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Abosheaishaa H, Abdelhalim O, Hegazy Y, Abdelwahed A, Ahmed N, Nassar M. Small Intestine Ectopic Varices as a Cause of Obscure Gastrointestinal Bleeding in a Cirrhotic Patient. Cureus 2024; 16:e65959. [PMID: 39221393 PMCID: PMC11365586 DOI: 10.7759/cureus.65959] [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: 08/01/2024] [Indexed: 09/04/2024] Open
Abstract
Portal hypertension is a major complication of liver cirrhosis, leading to various life-threatening conditions. The most common of these is the formation and bleeding of varices at the portosystemic anastomosis. Varices are most commonly esophageal or gastric and less commonly ectopic. Although ectopic varices are rare, they should be considered as a cause of obscure gastrointestinal bleeding in cirrhotic patients. We present a case of ruptured ectopic varices in the small intestine of a known cirrhotic patient who presented with anemia and melena, alternated with hematochezia. The case was managed with Histoacryl® injection using push enteroscopy, resulting in adequate hemostasis.
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Affiliation(s)
- Hazem Abosheaishaa
- Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, New York, USA
| | - Omar Abdelhalim
- Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, New York, USA
| | - Yasser Hegazy
- Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, New York, USA
| | | | - Nourhan Ahmed
- Internal Medicine, Faculty of Medicine Cairo University, Cairo, EGY
| | - Mahmoud Nassar
- Endocrinology, Diabetes and Metabolism, Jacobs School of Medicine and Biomedical Sciences, University of Buffalo, Buffalo, USA
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Cocchia R, Chianese S, Lombardi G, Romano L, Capone V, Amitrano L, Bennato R, Ranieri B, Russo G, Mauro C, Bossone E. Severe Stenosis of Mitral Bioprosthetic Valve Thrombosis in a Patient with HCV-Related Cirrhosis and Duodenal Variceal Bleeding: The Deadly Triad. Clin Pract 2022; 12:686-691. [PMID: 36136865 PMCID: PMC9498389 DOI: 10.3390/clinpract12050071] [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: 06/18/2022] [Revised: 08/02/2022] [Accepted: 08/24/2022] [Indexed: 11/16/2022] Open
Abstract
Bioprosthetic valve thrombosis (BPVT) is considered a relatively rare but life-threatening clinical entity. Thus, there is the need of high clinical suspicion in order to make a timely diagnosis and related appropriate therapeutic interventions. In this regard, the management of BPVT is high risk, whatever the option taken (surgery and/or systemic fibrinolysis). The presence of severe comorbidities—as decompensated cirrhosis—further complicates the clinical decision-making process, calling for a patient-tailored integrated multidisciplinary approach. We report a challenging case of a 45-year-old patient with mitral bioprosthetic valve thrombosis and hepatitis C virus (HCV)-related cirrhosis complicated by active duodenal variceal bleeding.
