 10.1053/j.tvir.2013.02.004] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Ectopic varices are dilated splanchnic (mesoportal) veins/varicosities and/or are dilated portosystemic collaterals that can occur along the entire gastrointestinal tract outside the common pathologic variceal sites. Ectopic varices are complex and highly variable entities that are not fully understood. Ectopic varices represent 2%-5% of a gastrointestinal tract variceal bleeding. However, ectopic varices have a 4-fold increased risk of bleeding when compared with esophageal varices and can have a mortality rate as high as 40%. All treatment strategies and techniques have been utilized in managing these potentially mortal varices and have shown poor outcomes. The debate of whether to manage these varices by decompression with a transjugular portosystemic shunt, or other portosystemic shunts, vs transvenous obliteration is unresolved. The rebleed rates after transjugular portosystemic shunt decompression are 20%-40%. The rebleed rates after transvenous obliteration and the mortality rate at 3-6 months are 30%-40% and 50%-60%, respectively. Hemodynamically from an etiology standpoint, there are 2 types: occlusive (type-b) and nonocclusive (oncotic or type-a). Hemodynamically from a vascular-shunting standpoint, there could be a component of portoportal or portosystemic shunting or both with varying dominance. This is the basis of the new classification system described herein. Management strategies (decompression vs sclerosis) are discussed. The ideal management strategy is a treatment that leads to prompt hemostasis but also addresses the etiology or hemodynamics of the ectopic varices. It is the hope that with better understanding, description, and categorization of ectopic varices comes a more systematic approach to this rare but menacing problem.
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Affiliation(s)
- Wael E A Saad
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA.
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Hiramine Y, Imamura Y, Ijuin S, Nishi N, Kanetsuki I, Ogura Y, Miyawaki T, Nisizima H, Maenohara S. A Case of refractory hepatic encephalopathy with poor residual liver function effectively treated with trans-ileocolic venous obliteration (TIO) using Doppler ultrasonography. KANZO 2014; 55:66-75. [DOI: 10.2957/kanzo.55.66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Hashimoto R, Sofue K, Takeuchi Y, Shibamoto K, Arai Y. Successful balloon-occluded retrograde transvenous obliteration for bleeding duodenal varices using cyanoacrylate. World J Gastroenterol 2013; 19:951-954. [PMID: 23429766 PMCID: PMC3574895 DOI: 10.3748/wjg.v19.i6.951] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2012] [Accepted: 10/30/2012] [Indexed: 02/06/2023] Open
Abstract
A 76-year-old woman with hepatitis C cirrhosis presented with tarry stools and hematemesis. An endoscopy demonstrated bleeding duodenal varices in the second portion of the duodenum. Contrast-enhanced computed tomography revealed markedly tortuous varices around the wall in the duodenum. Several afferent veins appeared to have developed, and the right ovarian vein draining into the inferior vena cava was detected as an efferent vein. Balloon-occluded retrograde transvenous obliteration (BRTO) of the varices using cyanoacrylate was successfully performed in combination with the temporary occlusion of the portal vein. Although no previous publications have used cyanoacrylate as an embolic agent for BRTO to control bleeding duodenal varices, this strategy can be considered as an alternative procedure to conventional BRTO using ethanolamine oleate when numerous afferent vessels that cannot be embolized are present.
