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Mitamura Y, Murakami E, Hashimoto K, Emori T, Tanaka A, Tanaka Y, Hiraoka K, Shirane Y, Kosaka M, Johira Y, Miura R, Murakami S, Yamaoka K, Fujii Y, Uchikawa S, Fujino H, Ono A, Kawaoka T, Miki D, Hayes CN, Tsuge M, Chosa K, Awai K, Oka S. Analysis of the treatment outcome of duodenal varices: A retrospective case series of 15 patients from a single institution. DEN OPEN 2025; 5:e70119. [PMID: 40248442 PMCID: PMC12003208 DOI: 10.1002/deo2.70119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2025] [Revised: 03/29/2025] [Accepted: 04/06/2025] [Indexed: 04/19/2025]
Abstract
Background & aims Duodenal varices (DVs) are a rare type of ectopic varices occurring in portal hypertension, for which no standardized treatment strategy has been established. This retrospective study analyzed the outcomes of DV treatments in 15 patients. Material and methods All enrolled patients with DVs were treated at a single institution Hospital between 2011 and 2022. The treatment procedure and outcome were analyzed retrospectively. Results Six patients presented with hemorrhagic DVs. Endoscopic variceal ligation was used for initial hemostasis in five bleeding cases. Balloon-occluded retrograde transvenous obliteration was the initial treatment in nine cases, achieving curative obliteration in eight cases. Percutaneous transhepatic variceal obliteration was performed as the initial treatment in three cases for which balloon-occluded retrograde transvenous obliteration was difficult to perform for anatomical reasons, and all cases achieved curative obliterations. Splenectomy was performed as the initial treatment in three patients due to complicating gastroesophageal varices. DVs recurred in two cases with splenectomy after approximately 1 year, but balloon-occluded retrograde transvenous obliteration and percutaneous transhepatic variceal obliteration were curatively applied in each case, and no recurrence has been observed since then. Gastroesophageal varices aggravated after the initial DV treatment in eight of the 15 cases during the observation period, and the cumulative aggravating rate was 58.1% at 4 years. Conclusion All 15 cases with DVs were preferably controlled by selecting appropriate treatment based on individual hemodynamics of varices. Because of the relatively high rate of aggravation of gastroesophageal varices, careful long-term follow-up may be important for the treatment of DVs.
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Affiliation(s)
- Yuri Mitamura
- Department of GastroenterologyGraduate School of Life ScienceInstitute of Biomedical & Health ScienceHiroshima UniversityHiroshimaJapan
| | - Eisuke Murakami
- Department of GastroenterologyGraduate School of Life ScienceInstitute of Biomedical & Health ScienceHiroshima UniversityHiroshimaJapan
- Liver Disease CenterHiroshima University HospitalHiroshimaJapan
| | - Ko Hashimoto
- Department of GastroenterologyGraduate School of Life ScienceInstitute of Biomedical & Health ScienceHiroshima UniversityHiroshimaJapan
| | - Tomoaki Emori
- Department of GastroenterologyGraduate School of Life ScienceInstitute of Biomedical & Health ScienceHiroshima UniversityHiroshimaJapan
| | - Aiko Tanaka
- Department of GastroenterologyGraduate School of Life ScienceInstitute of Biomedical & Health ScienceHiroshima UniversityHiroshimaJapan
| | - Yusuke Tanaka
- Department of GastroenterologyGraduate School of Life ScienceInstitute of Biomedical & Health ScienceHiroshima UniversityHiroshimaJapan
| | - Keiichi Hiraoka
- Department of GastroenterologyGraduate School of Life ScienceInstitute of Biomedical & Health ScienceHiroshima UniversityHiroshimaJapan
| | - Yuki Shirane
- Department of GastroenterologyGraduate School of Life ScienceInstitute of Biomedical & Health ScienceHiroshima UniversityHiroshimaJapan
| | - Masanari Kosaka
- Department of GastroenterologyGraduate School of Life ScienceInstitute of Biomedical & Health ScienceHiroshima UniversityHiroshimaJapan
| | - Yusuke Johira
- Department of GastroenterologyGraduate School of Life ScienceInstitute of Biomedical & Health ScienceHiroshima UniversityHiroshimaJapan
| | - Ryoichi Miura
- Department of GastroenterologyGraduate School of Life ScienceInstitute of Biomedical & Health ScienceHiroshima UniversityHiroshimaJapan
| | - Serami Murakami
- Department of GastroenterologyGraduate School of Life ScienceInstitute of Biomedical & Health ScienceHiroshima UniversityHiroshimaJapan
| | - Kenji Yamaoka
- Department of GastroenterologyGraduate School of Life ScienceInstitute of Biomedical & Health ScienceHiroshima UniversityHiroshimaJapan
| | - Yasutoshi Fujii
- Department of GastroenterologyGraduate School of Life ScienceInstitute of Biomedical & Health ScienceHiroshima UniversityHiroshimaJapan
| | - Shinsuke Uchikawa
- Department of GastroenterologyGraduate School of Life ScienceInstitute of Biomedical & Health ScienceHiroshima UniversityHiroshimaJapan
| | - Hatsue Fujino
- Department of GastroenterologyGraduate School of Life ScienceInstitute of Biomedical & Health ScienceHiroshima UniversityHiroshimaJapan
- Liver Disease CenterHiroshima University HospitalHiroshimaJapan
| | - Atsushi Ono
- Department of GastroenterologyGraduate School of Life ScienceInstitute of Biomedical & Health ScienceHiroshima UniversityHiroshimaJapan
| | - Tomokazu Kawaoka
- Department of GastroenterologyGraduate School of Life ScienceInstitute of Biomedical & Health ScienceHiroshima UniversityHiroshimaJapan
| | - Daiki Miki
- Department of GastroenterologyGraduate School of Life ScienceInstitute of Biomedical & Health ScienceHiroshima UniversityHiroshimaJapan
| | - Clair Nelson Hayes
- Department of GastroenterologyGraduate School of Life ScienceInstitute of Biomedical & Health ScienceHiroshima UniversityHiroshimaJapan
| | - Masataka Tsuge
- Department of GastroenterologyGraduate School of Life ScienceInstitute of Biomedical & Health ScienceHiroshima UniversityHiroshimaJapan
- Liver Disease CenterHiroshima University HospitalHiroshimaJapan
| | - Keigo Chosa
- Department of Diagnostic RadiologyGraduate School of Biomedical and Health SciencesHiroshima UniversityHiroshimaJapan
| | - Kazuo Awai
- Department of Diagnostic RadiologyGraduate School of Biomedical and Health SciencesHiroshima UniversityHiroshimaJapan
| | - Shiro Oka
- Department of GastroenterologyGraduate School of Life ScienceInstitute of Biomedical & Health ScienceHiroshima UniversityHiroshimaJapan
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Xiao NJ, Chu JG, Ning SB, Wei BJ, Xia ZB, Han ZY. Successful management of bleeding ectopic small bowel varices secondary to portal hypertension: A retrospective study. World J Gastrointest Surg 2025; 17:102589. [PMID: 40162398 PMCID: PMC11948116 DOI: 10.4240/wjgs.v17.i3.102589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2024] [Revised: 01/06/2025] [Accepted: 01/20/2025] [Indexed: 02/24/2025] Open
Abstract
BACKGROUND Bleeding ectopic varices located in the small bowel (BEV-SB) caused by portal hypertension (PH) are rare and life-threatening clinical scenarios. The current management of BEV-SB is unsatisfactory. This retrospective study analyzed four cases of BEV-SB caused by PH and detailed the management of these cases using enteroscopic injection sclerotherapy (EIS) and subsequent interventional radiology (IR). AIM To analyze the management of BEV-SB caused by PH and develop a treatment algorithm. METHODS This was a single tertiary care center before-after study, including four patients diagnosed with BEV-SB secondary to PH between January 2019 and December 2023 in the Air Force Medical Center. A retrospective review of the medical records was conducted. The management of these four patients involved the utilization of EIS followed by IR. The management duration of BEV-SB in each patient can be retrospectively divided into three phases based on these two approaches: Phase 1, from the initial occurrence of BEV-SB to the initial EIS; phase 2, from the initial EIS to the initial IR treatment; and phase 3, from the initial IR to December 2023. Descriptive statistics were performed to clarify the blood transfusions in each phase. RESULTS Four out of 519 patients diagnosed with PH were identified as having BEV-SB. The management duration of each phase was 20 person-months, 42 person-months, and 77 person-months, respectively. The four patients received a total of eight and five person-times of EIS and IR treatment, respectively. All patients exhibited recurrent gastrointestinal bleeding following the first EIS, while no further instances of gastrointestinal bleeding were observed after IR treatment. The transfusions administered during each phase were 34, 31, and 3.5 units of red blood cells, and 13 units, 14 units, and 1 unit of plasma, respectively. CONCLUSION EIS may be effective in achieving hemostasis for BEV-SB, but rebleeding is common, and IR aiming to reduce portal pressure gradient may lower the rebleeding rate.