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Affiliation(s)
| | | | - Giovanni Lombardi
- Gastroenterology Unit, Antonio Cardarelli Hospital, 80131 Naples, Italy
| | - Luigia Romano
- Department of General and Emergency Radiology, Antonio Cardarelli Hospital, 80131 Naples, Italy
| | - Valentina Capone
- Cardiology Unit, Antonio Cardarelli Hospital, 80131 Naples, Italy
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Lucio Amitrano
- Gastroenterology Unit, Antonio Cardarelli Hospital, 80131 Naples, Italy
| | - Raffaele Bennato
- Gastroenterology Unit, Antonio Cardarelli Hospital, 80131 Naples, Italy
| | - Brigida Ranieri
- IRCCS SYNLAB SDN, Via Emanuele Gianturco, 80143 Naples, Italy
| | - Giuseppe Russo
- Chief Medical Officer, Antonio Cardarelli Hospital, 80131 Naples, Italy
| | - Ciro Mauro
- Cardiology Unit, Antonio Cardarelli Hospital, 80131 Naples, Italy
| | - Eduardo Bossone
- Cardiology Unit, Antonio Cardarelli Hospital, 80131 Naples, Italy
- Correspondence:
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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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Mallea P, Allen A, Lynch MK, Jensen-Otsu E, Tompkins D. Massive gastrointestinal bleeding due to ectopic varix in distal duodenum: a case report. J Community Hosp Intern Med Perspect 2021; 11:370-375. [PMID: 34234909 PMCID: PMC8118526 DOI: 10.1080/20009666.2021.1890338] [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] [Indexed: 10/29/2022] Open
Abstract
Duodenal ectopic varices (DEV) are an uncommon etiology of upper gastrointestinal bleeding and are associated with high mortality. Both the diagnosis and management of DEV are challenging. Multiple treatment modalities exist including endoscopic guided management (ligation and sclerotherapy), surgical resection, transvenous obliteration and transjugular intrahepatic portosystemic shunt (TIPS), but management depends on the underlying vascular anatomy and underlying pathology. We present a case of a 41-year-old man with a history of an alcohol use disorder, prior splenic vein thrombosis as a complication of pancreatitis who presented with massive gastrointestinal bleeding, and was ultimately diagnosed with distal duodenal ectopic varix, which contained inflow from a medial branch of the superior mesenteric vein and outflow into the left renal vein. He was successfully treated with transjugular portosystemic shunt and coil embolization.
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Affiliation(s)
- Patrick Mallea
- University of Utah School of Medicine, Salt Lake City, USA
| | - Aaron Allen
- Department of Diagnostic Radiology, Boise Veterans Administration Medical Center, Boise, USA
| | - Maureen Kim Lynch
- Department of General Surgery, Boise Veterans Administration Medical Center, Boise, USA
| | - Elsbeth Jensen-Otsu
- Department of Internal Medicine, Section of Gastroenterology, Boise Veterans Administration Medical Center, Boise, USA
| | - David Tompkins
- Department of Internal Medicine, Boise Veterans Administration Medical Center, Boise, USA
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Park SJ, Kim YH, Kang UR, Ji SW. Successful Treatment of Duodenal Variceal Bleeding with Coil-Assisted Retrograde Transvenous Obliteration: A Case Report. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2020; 81:231-236. [PMID: 36238109 PMCID: PMC9432092 DOI: 10.3348/jksr.2020.81.1.231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/22/2019] [Accepted: 06/03/2019] [Indexed: 11/17/2022]
Abstract
십이지장 정맥류는 간경화증에 의한 문맥압 고혈압 환자에서 발생할 수 있으며, 치명적인 심한 상부 위장관 출혈을 일으킬 수 있으나 아직까지 명확한 치료 지침이 정립되어 있지는 않다. 일차적으로 내시경으로 치료를 시도하고 지혈 실패 시 목정맥경유간속문맥전신순환연결술, 풍선 혹은 혈관 마개를 이용한 역행성 경정맥 폐색술, 피부간경유 폐색술 등과 같은 중재적 치료를 고려할 수 있다. 저자들은 내시경적 치료에 실패한 십이지장 정맥류 출혈 환자에게 저하된 간 기능과 해부학적인 구조의 제한으로 인해 코일을 이용한 역행성 경정맥 폐색술을 시행하여 성공적으로 치료한 1예를 경험하였기에 이를 보고하고자 한다.