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12
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Transjugular Retrograde Obliteration prior to Liver Resection for Hepatocellular Carcinoma Associated with Hyperammonemia due to Spontaneous Portosystemic Shunt. Case Reports Hepatol 2013; 2013:809543. [PMID: 25379302 PMCID: PMC4208424 DOI: 10.1155/2013/809543] [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: 05/15/2013] [Accepted: 07/14/2013] [Indexed: 11/18/2022] Open
Abstract
A 67-year-old woman had hepatocellular carcinoma (HCC) measuring 3.7 cm at S8 of the liver with hyperammonemia due to a spontaneous giant mesocaval shunt. Admission laboratory data revealed albumin, 2.9 g/dL; total bilirubin, 1.3 mg/dL; plasma ammonia level (NH3), 152 g/dL; total bile acid (TBA) 108.5 μmoL/L; indocyanine green retention rate at 15 min (ICG15), 63%. Superior mesenteric arterial portography revealed a hepatofugal giant mesocaval shunt, and the portal vein was not visualized. Before surgery, transjugular retrograde obliteration (TJO) for the mesocaval shunt was attempted to normalize the portal blood flow. Via the right internal jugular vein, a 6 F occlusive balloon catheter was inserted superselectively into the mesocaval shunt. The mesocaval shunt was successfully embolized using absolute ethanol and a 50% glucose solution. Eleven days after TJO, NH3, TBA, and ICG15 decreased to 56, 44, and 33, respectively. Superior mesenteric arterial portography after TJO revealed a hepatopetal portal flow. Partial hepatectomy of S8 was performed 25 days after TJO. The subsequent clinical course showed no complications, and the woman was discharged on postoperative day 14. We conclude that the combined therapy of surgery and TJO is an effective means of treating HCC with hyperammonemia due to a spontaneous portosystemic shunt.
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13
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Anatomic Features and Retrograde Transvenous Obliteration of Duodenal Varices Associated with Mesocaval Collateral Pathway. J Vasc Interv Radiol 2012; 23:1339-46. [DOI: 10.1016/j.jvir.2012.06.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2012] [Revised: 06/25/2012] [Accepted: 06/29/2012] [Indexed: 01/25/2023] Open
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Saad WEA, Sze DY. Variations of Balloon-occluded Retrograde Transvenous Obliteration (BRTO): Balloon-occluded Antegrade Transvenous Obliteration (BATO) and Alternative/Adjunctive Routes for BRTO. Semin Intervent Radiol 2012; 28:314-24. [PMID: 22942549 DOI: 10.1055/s-0031-1284458] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Alternative routes for transvenous obliteration are often sought in the management of gastric varices, as well as in the management of other nongastric varices (ectopic varices) such as duodenal and mesenteric varices. These alternative routes can be classified into A-portal venous access routes and B-systemic venous access routes. Anecdotally, alternative routes are more commonly required with duodenal and mesenteric varices compared with gastric varices. Twelve percent (2-19%) of patients with gastric varices require alternative/adjunctive variceal access routes. The most common alternative route described for transvenous obliteration of gastric varices is the percutaneous transhepatic route, which is commonly referred to in the Japanese literature as percutaneous transhepatic obliteration (PTO). The percutaneous transhepatic obliteration route can be performed alone or in combination with the more traditional balloon-occluded retrograde transvenous obliteration (BRTO) transrenal route. Percutaneous transhepatic obliteration by itself is successful in 44-100% of cases for obliterating gastric varices and is rarely unsuccessful when it is combined with BRTO. Other alternative routes are less commonly described and as a result, their clinical outcomes are relatively anecdotal. However, they are technically more challenging and are less commonly successful. These routes include, but are not confined to transphrenic, transileocolic, trans-TIPS (transvenous intrahepatic portosystemic shunt), transgonadal, transazygous, and transrenal capsular vein approaches.
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Sharma M, Mohan P, Rameshbabu CS, Jayanthi V. Identification of Perforators in Patients with Duodenal Varices by Endoscopic Ultrasound-A Case Series [with video]. J Clin Exp Hepatol 2012; 2:229-37. [PMID: 25755439 PMCID: PMC3940111 DOI: 10.1016/j.jceh.2012.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 08/08/2012] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIMS Duodenal varices (DV) are ectopic varices which can cause massive gastrointestinal bleeding. The diagnosis of DV may be difficult; sometimes they can be hidden behind duodenal folds. The aim of the study was to evaluate DV by endoscopic ultrasound. METHODS Endoscopic ultrasound was done in patients detected or suspected to be having DV. The para duodenal varices were identified and subsequently hemodynamic evaluation of DV was done. RESULTS Endoscopic ultrasound identified perforators in seven cases of DV. CONCLUSION The endoscopic ultrasound can help in detection of DV underlying thickened folds. It can also help in hemodynamic evaluation of DV.