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Affiliation(s)
- Nian-Jun Xiao
- Department of Gastroenterology, Air Force Medical Center, Air Force Medical University, Beijing 100142, China
| | - Jian-Guo Chu
- Department of Gastroenterology, Air Force Medical Center, Air Force Medical University, Beijing 100142, China
| | - Shou-Bin Ning
- Department of Gastroenterology, Air Force Medical Center, Air Force Medical University, Beijing 100142, China
| | - Bao-Jie Wei
- Department of Gastroenterology, Air Force Medical Center, Air Force Medical University, Beijing 100142, China
| | - Zhi-Bo Xia
- Department of Gastroenterology, Air Force Medical Center, Air Force Medical University, Beijing 100142, China
| | - Zhe-Yi Han
- Department of Gastroenterology, Air Force Medical Center, Air Force Medical University, Beijing 100142, China
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Dolu S, Arayici ME, Onem S, Buyuktorun I, Dongelli H, Bengi G, Akarsu M. Effectiveness of Double Balloon Enteroscopy in the Diagnosis and Treatment of Small Bowel Varices. Diagnostics (Basel) 2025; 15:336. [PMID: 39941266 PMCID: PMC11817830 DOI: 10.3390/diagnostics15030336] [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] [Received: 12/31/2024] [Revised: 01/28/2025] [Accepted: 01/30/2025] [Indexed: 02/16/2025] Open
Abstract
Background/Aims: Double balloon enteroscopy (DBE) is an innovative method for the diagnosis and management of small bowel (SB) diseases. SB varices are rare disorders, and their diagnosis and treatment can be challenging for clinicians. This study evaluates the use of double balloon enteroscopy (DBE) in diagnosing and treating small bowel varices. Materials and Methods: SB varices were detected in 28 out of 900 double balloon enteroscopy procedures over an 18-year period. Eleven cases of SB varices of various etiologies, diagnosed via DBE, are described. The characteristics of SB varices and endoscopic procedural details were evaluated. Results: A retrospective investigation of 750 patients identified eleven patients (eight males and three females; median age 59 years, range 40-80 years) with small bowel varices. The most common site of SB varices was the jejunum. At least one abdominopelvic surgical procedure had been previously performed on five patients. Endotherapy by DBE was administered to nine patients (seven emergent and two prophylactic). Post-endotherapy, three patients experienced bleeding that required re-endotherapy. Endoscopic therapy for small bowel varices included injection sclerotherapy in eight cases (six with cyanoacrylate and two with polidocanol) and injection sclerotherapy plus hemoclipping in one case. Conclusions: SB varices can present a diagnostic challenge for clinicians. DBE is a valuable tool for both the diagnosis and management of small bowel varices.
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Affiliation(s)
- Suleyman Dolu
- Department of Gastroenterology, Faculty of Medicine, Dokuz Eylül University, Izmir 35340, Turkey; (I.B.); (G.B.)
| | - Mehmet Emin Arayici
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Dokuz Eylül University, Izmir 35340, Turkey;
| | - Soner Onem
- Department of Gastroenterology, Samsun Training and Research Hospital, Samsun 55090, Turkey;
| | - Ilker Buyuktorun
- Department of Gastroenterology, Faculty of Medicine, Dokuz Eylül University, Izmir 35340, Turkey; (I.B.); (G.B.)
| | - Huseyin Dongelli
- Department of Internal Medicine, Faculty of Medicine, Dokuz Eylül University, Izmir 35340, Turkey;
| | - Goksel Bengi
- Department of Gastroenterology, Faculty of Medicine, Dokuz Eylül University, Izmir 35340, Turkey; (I.B.); (G.B.)
| | - Mesut Akarsu
- Private Gastroenterology Clinic, Izmir 35535, Turkey;
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Ogawa S, Yamamoto A, Jogo A, Kageyama K, Sohgawa E, Ohira G, Kimura K, Tanaka S, Amano R, Takemura S, Ishizawa T, Miki Y. Embolization with or without portal vein stenting for bleeding ectopic jejunal varices in hepatopetal portal collaterals due to extrahepatic portal vein occlusion or stenosis after hepatobiliary and pancreatic surgery. Jpn J Radiol 2024; 42:1342-1351. [PMID: 38935221 PMCID: PMC11522060 DOI: 10.1007/s11604-024-01616-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 06/17/2024] [Indexed: 06/28/2024]
Abstract
PURPOSE To evaluate the efficacy and safety of embolization with or without portal vein stenting for bleeding ectopic jejunal varices in the hepatopetal portal collateral due to extrahepatic portal vein occlusion or stenosis after hepatobiliary and pancreatic surgery. MATERIALS AND METHODS This study included consecutive patients who underwent embolization for bleeding ectopic jejunal varices in the hepatopetal collateral due to extrahepatic portal vein occlusion or stenosis after hepatobiliary and pancreatic surgery between September 2012 and December 2020. The safety, technical and clinical success rates (no re-bleeding within 1 month) and re-bleeding-free survival after the first therapy and overall survival were assessed. RESULTS Fourteen sessions in 11 patients were included. Four patients (7 sessions) underwent variceal embolization only, and the remaining seven patients (7 sessions) underwent portal vein stenting and variceal embolization. Technical success was achieved in all 14 sessions (100%). Clinical success was achieved in 13 of 14 sessions (92.9%). No treatment-related serious complications including liver failure were observed. One-year and 2-year re-bleeding-free survival rate after the first endovascular therapy in all 11 patients was 90.9 and 60.6%, respectively. Two patients who experienced re-bleeding had repeat embolization treatment. There was no significant difference in re-bleeding-free survival after endovascular therapy between the combination with stenting and embolization group and the embolization-only group (p = 0.13). CONCLUSION Embolization with or without portal vein stenting of bleeding ectopic jejunal varices in the hepatopetal portal collateral due to extrahepatic portal vein occlusion or stenosis after hepatobiliary and pancreatic surgery can be considered a safe, effective, and repeatable therapy for long-term hemostasis of uncontrollable bleeding.