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Affiliation(s)
- Se Jin Park
- Department of Radiology, Daegu Catholic University College of Medicine, Daegu, Korea
| | - Young Hwan Kim
- Department of Radiology, Daegu Catholic University College of Medicine, Daegu, Korea
| | - Ung Rae Kang
- Department of Radiology, Daegu Catholic University College of Medicine, Daegu, Korea
| | - Seung Woo Ji
- Department of Radiology, CHA Gumi Medical Center, CHA University, Gumi, Korea
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Lee JH, Kim TH, Choi JW, Kim SY, Choi JY, Lee CK, Park BK, Chung JB. A case report of bleeding from duodenal varices treated with percutaneous transhepatic obliteration. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2019. [DOI: 10.18528/ijgii190002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Ji Hyun Lee
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Hwan Kim
- Department of Vascular and Interventional Radiology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jong Won Choi
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Sun Young Kim
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jin Young Choi
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Chun Kyon Lee
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Byung Kyu Park
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jae Bok Chung
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
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Khor V, Soon Y, Aung L. A case report of bleeding from a duodenal varix: Rare cause of upper gastrointestinal bleeding. Int J Surg Case Rep 2018; 49:205-208. [PMID: 30029079 PMCID: PMC6077164 DOI: 10.1016/j.ijscr.2018.06.031] [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: 05/04/2018] [Accepted: 06/25/2018] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Ectopic variceal bleeding is uncommon, accounts for 2-5% of variceal bleeding, of which 17% is in duodenum. PRESENTATION OF CASE 62-year-old lady with newly diagnosed liver cirrhosis on admission, presented with severe upper gastrointestinal bleeding (UGIB), was ultimately diagnosed with bleeding duodenal varices with single-balloon enteroscopy, after multiple oesophagogastroduodenoscopies (OGDs) and CT scans which failed to identify the varices. She was treated successfully with duodenectomy. DISCUSSION Endoscopy and CT angiography remain the diagnostic modalities of choice. However, diagnosis can be difficult as evidenced by three OGDs and two CTMAs yielding negative findings in this case. Endoscopic diagnosis is challenging and often delayed due to its rarity and unusual location. CONCLUSION Ectopic variceal bleeding is a rare but important cause of UGIB. Diagnosis is challenging and management of this condition should take a multidisciplinary approach, involving experienced gastroenterologists, interventional radiologists and surgeons. Endoscopic ligation or sclerotherapy is the first-line of treatment.
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Affiliation(s)
- Vincent Khor
- MOH Holdings Singapore, 1 Maritime Square, #11-25 HarbourFront Centre, 099235, Singapore; Department of General Surgery, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, 609606, Singapore.
| | - Yuen Soon
- Department of General Surgery, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, 609606, Singapore
| | - Lwin Aung
- Department of General Surgery, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, 609606, Singapore
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Enteroscopic Management of Ectopic Varices in a Patient with Liver Cirrhosis and Portal Hypertension. Case Reports Hepatol 2016; 2016:2018642. [PMID: 27595025 PMCID: PMC4995326 DOI: 10.1155/2016/2018642] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 07/19/2016] [Indexed: 12/12/2022] Open
Abstract
Portal hypertension and liver cirrhosis may predispose patients to varices, which have a propensity to bleed and cause significant morbidity and mortality. These varices are most commonly located in the gastroesophageal area; however, rarely ectopic varices may develop in unusual locations outside of this region. Haemorrhage from these sites can be massive and difficult to control; thus early detection and management may be lifesaving. We present a case of occult gastrointestinal bleeding in a patient with underlying alcoholic liver disease where an ectopic varix was ultimately detected with push enteroscopy.
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Hsu WF, Tsang YM, Teng CJ, Chung CS. Protein C deficiency related obscure gastrointestinal bleeding treated by enteroscopy and anticoagulant therapy. World J Gastroenterol 2015; 21:1024-1027. [PMID: 25624741 PMCID: PMC4299320 DOI: 10.3748/wjg.v21.i3.1024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Revised: 07/05/2014] [Accepted: 07/30/2014] [Indexed: 02/06/2023] Open
Abstract
Obscure gastrointestinal bleeding is an uncommonly encountered and difficult-to-treat clinical problem in gastroenterology, but advancements in endoscopic and radiologic imaging modalities allow for greater accuracy in diagnosing obscure gastrointestinal bleeding. Ectopic varices account for less than 5% of all variceal bleeding cases, and jejunal variceal bleeding due to extrahepatic portal hypertension is rare. We present a 47-year-old man suffering from obscure gastrointestinal bleeding. Computed tomography of the abdomen revealed multiple vascular tufts around the proximal jejunum but no evidence of cirrhosis, and a visible hypodense filling defect suggestive of thrombus was visible in the superior mesenteric vein. Enteroscopy revealed several serpiginous varices in the proximal jejunum. Serologic data disclosed protein C deficiency (33.6%). The patient was successfully treated by therapeutic balloon-assisted enteroscopy and long-term anticoagulant therapy, which is normally contraindicated in patients with gastrointestinal bleeding. Diagnostic modalities for obscure gastrointestinal bleeding, such as capsule endoscopy, computed tomography enterography, magnetic resonance enterography, and enteroscopy, were also reviewed in this article.