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Key Words
- CBD, common bile duct
- DV, duodenal varices
- ECD, epicholedochal
- EHPVO, extra hepatic portal vein obstruction
- EUS, Endoscopic ultrasound
- EVL, endoscopic variceal ligation
- HDA, hemodynamic assessment
- IVC, inferior vena cava
- PCD, para-choledochal
- PDV, paraduodenal varices
- PV, portal vein
- SMV, superior mesenteric vein
- duodenal varices
- endoscopic ultrasound
- endoscopic variceal ligation
- portal hypertension
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Affiliation(s)
- Malay Sharma
- Jaswant Rai Speciality Hospital, Saket, Meerut 250 001, Uttar Pradesh, India,Address for Correspondence: Dr. Malay Sharma, Gastroenterologist, Jaswant Rai Speciality Hospital, Saket, Meerut 250 001, Uttar Pradesh, India. Tel.: +91 9837031148 (mobile).
| | - Pazhanivel Mohan
- Department of Gastroenterology, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
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16
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Saad WE, Al-Osaimi AM, Caldwell SH. Pre– and Post–Balloon-Occluded Retrograde Transvenous Obliteration Clinical Evaluation, Management, and Imaging: Indications, Management Protocols, and Follow-up. Tech Vasc Interv Radiol 2012; 15:165-202. [DOI: 10.1053/j.tvir.2012.07.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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17
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Kakutani H, Sasaki S, Ueda K, Takakura K, Sumiyama K, Imazu H, Hino S, Kawamura M, Tajiri H. Is it safe to perform endoscopic band ligation for the duodenum? A pilot study in ex vivo porcine models. MINIM INVASIV THER 2012; 22:80-3. [PMID: 22793777 DOI: 10.3109/13645706.2012.703955] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM In the digestive tract, endoscopic band ligation (EBL) has been routinely used for the treatment of variceal bleeding and superficial malignancies. In recent years, endoscopic treatments for duodenal varices, adenoma, and cancer have also actively incorporated EBL. Although there have been a number of reports on the risks associated with the use of EBL in the esophagus, stomach, and colon, few studies have focused on EBL in the duodenum. We performed EBL procedures to evaluate the risks associated with the use of EBL in the duodenum. MATERIAL AND METHODS Overall, EBLs were performed at nine sites in duodenum sampled from a pig immediately after sacrifice. Submucosal saline injections were placed in three of the nine studied sites. RESULTS Regardless of saline injection, the full thickness of the duodenal wall was ligated in all attempts. CONCLUSIONS Routine EBL is not recommended in the duodenum because the risk of perforation is unacceptably high.
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Affiliation(s)
- Hiroshi Kakutani
- Department of Endoscopy, The JikeiUniversity School of Medicine, Tokyo, Japan.
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18
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Saad WEA. Balloon-occluded retrograde transvenous obliteration of gastric varices: concept, basic techniques, and outcomes. Semin Intervent Radiol 2012; 29:118-28. [PMID: 23729982 PMCID: PMC3444869 DOI: 10.1055/s-0032-1312573] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Patients with gastric variceal bleeding require a multidisciplinary team approach including hepatologists, endoscopists, diagnostic radiologists, and interventional radiologists. Upper gastrointestinal endoscopy is the first-line diagnostic and management tool for bleeding gastric varices, as it is in all upper gastrointestinal bleeding scenarios. In the United States when endoscopy fails to control gastric variceal bleeding, a transjugular intrahepatic portosystemic shunt (TIPS) traditionally is performed along the classic teachings of decompressing the portal circulation. However, TIPS has not shown the same effectiveness in controlling gastric variceal bleeding that it has with esophageal variceal bleeding. For the past 2 decades, the balloon-occluded retrograde transvenous obliteration (BRTO) procedure has become common practice in Asia for the management of gastric varices. BRTO is gaining popularity in the United States. It has been shown to be effective in controlling gastric variceal bleeding with low rebleed rates. BRTO has many advantages over TIPS in that it is less invasive and can be performed on patients with poor hepatic reserve and those with encephalopathy (and may even improve both). However, its by-product is occlusion of a spontaneous hepatofugal (TIPS equivalent) shunt, and thus it is contradictory to the traditional American doctrine of portal decompression. Indeed, BRTO causes an increase in portal hypertension, with potential aggravation of esophageal varices and ascites. This article discusses the concept, technique, and outcomes of BRTO within the broader management of gastric varices.