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Affiliation(s)
- Satoyuki Ogawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
- Department of Diagnostic Radiology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-Ku, Osaka, 530-0012, Japan
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan.
| | - Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
| | - Ken Kageyama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
| | - Etsuji Sohgawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
| | - Go Ohira
- Department of Hepato-Biliary-Pancreatic Surgery Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Kenjiro Kimura
- Department of Hepato-Biliary-Pancreatic Surgery Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Shogo Tanaka
- Department of Hepato-Biliary-Pancreatic Surgery Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Ryosuke Amano
- Department of Hepato-Biliary-Pancreatic Surgery Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Shigekazu Takemura
- Department of Hepato-Biliary-Pancreatic Surgery Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Takeaki Ishizawa
- Department of Hepato-Biliary-Pancreatic Surgery Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
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Desouky O, Chkir B, Zuhair T. Parastomal Varices as an Atypical Source of Bleeding From a Urostomy in a Patient With Alcoholic Liver Disease. Cureus 2024; 16:e73886. [PMID: 39697918 PMCID: PMC11653097 DOI: 10.7759/cureus.73886] [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: 11/18/2024] [Indexed: 12/20/2024] Open
Abstract
Parastomal varices are an uncommon but significant source of hemorrhage in patients with portal hypertension, often posing diagnostic and therapeutic challenges. We report the case of a 73-year-old male with a history of alcoholic liver disease and a urostomy following cystoprostatectomy for bladder cancer. The patient presented with profuse bleeding from his urostomy site. Imaging revealed dilated vessels within the ileal conduit and associated mesentery and peri esophageal varices, suggesting possible underlying portal hypertension. This case highlights the importance of considering parastomal varices in patients with stomas and liver disease who present with bleeding.
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Affiliation(s)
- Omar Desouky
- Urology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, GBR
| | - Baraa Chkir
- Urology, Furness General Hospital, Barrow-in-Furness, GBR
| | - Thihnaan Zuhair
- Internal Medicine, North Manchester General Hospital, Manchester University NHS Foundation Trust, Manchester, GBR
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Kumar S, Khurana AK, Batra A, Khanna D. Rescue therapy for bleeding ectopic ileal varices with a transjugular intrahepatic portosystemic shunt and antegrade variceal embolization. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2024; 13:141-143. [DOI: 10.18528/ijgii240050] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2024] [Revised: 09/25/2024] [Accepted: 09/25/2024] [Indexed: 05/20/2025] Open
Affiliation(s)
- Saurabh Kumar
- Department of Interventional Radiology, Fortis Memorial Research Institute, Haryana, India
| | - Arvind Kumar Khurana
- Department of Gastroenterology and Hepatology, Fortis Memorial Research Institute, Haryana, India
| | - Apoorva Batra
- Department of Interventional Radiology, Fortis Memorial Research Institute, Haryana, India
| | - Deepanshu Khanna
- Department of Gastroenterology and Hepatology, Fortis Memorial Research Institute, Haryana, India
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Kóder G, Dinya T, Tóth D, Damjanovich L, Ágoston L, Tanyi M. Rare case of successfully operated idiopathic colonic varicosity. Int J Surg Case Rep 2024; 123:110196. [PMID: 39181031 PMCID: PMC11388158 DOI: 10.1016/j.ijscr.2024.110196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 08/15/2024] [Accepted: 08/17/2024] [Indexed: 08/27/2024] Open
Abstract
INTRODUCTION Ectopic gastrointestinal varicosities are defined as dilated portosystemic collateral veins that may localize anywhere in the gastrointestinal tract outside the gastroesophageal region. Ectopic colonic varices can be considered idiopathic when other etiology that related to portal hypertension or portal vein thrombosis have been excluded. CASE PRESENTATION A forty-five-year-old female patient has been under treatment for histopathologically confirmed ulcerative colitis since the age of 17. In her forties, the patient developed worsening hematochezia leading to severe anemia. Routine colonoscopy was performed which confirmed extensive rectosigmoid varices. A thorough investigation did not confirm any underlying causes, such as portal hypertension or cirrhosis. DISCUSSION The selective percutaneous transhepatic mesenteric angiography, which is recommended as a diagnostic and therapeutic option, was not performed because the interventional radiologists did not consider embolization feasible. Laparoscopic rectosigmoid resection with high ligation of the inferior mesenteric vein led to complete remission of hematochezia. The final histological examination confirmed ectopic rectum and sigmoid varices, and ulcerative colitis was ruled out. CONCLUSIONS Lower gastrointestinal bleeding from the colonic varices is very rare, with only a few cases reported in the literature. In the idiopathic form, the prognosis is very good, given the absence of other underlying diseases causing portal hypertension. Ectopic varices present a clinical challenge as they are difficult to diagnose and localize. There are currently no clear guidelines for diagnosis and therapy, and recommendations are based on different case reports. Idiopathic cases can be treated effectively by resection of the affected bowel segment.
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Affiliation(s)
- Gergely Kóder
- Department of Surgery, Faculty of General Medicine, University of Debrecen, Debrecen, Móricz Zsigmond körút 22, Hungary.
| | - Tamás Dinya
- Department of Surgery, Faculty of General Medicine, University of Debrecen, Debrecen, Móricz Zsigmond körút 22, Hungary
| | - Dezső Tóth
- Department of Surgery, Faculty of General Medicine, University of Debrecen, Debrecen, Móricz Zsigmond körút 22, Hungary
| | - László Damjanovich
- Department of Surgery, Faculty of General Medicine, University of Debrecen, Debrecen, Móricz Zsigmond körút 22, Hungary
| | - Lóránt Ágoston
- Prestige Private Hospital, Lujza u. 16, Nyíregyháza 4405, Hungary
| | - Miklós Tanyi
- Department of Surgery, Faculty of General Medicine, University of Debrecen, Debrecen, Móricz Zsigmond körút 22, Hungary
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Shalaby S, Nicoară-Farcău O, Perez-Campuzano V, Olivas P, Torres S, García-Pagán JC, Hernández-Gea V. Transjugular Intrahepatic Portosystemic Shunt (TIPS) for Treatment of Bleeding from Cardiofundal and Ectopic Varices in Cirrhosis. J Clin Med 2024; 13:5681. [PMID: 39407741 PMCID: PMC11476950 DOI: 10.3390/jcm13195681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 07/26/2024] [Accepted: 09/21/2024] [Indexed: 10/20/2024] Open
Abstract
Acute variceal bleeding in cirrhosis represents a critical clinical event that significantly impacts patient prognosis, with mortality rates increasing further after a second episode. This underscores the need for immediate intervention and optimal prophylaxis. The creation of a transjugular intrahepatic portosystemic shunt (TIPS) has been proven to be highly effective for managing esophageal variceal bleeding. However, the use of TIPS for managing cardiofundal gastric varices and ectopic varices remains debated due to their unique vascular anatomy and the limited data available. These varices, although less prevalent than esophageal varices, are complex and heterogeneous vascular shunts between the splanchnic venous system and the systemic veins. Indeed, while endoscopic therapy with tissue adhesives is widely endorsed for achieving hemostasis in active hemorrhage, there is no consensus regarding the optimal approach for secondary prophylaxis. Recent research emphasizes the efficacy of endovascular techniques over endoscopic treatments, such as TIPS and endovascular variceal embolization techniques. This review examines the use of TIPS in managing acute variceal bleeding in patients with cirrhosis, focusing specifically on cardiofundal gastric varices and ectopic varices, discussing optimal patient care based on the latest evidence, aiming to improve outcomes for this challenging subset of patients.