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Aoyama T, Oka S, Aikata H, Igawa A, Nakano M, Naeshiro N, Yoshida S, Tanaka S, Chayama K. Major predictors of portal hypertensive enteropathy in patients with liver cirrhosis. J Gastroenterol Hepatol 2015; 30:124-30. [PMID: 24988903 DOI: 10.1111/jgh.12658] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2014] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIM Portal hypertensive enteropathy (PHE) is acknowledged as a source of bleeding, and predicting its presence has become more important. We assessed PHE using capsule endoscopy (CE) and investigated factors that may predict its presence, including portosystemic shunts (PSs). METHODS We analyzed data from 134 consecutive patients with liver cirrhosis, from February 2009 to September 2013. All patients had undergone dynamic computed tomography and esophagogastroduodenoscopy before CE examination. The frequencies and types of PHE lesions, and the relationships between the presence of PHE and patients' clinical characteristics were evaluated. The distribution of the lesions was also determined. RESULTS PHE was found in 91 (68%), erythema in 70 (52%), erosions in 25 (19%), angioectasia in 24 (18%), villous edema in 18 (13%), and varices in 10 (7%) patients. Most lesions were located in the jejunum. The clinical characteristics associated with the presence of PHE were a Child-Pugh grade of B or C (P = 0.0058), and the presence of PSs (P < 0.0001), ascites (P = 0.0017), portal thrombosis (P = 0.016), esophageal varices (P = 0.0017), and portal hypertensive gastropathy (P = 0.0029). The presence of PSs was an independent predictor of PHE (odds ratio [OR]: 3.15; 95% confidence interval [CI]: 1.27-7.95). Among the shunt types, left gastric vein (OR: 5.31; 95% CI: 1.97-17.0) and splenorenal shunts (OR: 4.26; 95% CI: 1.29-19.4) were independent predictors of PHE. CONCLUSION PSs, especially left gastric vein and splenorenal shunts, appear to reliably predict the presence of PHE.
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Affiliation(s)
- Taiki Aoyama
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
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Larson JV, Steensma EA, Burke LH, Bartholomew DM. Fatal upper gastrointestinal bleed arising from duodenal varices secondary to undiagnosed portal hypertension. BMJ Case Rep 2013; 2013:bcr-2013-200194. [PMID: 23955984 DOI: 10.1136/bcr-2013-200194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Duodenal varices are an unexpected source of upper gastrointestinal haemorrhage associated with high mortality. The prevalence of ectopic variceal bleeding accounts for 2-5% of all variceal bleeding; of this, only 17% occurs in the duodenum. Diagnosis is difficult, and insufficient evidence exists to demonstrate the best treatment option when haemorrhage occurs. We report the case of a 69-year-old man with a history of chronic alcoholism who presented to the emergency department (ED) with nausea, vomiting and several episodes of haematochezia. Diagnostic workup in the ED included CT with multiplanar reconstruction, which revealed a network of large tortuous blood vessels running near the second portion of the duodenum between the inferior vena cava and portal vein. The patient was emergently treated with endoscopic therapy and clipping of the vessel. This failed, and he was subsequently taken to the operating room for suture ligation of the bleeding duodenal varices.