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Affiliation(s)
- Wael E. A. Saad
- Division of Vascular Interventional Radiology, Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia
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19
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Kakizaki S, Toyoda M, Ichikawa T, Sato K, Takagi H, Arai H, Sohara N, Iizuka H, Onozato Y, Mori M. Clinical characteristics and treatment for patients presenting with bleeding duodenal varices. Dig Endosc 2010; 22:275-281. [PMID: 21175479 DOI: 10.1111/j.1443-1661.2010.01007.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIM Bleeding from ectopic varices, including duodenal varices, is uncommon, but it can be difficult to manage. The clinical data of patients diagnosed and treated for duodenal varices were reviewed to investigate the strategy for treatment. METHODS The present study reviewed the clinical data of 10 patients with duodenal varices (mean age, 58.2 ± 15.6 years) at our associated institutes during the period between January 1996 and December 2008. RESULTS Nine patients had duodenal varices located in the second portion, whereas in one case they were located in the duodenal bulbus. The underlying diseases included liver cirrhosis in eight patients, and extrahepatic portal vein obstruction in two patients. The lesions were identified with bleeding from varices in eight of 10 patients. Initial hemostasis was achieved in all eight patients. However, among four patients treated endoscopically only, two patients died from rebleeding from varices and two died from hepatic failure resulting from variceal bleeding. Additional interventional radiology (IVR) was used in three patients and additional surgery was carried out in one case. One patient who was treated with balloon-occluded retrograde transvenous obliteration rebled during IVR and died from bleeding. Two patients who underwent double balloon-occluded embolotherapy and one case who had surgery achieved good clinical outcomes. CONCLUSIONS Although endoscopic treatment is useful for initial hemostasis of hemorrhagic duodenal varices, the patients who underwent additional IVR after endoscopic treatment achieved good outcomes.
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Affiliation(s)
- Satoru Kakizaki
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Gunma, Japan.
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20
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Soga K, Tomikashi K, Fukumoto K, Miyawaki KI, Okuda K, Konishi H, Yagi N, Wakabayashi N, Kokura S, Naito Y, Yoshikawa T. Successful endoscopic hemostasis for ruptured duodenal varices after balloon-occluded retrograde transvenous obliteration. Dig Endosc 2010; 22:329-33. [PMID: 21175490 DOI: 10.1111/j.1443-1661.2010.01023.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A 75-year-old man with general malaise and appetite loss was transferred to our hospital for assessment and treatment of liver failure. Laboratory findings on admission showed anemia, and gastroduodenoscopy (GDS) revealed linear esophageal varices and tensive duodenal varices (DV) in the second portion of the duodenum. Systemic examinations did not reveal any significant lesion capable of explaining his anemia, except for DV. Balloon-occluded retrograde transvenous obliteration was carried out to prevent DV bleeding. Good pooling of sclerosant was observed using two balloon catheters. However, contrast-enhanced computed tomography after the procedure revealed no thrombosis in DV, and the patient complained of tarry stools before additional therapy. Emergent GDS revealed ruptured DV with fresh blood and erosions on the surface. Emergent endoscopic obliteration using the tissue adhesive N-butyl-2-cyanoacrylate was carried out and complete hemostasis was achieved. Although no rebleeding episodes were observed after emergent obliteration, the patient died of sepsis following spontaneous bacterial peritonitis 53 days after admission. Autopsy revealed that DV dropped out, and the deep vein was replaced by granulation tissue. No signs of thrombi were detected, except varices. This autopsy case revealed the difficulty in DV management.
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Affiliation(s)
- Koichi Soga
- Department of Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Kyoto, Japan.