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Affiliation(s)
- Sarah Shalaby
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
| | - Oana Nicoară-Farcău
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Hepatology Department, Regional Institute of Gastroenterology and Hepatology “Octavian Fodor”, “Iuliu Hatieganu” University of Medicine and Pharmacy, 3rd Medical Clinic, 400394 Cluj-Napoca, Romania
| | - Valeria Perez-Campuzano
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
| | - Pol Olivas
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
| | - Sonia Torres
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
- Departament de Medicina i Ciències de la Salut, Universitat de Barcelona, 08036 Barcelona, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
- Departament de Medicina i Ciències de la Salut, Universitat de Barcelona, 08036 Barcelona, Spain
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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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10
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Kim HC, Miyayama S, Lee EW, Lim DY, Chung JW, Jae HJ, Choi JW. Interventional Radiology for Bleeding Ectopic Varices: Individualized Approach Based on Vascular Anatomy. Radiographics 2024; 44:e230140. [PMID: 38990775 DOI: 10.1148/rg.230140] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Abstract
Ectopic varices are rare but potentially life-threatening conditions usually resulting from a combination of global portal hypertension and local occlusive components. As imaging, innovative devices, and interventional radiologic techniques evolve and are more widely adopted, interventional radiology is becoming essential in the management of ectopic varices. The interventional radiologist starts by diagnosing the underlying causes of portal hypertension and evaluating the afferent and efferent veins of ectopic varices with CT. If decompensated portal hypertension is causing ectopic varices, placement of a transjugular intrahepatic portosystemic shunt is considered the first-line treatment, although this treatment alone may not be effective in managing ectopic variceal bleeding because it may not sufficiently resolve focal mesenteric venous obstruction causing ectopic varices. Therefore, additional variceal embolization should be considered after placement of a transjugular intrahepatic portosystemic shunt. Retrograde transvenous obliteration can serve as a definitive treatment when the efferent vein connected to the systemic vein is accessible. Antegrade transvenous obliteration is a vital component of interventional radiologic management of ectopic varices because ectopic varices often exhibit complex anatomy and commonly lack catheterizable portosystemic shunts. Superficial veins of the portal venous system such as recanalized umbilical veins may provide safe access for antegrade transvenous obliteration. Given the absence of consensus and guidelines, a multidisciplinary team approach is essential for the individualized management of ectopic varices. Interventional radiologists must be knowledgeable about the anatomy and hemodynamic characteristics of ectopic varices based on CT images and be prepared to consider appropriate options for each specific situation. ©RSNA, 2024 Supplemental material is available for this article.
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Affiliation(s)
- Hyo-Cheol Kim
- From the Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea (H.C.K., J.W. Chung., H.J.J., J.W. Choi); Department of Diagnostic Radiology, Fukui-ken Saiseikai Hospital, Fukui, Japan (S.M.); Department of Radiology, Division of Interventional Radiology and Department of Surgery, Division of Liver and Pancreas Transplantation, University of California at Los Angeles Medical Center, David Geffen School of Medicine, Los Angeles, Calif (E.W.L.); and Department of Diagnostic Radiology, Changi General Hospital, Singapore (D.Y.L.)
| | - Shiro Miyayama
- From the Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea (H.C.K., J.W. Chung., H.J.J., J.W. Choi); Department of Diagnostic Radiology, Fukui-ken Saiseikai Hospital, Fukui, Japan (S.M.); Department of Radiology, Division of Interventional Radiology and Department of Surgery, Division of Liver and Pancreas Transplantation, University of California at Los Angeles Medical Center, David Geffen School of Medicine, Los Angeles, Calif (E.W.L.); and Department of Diagnostic Radiology, Changi General Hospital, Singapore (D.Y.L.)
| | - Edward Wolfgang Lee
- From the Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea (H.C.K., J.W. Chung., H.J.J., J.W. Choi); Department of Diagnostic Radiology, Fukui-ken Saiseikai Hospital, Fukui, Japan (S.M.); Department of Radiology, Division of Interventional Radiology and Department of Surgery, Division of Liver and Pancreas Transplantation, University of California at Los Angeles Medical Center, David Geffen School of Medicine, Los Angeles, Calif (E.W.L.); and Department of Diagnostic Radiology, Changi General Hospital, Singapore (D.Y.L.)
| | - David Yurui Lim
- From the Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea (H.C.K., J.W. Chung., H.J.J., J.W. Choi); Department of Diagnostic Radiology, Fukui-ken Saiseikai Hospital, Fukui, Japan (S.M.); Department of Radiology, Division of Interventional Radiology and Department of Surgery, Division of Liver and Pancreas Transplantation, University of California at Los Angeles Medical Center, David Geffen School of Medicine, Los Angeles, Calif (E.W.L.); and Department of Diagnostic Radiology, Changi General Hospital, Singapore (D.Y.L.)
| | - Jin Wook Chung
- From the Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea (H.C.K., J.W. Chung., H.J.J., J.W. Choi); Department of Diagnostic Radiology, Fukui-ken Saiseikai Hospital, Fukui, Japan (S.M.); Department of Radiology, Division of Interventional Radiology and Department of Surgery, Division of Liver and Pancreas Transplantation, University of California at Los Angeles Medical Center, David Geffen School of Medicine, Los Angeles, Calif (E.W.L.); and Department of Diagnostic Radiology, Changi General Hospital, Singapore (D.Y.L.)
| | - Hwan Jun Jae
- From the Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea (H.C.K., J.W. Chung., H.J.J., J.W. Choi); Department of Diagnostic Radiology, Fukui-ken Saiseikai Hospital, Fukui, Japan (S.M.); Department of Radiology, Division of Interventional Radiology and Department of Surgery, Division of Liver and Pancreas Transplantation, University of California at Los Angeles Medical Center, David Geffen School of Medicine, Los Angeles, Calif (E.W.L.); and Department of Diagnostic Radiology, Changi General Hospital, Singapore (D.Y.L.)
| | - Jin Woo Choi
- From the Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea (H.C.K., J.W. Chung., H.J.J., J.W. Choi); Department of Diagnostic Radiology, Fukui-ken Saiseikai Hospital, Fukui, Japan (S.M.); Department of Radiology, Division of Interventional Radiology and Department of Surgery, Division of Liver and Pancreas Transplantation, University of California at Los Angeles Medical Center, David Geffen School of Medicine, Los Angeles, Calif (E.W.L.); and Department of Diagnostic Radiology, Changi General Hospital, Singapore (D.Y.L.)
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11
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Ghadimi DJ, Ghorani H, Moradi Z, Golezar MH, Nouri S, Irilouzadian R, Zare Dehnavi A, Ebrahimi P, Ghasemi Rad M. Management of ectopic variceal bleeding with transjugular intrahepatic portosystemic shunt: a systematic review of case reports. Emerg Radiol 2024; 31:581-594. [PMID: 38935315 DOI: 10.1007/s10140-024-02258-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024]
Abstract
Ectopic varices account for 5% of variceal bleedings and occur outside the gastro-esophageal region. This review evaluates the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) for ectopic variceal management. A comprehensive search through PubMed, Scopus, Web of Science, and Embase was conducted until January 16, 2023, using relevant keywords. Case reports and case series with fewer than 10 patients on TIPS for ectopic variceal management were included. The quality assessment followed the Joanna Briggs Institute checklist for case reports. This systematic review evaluated 43 studies involving 50 patients with ectopic varices undergoing TIPS. Patients had a mean age of 54.3 years, half were female, and two were pregnant. Alcoholic liver disease (48%) and hepatitis C infection (26%) were common causes of portal hypertension. Ascites and splenomegaly were reported in 32% and 28% of the patients, respectively. Rectal, oral, and stomal variceal bleeding accounted for 62%, 16%, and 22% of the patients, respectively. Ectopic varices were mainly located in the duodenum (28%) and rectum (26%) regions. Complications affected 42% of the patients, re-bleeding in eleven and hepatic encephalopathy in seven. The follow-up lasted 12 months on average, and finally, 5 received a liver transplant. Mortality post-TIPS was 18%. Despite complications and a notable mortality rate, favorable outcomes were observed in almost half of the patients with ectopic variceal bleeding managed with TIPS. Further research is warranted to refine strategies and improve patient outcomes.