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Affiliation(s)
- John V Larson
- College of Human Medicine, Michigan State University, Kalamazoo Campus, Kalamazoo, Michigan, USA
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12
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Usefulness of multi-detector row computed tomography for management of duodenal varices by emergency balloon-occluded retrograde transvenous obliteration. Clin J Gastroenterol 2013; 6:243-7. [DOI: 10.1007/s12328-013-0379-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Accepted: 03/27/2013] [Indexed: 11/26/2022]
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13
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Akhter NM, Haskal ZJ. Diagnosis and management of ectopic varices. GASTROINTESTINAL INTERVENTION 2012. [DOI: 10.1016/j.gii.2012.08.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Affiliation(s)
- Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Chandan K N Kumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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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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Lu CH, Bair MJ, Tsai YS. An unusual case with upper gastrointestinal bleeding. Gastroenterology 2011; 141:1565, 1951-2. [PMID: 21959075 DOI: 10.1053/j.gastro.2010.09.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2010] [Revised: 09/16/2010] [Accepted: 09/21/2010] [Indexed: 12/02/2022]
Affiliation(s)
- Chia-Hsing Lu
- Department of Radiology, National Cheng Kung University Hospital, Tainan, Taiwan
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Yoshida S, Watabe H, Akahane M, Kyoden Y, Ishikawa H, Yamada A, Sugimoto T, Ohta M, Ogura K, Yamaji Y, Ohtomo K, Kokudo N, Koike K, Omata M. Usefulness of multi-detector helical CT with multiplanar reconstruction for depicting the duodenal varices with multiple collateral shunt vessels. Hepatol Int 2010; 4:775-8. [PMID: 21286350 DOI: 10.1007/s12072-010-9191-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Accepted: 07/09/2010] [Indexed: 12/20/2022]
Abstract
Duodenal varices are a rare complication in patients with portal hypertension. Bleeding from duodenal varices often results in a severe prognosis. Diagnosis of the disease is usually based on findings obtained by endoscopy or angiography. However, it occasionally fails to detect the lesion and demonstrate its porto-systemic shunt vessels which are necessary information to decide an appropriate treatment. Recent advances in CT may make it possible for us to reveal duodenal varices with complicated porto-systemic shunt vessels. We report the case of a 58-year-old man with liver cirrhosis with repeated bleeding from duodenal varices. Esophagogastroduodenoscopy (EGD) revealed multinodular varices in the third portion of the duodenum. Then we conducted a capsule endoscopy (CE) and found fresh blood in the duodenum, suggesting duodenal variceal hemorrhage. Angiography depicted the varices with one afferent and two efferent vessels. Abdominal CT examination was conducted using a four-channel multi-detector row CT scanner. The multiplanar reconstructed images revealed not only the varices, but also three afferent and two efferent vessels. The patient was treated by surgical ligation and sclerotherapy, because of its complicated porto-systemic shunt and reserved liver function. No gastrointestinal bleeding has been seen after the surgery. Our case suggests the usefulness of multi-detector CT with multiplanar reconstruction (MPR) for the diagnosis and therapeutic decision of duodenal varices.
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BERTOLINI GIOVANNA. ACQUIRED PORTAL COLLATERAL CIRCULATION IN THE DOG AND CAT. Vet Radiol Ultrasound 2010; 51:25-33. [DOI: 10.1111/j.1740-8261.2009.01616.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Using capsule endoscopy to identify GI tract lesions in cirrhotic patients with portal hypertension and chronic anemia. J Clin Gastroenterol 2008; 42:844-8. [PMID: 18277884 DOI: 10.1097/mcg.0b013e318038d312] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
GOALS We aimed to evaluate the ability of capsule endoscopy (CE) to detect small intestine (SI) lesions, especially SI varices, in patients with intrahepatic cirrhosis, portal hypertension (PHTN), and chronic anemia. BACKGROUND Gastroesophageal variceal bleeding is a well-recognized complication of cirrhosis and PHTN, yet methods of identifying lesions in the SI that may contribute to covert bleeding and anemia, such as small bowel enteroscopy and angiography, are invasive and may be inadequate. STUDY In this observational pilot study, 19 consecutive patients presenting to a tertiary care, liver transplantation referral center with cirrhosis, PHTN, and chronic anemia after obliterative esophageal variceal therapy were evaluated with wireless CE using the GIVEN Pillcam SB M2A capsule. Two independent and blinded examiners reviewed the CE examinations. RESULTS SI varices were identified in 15.8% (3/19) of patients. Other PHTN-related findings included portal hypertensive gastropathy (13/19, 68.4%), portal hypertensive enteropathy (12/19, 63.1%), and portal hypertensive colopathy (3/19, 15.8%). Two patients had nonbleeding esophageal varices (2/19, 10.5%). A potential source of gastrointestinal blood loss was identified in 89.5% (17/19) of patients. Active bleeding sites were identified in 15.8% (3/19). CONCLUSIONS CE can identify potential bleeding sources and could have diagnostic utility in patients with end-stage liver disease and chronic anemia after obliterative esophageal variceal therapy.