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21
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Akasaka T, Shibata T, Isoda H, Taura K, Arizono S, Shimada K, Togashi K. Septic complication after balloon-occluded retrograde transvenous obliteration of duodenal variceal bleeding. Cardiovasc Intervent Radiol 2009; 33:1257-61. [PMID: 19902296 DOI: 10.1007/s00270-009-9740-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2009] [Accepted: 10/12/2009] [Indexed: 11/28/2022]
Abstract
We report a 64-year-old woman with duodenal varices who underwent balloon-occluded retrograde transvenous obliteration (B-RTO) complicated by intraprocedural variceal rupture. The patient developed shivering and a fever higher than 40°C 3 days after the B-RTO procedure. A blood culture grew Entereobacter cloacoe. This case represents a rare septic complication of B-RTO for duodenal varices.
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Affiliation(s)
- Thai Akasaka
- Department of Radiology, Kyoto University Graduate School of Medicine, 54-Kawaharacho, Shogoin, Sakyoku, Kyoto 606-8507, Japan
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22
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Abstract
Ectopic varices (EcV) comprise large portosystemic venous collaterals located anywhere other than the gastro-oesophageal region. No large series or randomized-controlled trials address this subject, and therefore its management is based on available expertise and facilities, and may require a multidisciplinary team approach. EcV are common findings during endoscopy in portal hypertensive patients and their bleeding accounts for only 1–5% of all variceal bleeding. EcV develop secondary to portal hypertension (PHT), surgical procedures, anomalies in venous outflow, or abdominal vascular thrombosis and may be familial in origin. Bleeding EcV may present with anaemia, shock, haematemesis, melaena or haematochezia and should be considered in patients with PHT and gastrointestinal bleeding or anaemia of obscure origin. EcV may be discovered during panendoscopy, enteroscopy, endoscopic ultrasound, wireless capsule endoscopy, diagnostic angiography, multislice helical computed tomography, magnetic resonance angiography, colour Doppler-flow imaging, laparotomy, laparoscopy and occasionally during autopsy. Patients with suspected EcV bleeding need immediate assessment, resuscitation, haemodynamic stabilization and referral to specialist centres. Management of EcV involves medical, endoscopic, interventional radiological and surgical modalities depending on patients’ condition, site of varices, available expertise and patients’ subsequent management plan.
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23
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Seo YS, Kwon YD, Park S, Keum B, Park BJ, Kim YS, Jeen YT, Chun HJ, Kim CD, Ryu HS, Um SH. Complete eradication of duodenal varices after endoscopic injection sclerotherapy with ethanolamine oleate: a case report. Gastrointest Endosc 2008; 67:759-62. [PMID: 18206152 DOI: 10.1016/j.gie.2007.08.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2007] [Accepted: 08/18/2007] [Indexed: 12/20/2022]
Affiliation(s)
- Yeon Seok Seo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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24
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Hotta M, Yoshida H, Mamada Y, Taniai N, Bando K, Mizuguchi Y, Kakinuma D, Kanda T, Watanabe KI, Tajiri T. Successful Management of Duodenal Varices by Balloon-occluded Retrograde Transvenous Obliteration. J NIPPON MED SCH 2008; 75:36-40. [DOI: 10.1272/jnms.75.36] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Masahiro Hotta
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Hiroshi Yoshida
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Yasuhiro Mamada
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Nobuhiko Taniai
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Koichi Bando
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Yoshiaki Mizuguchi
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Daisuke Kakinuma
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Tomohiro Kanda
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Ken-ichiro Watanabe
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Takashi Tajiri
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
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25
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Arai H, Abe T, Takagi H, Mori M. Efficacy of balloon-occluded retrograde transvenous obliteration, percutaneous transhepatic obliteration and combined techniques for the management of gastric fundal varices. World J Gastroenterol 2006; 12:3866-73. [PMID: 16804972 PMCID: PMC4087935 DOI: 10.3748/wjg.v12.i24.3866] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the effect of three interventional treatments involving transvenous obliteration for the treatment of gastric varices, and to compare the efficacy and adverse effects of these methods.