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Affiliation(s)
- Delaram J Ghadimi
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamed Ghorani
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Science, Tehran, Iran
| | - Zahra Moradi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Hossein Golezar
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Science, Tehran, Iran
- Student Research Committee, Faculty of Medicine, Shahed University, Tehran, Iran
| | - Shadi Nouri
- Department of Radiology, School of Medicine Arak, University of Medical Sciences, Arak, Iran
| | - Rana Irilouzadian
- Burn Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Zare Dehnavi
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine and Science, Rochester, MN, 55905, USA
| | - Pouya Ebrahimi
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ghasemi Rad
- Department of Interventional Radiology, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA.
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12
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Liu J, Wang P, Wang LM, Guo J, Zhong N. Outcomes of endoscopic sclerotherapy for jejunal varices at the site of choledochojejunostomy (with video): Three case reports. World J Gastroenterol 2024; 30:2059-2067. [PMID: 38681128 PMCID: PMC11045488 DOI: 10.3748/wjg.v30.i14.2059] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/09/2024] [Accepted: 03/26/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Hemorrhage associated with varices at the site of choledochojejunostomy is an unusual, difficult to treat, and often fatal manifestation of portal hypertension. So far, no treatment guidelines have been established. CASE SUMMARY We reported three patients with jejunal varices at the site of choledochojejunostomy managed by endoscopic sclerotherapy with lauromacrogol/α-butyl cyanoacrylate injection at our institution between June 2021 and August 2023. We reviewed all patient records, clinical presentation, endoscopic findings and treatment, outcomes and follow-up. Three patients who underwent pancreaticoduodenectomy with a Whipple anastomosis were examined using conventional upper gastrointestinal endoscopy for suspected hemorrhage from the afferent jejunal loop. Varices with stigmata of recent hemorrhage or active hemorrhage were observed around the choledochojejunostomy site in all three patients. Endoscopic injection of lauromacrogol/α-butyl cyanoacrylate was carried out at jejunal varices for all three patients. The bleeding ceased and patency was observed for 26 and 2 months in two patients. In one patient with multiorgan failure and internal environment disturbance, rebleeding occurred 1 month after endoscopic sclerotherapy, and despite a second endoscopic sclerotherapy, repeated episodes of bleeding and multiorgan failure resulted in eventual death. CONCLUSION We conclude that endoscopic sclerotherapy with lauromacrogol/α-butyl cyanoacrylate injection can be an easy, effective, safe and low-cost treatment option for jejunal varicose bleeding at the site of choledochojejunostomy.
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Affiliation(s)
- Jun Liu
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Peng Wang
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Li-Mei Wang
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Jing Guo
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Ning Zhong
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
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13
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Meram E, Russell E, Ozkan O, Kleedehn M. Variceal and Nonvariceal Upper Gastrointestinal Bleeding Refractory to Endoscopic Management: Indications and Role of Interventional Radiology. Gastrointest Endosc Clin N Am 2024; 34:275-299. [PMID: 38395484 DOI: 10.1016/j.giec.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
For over 60 years, diagnostic and interventional radiology have been heavily involved in the evaluation and treatment of patients presenting with gastrointestinal bleeding. For patients who present with upper GI bleeding and have a contraindication to endoscopy or have an unsuccessful attempt at endoscopy for identifying or controlling the bleeding, interventional radiology is often consulted for evaluation and consideration of catheter-based intervention.
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Affiliation(s)
- Ece Meram
- University of Wisconsin School of Medicine and Public Health, University of Wisconsin Hospitals and Clinics, 600 Highland Avenue, Madison, WI 53792, USA
| | - Elliott Russell
- University of Wisconsin School of Medicine and Public Health, University of Wisconsin Hospitals and Clinics, 600 Highland Avenue, Madison, WI 53792, USA
| | - Orhan Ozkan
- University of Wisconsin School of Medicine and Public Health, University of Wisconsin Hospitals and Clinics, 600 Highland Avenue, Madison, WI 53792, USA
| | - Mark Kleedehn
- University of Wisconsin School of Medicine and Public Health, University of Wisconsin Hospitals and Clinics, 600 Highland Avenue, Madison, WI 53792, USA.
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14
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Chavan R, Baraldo S, Patel N, Gandhi C, Rajput S. Technical tips for EUS-guided embolization of varices and pseudoaneurysms. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2024; 9:211-219. [PMID: 38618622 PMCID: PMC11009482 DOI: 10.1016/j.vgie.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Backgrounds and Aims EUS-guided vascular intervention has expanded the horizons of diagnostic as well as therapeutic interventions for vascular pathology. EUS-guided embolization is a commonly performed technique for the treatment of gastric varices. However, there is a lack of data on the standardization of the technique. Here, we review the techniques and difficulties encountered during EUS-guided embolization of varices and pseudoaneurysms. Methods This article and accompanying video describe the EUS-guided embolization techniques for various vascular lesions. EUS-guided embolization was achieved by combination therapy using coils and cyanoacrylate. Complete obliteration of the lesions was documented on follow-up. The existing literature of EUS-guided embolization therapy is also reviewed. Results Patients with various vascular lesions, including gastric varices, ectopic duodenal varices, and splenic artery pseudoaneurysms, were successfully treated with EUS-guided coil plus cyanoacrylate injection. Patients with gastric varices underwent treatment with 2 EUS-guided techniques: (1) direct puncture of the varix and embolization and (2) feeder vessel embolization. Following embolization, the absence of Doppler flow within the varix and pseudoaneurysm was documented. Conclusions Techniques of EUS-guided embolization of varices and pseudoaneurysms are demonstrated. Understanding the techniques and the challenges encountered during therapy is crucial to optimize outcomes and reduce adverse events.
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Affiliation(s)
| | | | - Nishant Patel
- Arnold Palmer Hospital for Children, Orlando Health, Orlando, Florida, USA
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15
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Pas M, Jogo A, Yamamoto A, Kageyama K, Sohgawa E, Oura T, Terayama E, Asano K, Matsushita K, Sakai Y, Ozaki M, Yonezawa H, Okazaki M, Nota T, Murai K, Kita R, Kaminou T, Miki Y. Transparaumbilical Intravariceal Sclerotherapy for Duodenal Varices Using Outflow Embolization. Intern Med 2024; 63:803-807. [PMID: 37495529 PMCID: PMC11008987 DOI: 10.2169/internalmedicine.2274-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/12/2023] [Indexed: 07/28/2023] Open
Abstract
A 55-year-old patient was admitted for variceal treatment, a complication of chronic portal hypertension and liver cirrhosis. Imaging studies revealed prominent duodenal varices, the pancreaticoduodenal vein as its afferent pathway, a drainer vessel into the inferior vena cava, and a paraumbilical vein. We successfully performed complete obliteration of the varix, including its afferent and efferent vessels, via the paraumbilical vein approach.