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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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Lopera JE, Arthurs B, Scheuerman C, Sandoz C, Petersosn S, Castaneda-Zuniga W. Bleeding Duodenal: Varices Treatment by TIPS and Transcatheter Embolization. Cardiovasc Intervent Radiol 2007; 31:431-4. [PMID: 17593432 DOI: 10.1007/s00270-004-0161-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We describe our clinical experience in 4 patients with portal hypertension who presented with bleeding mesenteric varices originating from the superior mesenteric vein with retrograde filling of collaterals draining into the inferior vena cava. The clinical presentation, imaging findings, and potential therapeutic management are discussed.
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Affiliation(s)
- Jorge E Lopera
- Department of Radiology, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, New Orleans, Louisiana 70112, USA.
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Bilbao Jaureguízar JI, Vivas Pérez I, Cano Rafart D, Martínez de la Cuesta A. Imaging and Intervention in Gastrointestinal Hemorrhage and Ischemia. Emerg Radiol 2007. [DOI: 10.1007/978-3-540-68908-9_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Roque A, Sebastià C, Quiroga S. Variz yeyunal aislada como causa de hemorragia digestiva oculta: diagnóstico por tomografía computarizada helicoidal. RADIOLOGIA 2005. [DOI: 10.1016/s0033-8338(05)72860-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Jain TP, Gulati MS, Makharia GK, Paul SB. Case of the season: detection of duodenal varices by CT enteroclysis. Semin Roentgenol 2005; 40:204-206. [PMID: 16060113 DOI: 10.1053/j.ro.2005.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Tarun P Jain
- Department of Radiology, All India Institute of Medical Sciences, New Delhi-110029, India
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Zhang LH, Zhang SZ, Hu HJ, Gao M, Zhang M, Cao Q, Zhang QW. Multi-detector CT enterography with iso-osmotic mannitol as oral contrast for detecting small bowel disease. World J Gastroenterol 2005; 11:2324-9. [PMID: 15818746 PMCID: PMC4305819 DOI: 10.3748/wjg.v11.i15.2324] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [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 assess the feasibility and usefulness of multi-detector CT enterography with orally administered iso-osmotic mannitol as negative contrast in demonstrating small bowel disease.
METHODS: Thirteen volunteers and 38 patients with various kinds of small bowel disease were examined. We administered about 1500 mL iso-osmotic mannitol as negative contrast agent and then proceeded with helical CT scanning on a Siemens Sensation 16 scanner. All volunteers and patients were interviewed about their tolerance of the procedure. Two radiologists post-processed imaging data with MPR, thin MIP, VRT and INSPACE when necessary and then interpreted the scans, and adequacy of luminal distention was evaluated on a four-point scale. Demonstration of features of various kinds of small bowel disease was analyzed.
RESULTS: The taste of iso-osmotic mannitol is good (slightly sweet) and acceptable by all. Small bowel distention was excellent and moderate in most volunteers and patients. CT features of many kinds of diseases such as tumors, Crohn’s disease,and small bowel obstruction, etc. were clearly displayed.
CONCLUSION: Multi-detector CT enterography with iso-osmotic mannitol as negative contrast to distend the small bowel is a simple, rapid, noninvasive and effective method of evaluating small bowel disease.
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Affiliation(s)
- Lian-He Zhang
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou 310016, Zhejiang Province, China.
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