METHODS: From 1995 to 2004, 93 patients with gastric fundal varices underwent interventional radiologic embolotherapy at our hospital. Of the 93 patients, 75 were treated with the balloon-occluded retrograde transvenous obliteration (BRTO) procedure; 8 were with the percutaneous transhepatic obliteration (PTO) procedure; and 10 were with the combined BRTO and PTO therapy. A follow-up evaluation examined the rates of survival, recurrence and rebleeding of the gastric varices, worsening of esophageal varices and complications in each group.
RESULTS: The BRTO, PTO, and combined therapy were technically successful in 81% (75/93), 44% (8/18), and 100% (10/10) patients, respectively. Recurrence of gastric varices was found in 3 patients in the BRTO group and in 3 patients in the PTO group. Rebleeding was observed in 1 patient in the BRTO group and in 1 patient in the PTO group. The 1- and 3-year survival rates were 98% and 87% in the patients without hepatocellular carcinoma (HCC) in the BRTO group, 100% and 100% in the PTO group, and 90% and 75% in the combined therapy group, respectively.
CONCLUSION: Combined BRTO and PTO therapy may rescue cases with uncontrollable gastric fundal varices that remained even after treatment with BRTO and/or PTO, though there were limitations of our study, including retrospective nature and discrepancy in sample size between the BRTO, PTO and combined therapy groups.
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Affiliation(s)
- Hirotaka Arai
- Department of Gastroenterology, Maebashi Red Cross Hospital, Japan.
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26
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Anan A, Irie M, Watanabe H, Sohda T, Iwata K, Suzuki N, Yoshikane M, Nakane H, Hashiba T, Yokoyama M, Higashihara H, Okazaki M, Sakisaka S. Colonic varices treated by balloon-occluded retrograde transvenous obliteration in a cirrhotic patient with encephalopathy: a case report. Gastrointest Endosc 2006; 63:880-4. [PMID: 16650568 DOI: 10.1016/j.gie.2005.11.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2005] [Accepted: 11/27/2005] [Indexed: 12/11/2022]
Affiliation(s)
- Akira Anan
- Third Department of Internal Medicine, Department of Emergency and Critical Care Medicine, Fukuoka University School of Medicine, Fukuoka, Japan
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27
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Machida T, Sato K, Kojima A, Takezawa J, Sohara N, Kakizaki S, Takagi H, Mori M. Ruptured duodenal varices after endoscopic ligation of esophageal varices: an autopsy case. Gastrointest Endosc 2006; 63:352-354. [PMID: 16427959 DOI: 10.1016/j.gie.2005.08.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2005] [Accepted: 08/29/2005] [Indexed: 01/09/2023]
Affiliation(s)
- Takashi Machida
- Department of Internal Medicine, Kiryu Welfare General Hospital, Kiryu, Gunma, Japan
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28
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Takamura K, Miyake H, Mori H, Terashima Y, Ando T, Fujii M, Tashiro S, Shimada M. Balloon occluded retrograde transvenous obliteration and percutaneous transhepatic obliteration for ruptured duodenal varices after operation for rectal cancer with multiple liver metastasis: report of a case. THE JOURNAL OF MEDICAL INVESTIGATION 2005; 52:212-7. [PMID: 16167541 DOI: 10.2152/jmi.52.212] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
We report a patient with duodenal varices oozing blood who had undergone low anterior resection of the rectum and resection of the liver tumor because of multiple liver metastasis from rectal cancer 80 months previously. Although endoscopic variceal ligation (EVL) was carried out for the ruptured duodenal varices, their bleeding persisted and hepatic encephalopathy also appeared. Finally, balloon occluded retrograde transvenous obliteration (BRTO) with percutaneous transhepatic obliteration (PTO) was carried out for the duodenal varices. Percutaneous transhepatic portography revealed detailed hemodynamics. Following PTO, the duodenal varices were stagnated by BRTO, and no complications were recognized. No re-bleeding episode has been observed since the treatment. In addition, the hepatic encephalopathy was also improved.