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Affiliation(s)
- Maciej Pas
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Ken Kageyama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Etsuji Sohgawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Tatsushi Oura
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Eisaku Terayama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Kazuo Asano
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Kazuki Matsushita
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Yuki Sakai
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Masanori Ozaki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Hiroki Yonezawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Masahiro Okazaki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Takehito Nota
- Advanced Imaging and Minimally Invasive Therapy Center, Tsukazaki Hospital, Japan
| | - Kazuki Murai
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Ryuichi Kita
- Department of Gastroenterology, Osaka Red Cross Hospital, Japan
| | - Toshio Kaminou
- Advanced Imaging and Minimally Invasive Therapy Center, Tsukazaki Hospital, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
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16
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Yamauchi R, Takata K, Yokoyama K, Shibata K, Fukuda H, Fukunaga A, Tanaka T, Shakado S, Yoshimitsu K, Hirai F. Partial splenic embolization improved stomal varices in patient with decompensated liver cirrhosis: a case report. Clin J Gastroenterol 2024; 17:100-105. [PMID: 37878139 DOI: 10.1007/s12328-023-01865-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/15/2023] [Indexed: 10/26/2023]
Abstract
A 63-year-old man with decompensated liver cirrhosis was admitted for treatment of stomal hemorrhage. Eighteen months earlier, he was diagnosed with rectal and sigmoid colon cancer with multiple lymph node metastases, and he underwent colostomy surgery and postoperative chemotherapy. Sixteen months after the surgery, his stoma began to bleed repeatedly, and he required frequent blood transfusions. A contrast-enhanced computed tomography revealed ectopic varices around the stoma. We considered surgical or endoscopic treatment; however, these approaches would have been technically difficult in this patient. The patient was treated with partial splenic embolization to improve thrombocytopenia and portal hypertension. After two-stage partial splenic embolization, the platelet counts increased, and the concentration of the liver fibrosis marker, Mac-2 binding protein, decreased. In addition, blood flow in the stomal varices decreased, with no recurrence of bleeding. This is a case of recurrent hemorrhage from stomal varices that was successfully treated with partial splenic embolization in a patient with liver cirrhosis. There are no guidelines for hemorrhage from ectopic varices. PSE may present potential utility as a treatment for ectopic variceal bleeding, such as stomal varices.
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Affiliation(s)
- Ryo Yamauchi
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan, Fukuoka, 814-0180, Japan.
| | - Kazuhide Takata
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan, Fukuoka, 814-0180, Japan
| | - Keiji Yokoyama
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan, Fukuoka, 814-0180, Japan
| | - Kumiko Shibata
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan, Fukuoka, 814-0180, Japan
| | - Hiromi Fukuda
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan, Fukuoka, 814-0180, Japan
| | - Atsushi Fukunaga
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan, Fukuoka, 814-0180, Japan
| | - Takashi Tanaka
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan, Fukuoka, 814-0180, Japan
| | - Satoshi Shakado
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan, Fukuoka, 814-0180, Japan
| | - Kengo Yoshimitsu
- Department of Radiology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Fumihito Hirai
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan, Fukuoka, 814-0180, Japan
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17
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Lee EW, Eghtesad B, Garcia-Tsao G, Haskal ZJ, Hernandez-Gea V, Jalaeian H, Kalva SP, Mohanty A, Thabut D, Abraldes JG. AASLD Practice Guidance on the use of TIPS, variceal embolization, and retrograde transvenous obliteration in the management of variceal hemorrhage. Hepatology 2024; 79:224-250. [PMID: 37390489 DOI: 10.1097/hep.0000000000000530] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/02/2023]
Affiliation(s)
- Edward Wolfgang Lee
- Department of Radiology and Surgery, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Bijan Eghtesad
- Department of General Surgery, Digestive Disease and Surgery Institute Cleveland Clinic, Cleveland, Ohio, USA
| | - Guadalupe Garcia-Tsao
- Yale University School of Medicine, Department of Internal Medicine, Section of Digestive Diseases, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Ziv J Haskal
- Department of Radiology and Medical Imaging/Interventional Radiology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). Universitat de Barcelona (UB). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
| | - Hamed Jalaeian
- Department of Interventional Radiology, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | | | - Arpan Mohanty
- Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Dominique Thabut
- AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Service d'Hépato-gastroentérologie, Paris, France
| | - Juan G Abraldes
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
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18
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Lee KK, Park JY, Choi WS, Cho YY. Plug-Assisted Retrograde Transvenous Obliteration for the Treatment of Duodenal Variceal Bleeding - A Case Report and Literature Review. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2023; 82:295-299. [PMID: 38129999 DOI: 10.4166/kjg.2023.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/06/2023] [Accepted: 10/25/2023] [Indexed: 12/23/2023]
Abstract
Duodenal varices are uncommon complications of portal hypertension. Although duodenal variceal bleeding is infrequent, it is a life-threatening condition with a high mortality rate. Non-surgical methods for duodenal variceal bleeding include endoscopic band ligation, endoscopic sclerotherapy, transjugular intrahepatic portosystemic shunt, and retrograde transvenous obliteration. On the other hand, an optimal treatment strategy for this rare condition has not been established. A 38-year-old male with a history of alcoholic liver cirrhosis presented with hematemesis. An emergency esophagogastroduodenoscopy (EGD) revealed large, multiple varices in the second portion of the duodenum, and plug-assisted retrograde transvenous obliteration (PARTO) was performed accordingly. Gastrointestinal bleeding was resolved after the procedure. Follow-up EGD conducted after 11 weeks revealed complete obliteration of the previously observed duodenal varices. PARTO may be considered a viable option for treating duodenal variceal bleeding.
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Affiliation(s)
- Kyung Kyu Lee
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jae Yong Park
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Woo Sun Choi
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Young Youn Cho
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
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19
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Seo B, Lee JH, Jang EJ, Park SW, Park JS, Park SJ, Kim SJ, Yeon JW, Lee AY, Seo JY. Small Bowel Variceal Bleeding in Patients with Liver Cirrhosis Treated with Transarterial Embolization: Case Series. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2023; 82:304-309. [PMID: 38130001 DOI: 10.4166/kjg.2023.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/26/2023] [Accepted: 10/29/2023] [Indexed: 12/23/2023]
Abstract
Small bowel variceal bleeding is a rare cause of gastrointestinal hemorrhage, with clinical manifestations ranging from asymptomatic incidental findings to life-threatening conditions. The diagnosis and management of small bowel bleeding are challenging because of the localization of the lesion and the difficulty of the procedure. Trans-arterial embolization (TAE) is a secure and straightforward method for treating ectopic varices. On the other hand, there have been limited local studies on the outcomes of TAE for patients with small bowel variceal hemorrhage. This paper reports patients diagnosed with small bowel variceal bleeding and treated with TAE.
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Affiliation(s)
- Boram Seo
- Department of Gastroenterology, DMC Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Ju Ho Lee
- Department of Gastroenterology, DMC Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Eun Jeong Jang
- Department of Gastroenterology, DMC Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Sang Woon Park
- Department of Gastroenterology, DMC Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Ju Sang Park
- Department of Gastroenterology, DMC Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Sang Jong Park
- Department of Gastroenterology, DMC Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Sang-Jung Kim
- Department of Gastroenterology, DMC Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Jae Woo Yeon
- Department of Radiology, DMC Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Ah Young Lee
- Department of Gastroenterology, CHA Gangnam Medical Center, CHA University of School of Medicine, Seoul, Korea
| | - Jun-Young Seo
- Department of Gastroenterology, DMC Bundang Jesaeng General Hospital, Seongnam, Korea
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20
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Gallagher J, Quach B, Sempokuya T, Sivaraman A. A Unique Presentation of Familial Idiopathic Colonic Varices. ACG Case Rep J 2023; 10:e01185. [PMID: 37928226 PMCID: PMC10621910 DOI: 10.14309/crj.0000000000001185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 09/21/2023] [Indexed: 11/07/2023] Open
Abstract
Colonic varices typically occur in the setting of portal hypertension, and patients may present with rectal bleeding or occult anemia. Idiopathic colonic varices occur infrequently in the absence of cirrhosis and can involve the entire colon. We present a case of a 54-year-old Eastern European woman who had undergone diagnostic colonoscopy for newly diagnosed sigmoid adenocarcinoma and was incidentally found to have colonic varices with normal portal pressure gradients. Her 38-year-old daughter was found to have similar varices, raising concerns for hereditary etiology.
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Affiliation(s)
- John Gallagher
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Bill Quach
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Tomoki Sempokuya
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Anita Sivaraman
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
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21
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Chooklin S, Chuklin S, Chukla R. Ectopic varices: anatomical features for surgeons and interventional radiologists. EMERGENCY MEDICINE 2023; 19:299-311. [DOI: 10.22141/2224-0586.19.5.2023.1605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Ectopic varices are defined as dilated portosystemic collateral veins located in unusual sites, other than the gastroesophageal region. They develop secondary to portal hypertension, surgical procedures, anomalies in venous outflow, or abdominal vascular thrombosis and may be familial. Ectopic varices represent a clinical challenge because they are difficult to localize. Missing or misinterpreting these lesions can have serious consequences, and treatment options are unclear. Ectopic varices may be detected during panendoscopy, enteroscopy, endoscopic ultrasound, wireless capsule endoscopy, diagnostic angiography, multislice helical computed tomography, magnetic resonance angiography, color Doppler flow imaging, laparotomy, laparoscopy and occasionally during autopsy. They can be an important cause of bleeding and hepatic encephalopathy, so radiologists must effectively identify them to assist in making therapeutic decisions. Knowledge of the anatomy and course of these unusual portosystemic collaterals is also important for interventional radiologists and surgeons as it helps avoid inadvertent vascular damage during invasive procedures. In this article, we explore the parts of the gastrointestinal tract and organs that may be involved in ectopic varices. Literature search was conducted in the MedLine database on the PubMed platform.
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22
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Qian W, Mac Curtain BM, Trivedi A. Surgical management of isolated caecal varices presenting with massive lower gastrointestinal haemorrhage: a case report and review of the literature. J Surg Case Rep 2023; 2023:rjad438. [PMID: 37545787 PMCID: PMC10401312 DOI: 10.1093/jscr/rjad438] [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] [Received: 06/28/2023] [Accepted: 07/06/2023] [Indexed: 08/08/2023] Open
Abstract
Caecal varices are extremely rare with poorly defined management due to paucity of data. A 52-year-old man was diagnosed with a 3-day history of melena with a background of chronic liver disease and non-steroidal anti-inflammatory use. Investigations revealed anaemia with haemoglobin of 62 g/L, liver function derangement (Gamma-glutamyl transferase 251 U/L, alanine transaminase 40 U/L, bilirubin 84 umol/L, alkaline phosphatase 85 U/L), coagulopathy (International Normalized Ratio 1.6) and acute kidney injury (Creatinine 285 umol/L). Gastroscopy demonstrated no signs of upper gastrointestinal bleeding or portal hypertension. A large volume haematochezia occurred necessitating resuscitation with massive transfusion protocol, and colonoscopy was abandoned in favour of computerized tomography (CT) angiography, which revealed a large varix feeding the caecum. Urgent laparotomy and a right hemicolectomy was performed with application of abdominal vacuum dressing. The hemicolectomy sample was opened on back table demonstrating large caecal varix causing intraluminal bleeding. The patient was stabilized in intensive care, and a further laparotomy was performed 2 days later where an end ileostomy was formed. Caecal varices have been reported in literature with management via trans-jugular intrahepatic portosystemic shunt, endoscopically or conservatively with beta-blockade. Here we present, to the best of the author's knowledge, the first reported case of successful surgical management of caecal varices.
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Affiliation(s)
- Wanyang Qian
- Correspondence address. St John of God Subiaco Hospital, Subiaco, WA 6008, Australia. Tel: +61416719008;
| | | | - Anand Trivedi
- Acute Surgical Unit, Fiona Stanley Hospital, Murdoch, WA 6150, Australia
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23
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Vashishtha C, Sarin SK. Management of Gastric and Ectopic Varices. CURRENT HEPATOLOGY REPORTS 2023. [DOI: 10.1007/s11901-023-00597-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/13/2023] [Indexed: 01/04/2025]
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24
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O'Neill RS, Wang WJ, Chan P, Ho V, Verdon C, Turner I, Acharya P. An obscure cause of gastrointestinal bleeding: Recurrent duodenal variceal hemorrhage treated with intramuscular octreotide in the absence of portal hypertension. JGH Open 2023; 7:78-80. [PMID: 36660056 PMCID: PMC9840189 DOI: 10.1002/jgh3.12847] [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] [Received: 11/04/2022] [Accepted: 11/12/2022] [Indexed: 12/15/2022]
Abstract
Duodenal varices (DVs) are ectopic gastrointestinal varices (ECVs) associated with portal hypertension (PH). We present the case of an 82-year-old woman who presented with symptomatic anemia secondary to DV hemorrhage diagnosed on oesophagogastroduodenoscopy. This lesion was treated with endoscopic adrenaline injection and clip application. The patient re-presented on multiple occasions with bleeding recurrence localized to the duodenum, which was managed with intramuscular octreotide and oral beta-blockade resulting in sustained remission of bleeding. This case highlights a rare cause of upper gastrointestinal hemorrhage and highlights the value of somatostatin analogues for conservative treatment of DVs.
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Affiliation(s)
- Robert S O'Neill
- Department of GastroenterologyCampbelltown HospitalCampbelltownNew South WalesAustralia
- St Vincent's Clinical School, Faculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia
| | - William J Wang
- Department of GastroenterologyCampbelltown HospitalCampbelltownNew South WalesAustralia
- Western Sydney UniversityCampbelltownNew South WalesAustralia
- Townsville University HospitalDouglasQueenslandAustralia
| | - Patrick Chan
- Department of GastroenterologyCampbelltown HospitalCampbelltownNew South WalesAustralia
| | - Vincent Ho
- Department of GastroenterologyCampbelltown HospitalCampbelltownNew South WalesAustralia
- Western Sydney UniversityCampbelltownNew South WalesAustralia
| | - Christine Verdon
- Department of GastroenterologyCampbelltown HospitalCampbelltownNew South WalesAustralia
- Western Sydney UniversityCampbelltownNew South WalesAustralia
| | - Ian Turner
- Department of GastroenterologyCampbelltown HospitalCampbelltownNew South WalesAustralia
- Western Sydney UniversityCampbelltownNew South WalesAustralia
| | - Priya Acharya
- Department of GastroenterologyCampbelltown HospitalCampbelltownNew South WalesAustralia
- Western Sydney UniversityCampbelltownNew South WalesAustralia
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25
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Shafiq S, Devarbhavi H, Patil M. Endoscopic Cyanoacrylate Glue Injection for Duodenal Varices—A Single-Center Study. JOURNAL OF DIGESTIVE ENDOSCOPY 2022. [DOI: 10.1055/s-0042-1757469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Aim/Objectives Duodenal varices (DVs), although rare, can present with massive, potentially fatal upper gastrointestinal bleeding; however, there are no randomized trials regarding management of this relatively uncommon presentation. We aim to report our experience with endoscopic cyanoacrylate glue injection in patients with DVs.
Materials and Methods We retrospectively evaluated the medical records of all patients with portal hypertension at our center between January 2010 and December 2021. Demographic characteristics along with the etiology, location, and effectiveness of cyanoacrylate glue injection for bleeding DVs were collected and analyzed.