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Affiliation(s)
- Kazuhito Takamura
- Department of Digestive Surgery, Ehime Prefectural Central Hospital, 83, Kasuga-cho, Matsuyama, Ehime 790-0024, Japan
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29
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Tsurusaki M, Sugimoto K, Matsumoto S, Izaki K, Fukuda T, Akasaka Y, Fujii M, Hirota S, Sugimura K. Bleeding Duodenal Varices Successfully Treated with Balloon-Occluded Retrograde Transvenous Obliteration (B-RTO) Assisted by CT During Arterial Portography. Cardiovasc Intervent Radiol 2005; 29:1148-51. [PMID: 15999240 DOI: 10.1007/s00270-004-0189-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
A 60-year-old woman with massive hemorrhage from duodenal varices was transferred to our hospital for the purpose of transcatheter intervention. Although digital subtraction arterial portography could not depict the entire pathway of collateral circulation, the efferent route of the duodenal varices was clearly demonstrated on subsequent CT during arterial portography. Balloon-occluded retrograde transvenous obliteration (B-RTO) of the varices was performed via the efferent vein and achieved complete thrombosis of the varices.
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Affiliation(s)
- Masakatsu Tsurusaki
- Department of Radiology, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
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30
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Zamora CA, Sugimoto K, Tsurusaki M, Izaki K, Fukuda T, Matsumoto S, Kuwata Y, Kawasaki R, Taniguchi T, Hirota S, Sugimura K. Endovascular obliteration of bleeding duodenal varices in patients with liver cirrhosis. Eur Radiol 2005; 16:73-9. [PMID: 15856238 DOI: 10.1007/s00330-005-2781-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2004] [Revised: 03/22/2005] [Accepted: 04/08/2005] [Indexed: 02/07/2023]
Abstract
The purpose of this paper is to describe our experience with endovascular obliteration of duodenal varices in patients with liver cirrhosis and portal hypertension. Balloon-occluded transvenous retrograde and percutaneous transhepatic anterograde embolizations were performed for duodenal varices in five patients with liver cirrhosis, portal hypertension, and decreased liver function. All patients had undergone previous endoscopic treatments that failed to stop bleeding and were poor surgical candidates. Temporary balloon occlusion catheters were used to achieve accumulation of an ethanolamine oleate-iopamidol mixture inside the varices. Elimination of the varices was successful in all patients. Retrograde transvenous obliteration via efferent veins to the inferior vena cava was enough to achieve adequate sclerosant accumulation in three patients. A combined anterograde-retrograde embolization was used in one patient with balloon occlusion of afferent and efferent veins. Transhepatic embolization through the afferent vein was performed in one patient under balloon occlusion of both efferent and afferent veins. There was complete variceal thrombosis and no bleeding was observed at follow-up. No major complications were recorded. Endovascular obliteration of duodenal varices is a feasible and safe alternative procedure for managing patients with portal hypertension and hemorrhage from this source.
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Affiliation(s)
- Carlos Armando Zamora
- Department of Radiology, Kobe University School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe-shi, Hyogo-ken, 650-0017, Japan.
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31
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Oberti F. Comment prévenir et traiter les hémorragies par varices gastriques, ou ectopiques ou par gastropathie congestive. ACTA ACUST UNITED AC 2004; 28 Spec No 2:B53-72. [PMID: 15150498 DOI: 10.1016/s0399-8320(04)95241-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Frédéric Oberti
- Service d'Hépato-Gastroentérologie, Centre Hospitalo-Universitaire Angers, 49100 Angers
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32
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Sonomura T, Horihata K, Yamahara K, Dozaiku T, Toyonaga T, Hiroka T, Sato M. Ruptured duodenal varices successfully treated with balloon-occluded retrograde transvenous obliteration: usefulness of microcatheters. AJR Am J Roentgenol 2003; 181:725-7. [PMID: 12933468 DOI: 10.2214/ajr.181.3.1810725] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Tetsuo Sonomura
- Department of Radiology, Kishiwada Tokushukai Hospital, 4-27-1, Kamori-cho, Kishiwada-shi 596-8522, Japan
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