Results A total of 5,892 patients with portal hypertension underwent endoscopy during the study period, of whom 41 patients (M:F = 29:12) with mean age of 38 years were noted to have DVs. While extrahepatic portal vein obstruction was the commonest etiology (n = 26), the most common site of DVs was the duodenal bulb (n = 21). Twenty-one (51%) out of these 41 patients presented primarily with DV bleeding and underwent endoscopic cyanoacrylate glue injection with successful hemostasis achieved of the index bleed; however, four of these 21 patients had rebleeding between 2 weeks and 12 months of follow-up requiring repeat endotherapy.. While three patients underwent successful repeat glue injections, one patient had recurrent massive bleedings, not amenable to endotherapy and was subjected to duodenal resection with surgical shunt procedure.
Conclusion While the prevalence of DVs in portal hypertension patients was 0.7% (41/5892), DVs accounted for 0.42% (21/4889) of portal hypertension-related bleedings. Endotherapy with cyanoacrylate glue appears to be a safe and cost-effective treatment for acute DV bleeding in a resource-limited setting.
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Affiliation(s)
- Syed Shafiq
- Department of Gastroenterology, St. John's Medical College Hospital, Bengaluru, Karnataka, India
| | - Harshad Devarbhavi
- Department of Gastroenterology, St. John's Medical College Hospital, Bengaluru, Karnataka, India
| | - Mallikarjun Patil
- Department of Gastroenterology, St. John's Medical College Hospital, Bengaluru, Karnataka, India
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26
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D'Silva M, Yoon YS, Lee JS, Cho JY, Lee HW, Lee B, Kim M, Han HS. Incidence, risk factors, and outcomes of jejunal varix of the afferent loop after pancreatoduodenectomy. HPB (Oxford) 2022; 24:2193-2201. [PMID: 36150971 DOI: 10.1016/j.hpb.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 06/13/2022] [Accepted: 08/22/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Jejunal varix is a concerning late complication after pancreatoduodenectomy (PD) due to the risk of recurrent and intractable bleeding. Our aim was to investigate the incidence, risk factors, and outcomes of jejunal varix after PD. METHODS A total of 709 patients who underwent PD between 2007 and 2017 were included. Preoperative and postoperative CT images were reviewed to evaluate the development of portal vein (PV) stenosis (≥50%) and jejunal varices. RESULTS Jejunal varix developed in 83 (11.7%) patients at a median of 12 months after PD. Eighteen (21.7%) patients experienced variceal bleeding. PV stenosis (P < 0.001; odds ratio [OR] 33.2, 95% confidence interval [CI] 15.6-66.7) and PV/superior mesenteric vein resection (P = 0.028; OR 2.3, 95% CI 1.1-4.7) were independent risk factors for jejunal varix. Of the nine patients who underwent stent placement for PV stenosis before the formation of jejunal varices, none experienced variceal bleeding. By contrast, 18 (27.3%) of the 135 patients without PV stent placement experienced at least one episode of variceal bleeding. CONCLUSIONS The incidence of jejunal varix was substantial after PD. PV stenosis was a strong risk factor for jejunal varix. Early PV stent placement and maintaining stent patency could reduce the risk of variceal bleeding in patients with PV stenosis.
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Affiliation(s)
- Mizelle D'Silva
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Republic of Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Republic of Korea.
| | - Jun Suh Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Republic of Korea
| | - Jai Young Cho
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Republic of Korea
| | - Hae Won Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Republic of Korea
| | - Boram Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Republic of Korea
| | - Moonhwan Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Republic of Korea
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Republic of Korea
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27
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Ectopic Vaginal Varices With Hemorrhage After Hysterectomy. ACG Case Rep J 2022; 9:e00878. [PMID: 36247382 PMCID: PMC9561389 DOI: 10.14309/crj.0000000000000878] [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: 05/31/2022] [Accepted: 08/25/2022] [Indexed: 11/14/2022] Open
Abstract
Vaginal and uterine varices are well documented in pregnancy, although development of vaginal varices in patients with portal hypertension occurs in an exceptionally rare subset. Only 12 cases are reported in the literature; all but 3 of these cases involved patients with a history of hysterectomy, with 1 of the remaining 2 exhibiting partial obliteration of the uterine plexus due to radiation therapy for cervical cancer. We present a case of recurrent vaginal variceal bleeding in a patient with a history of hysterectomy, initially managed with vaginal tamponade and ultimately requiring definitive treatment with transjugular intrahepatic portosystemic shunt insertion.
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28
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Percutaneous transhepatic obliteration for rupture of varices in the small intestine: a case report. Clin J Gastroenterol 2022; 15:890-894. [DOI: 10.1007/s12328-022-01660-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 06/11/2022] [Indexed: 10/17/2022]
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29
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Khedr A, Mahmoud EE, Attallah N, Mir M, Boike S, Rauf I, Jama AB, Mushtaq H, Surani S, Khan SA. Role of octreotide in small bowel bleeding. World J Clin Cases 2022; 10:9192-9206. [PMID: 36159407 PMCID: PMC9477697 DOI: 10.12998/wjcc.v10.i26.9192] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 07/30/2022] [Accepted: 08/15/2022] [Indexed: 02/05/2023] Open
Abstract
Gastrointestinal bleeding accounts for a drastic negative impact on the quality of the patients' lives as it requires multiple diagnostic and therapeutic interventions to identify the source of the bleeding. Small bowel bleeding is the least common cause of gastrointestinal bleeding. However, it is responsible for the majority of complaints from patients with persisting or recurring bleeding where the primary source of bleeding cannot be identified despite investigation. A somatostatin analog known as octreotide is among the medical treatment modalities currently used to manage small bowel bleeding. This medication helps control symptoms of gastrointestinal bleeding by augmenting platelet aggregation, decreasing splanchnic blood flow, and antagonizing angiogenesis. In this review article, we will highlight the clinical efficacy of octreotide in small bowel bleeding and its subsequent effect on morbidity and mortality.
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Affiliation(s)
- Anwar Khedr
- Department of Internal Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | | | - Noura Attallah
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Mikael Mir
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States
| | - Sydney Boike
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States
| | - Ibtisam Rauf
- Department of Medicine, St. George School of Medicine, Grenada, West Indies
| | - Abbas B Jama
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Hisham Mushtaq
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Salim Surani
- Department of Medicine, Texas A&M University Health Science Center, Bryan, TX 77807, United States
| | - Syed A Khan
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
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30
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Nadeem IM, Badar Z, Giglio V, Stella SF, Markose G, Nair S. Embolization of parastomal and small bowel ectopic varices utilizing a transhepatic antegrade approach: A case series. Acta Radiol Open 2022; 11:20584601221112618. [PMID: 35833193 PMCID: PMC9272059 DOI: 10.1177/20584601221112618] [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: 11/21/2021] [Accepted: 04/21/2022] [Indexed: 11/17/2022] Open
Abstract
Background The ideal approach to managing parastomal and small bowel ectopic varices (EVs) is yet to be established. Purpose To evaluate outcomes following percutaneous antegrade transhepatic venous obliteration (PATVO) in patients presenting with bleeding from parastomal or small bowel EVs. Material and Methods A case series of 12 patients presenting with active or recurrent bleeding from parastomal or small bowel EVs who underwent 17 PATVO interventions at our tertiary care institution was performed. Data extraction from electronic medical records included baseline characteristics and procedural details. Endpoints included technical success, early clinical success, and re-bleeding. Results Technical success was 100% ( n = 17), and early clinical success was 82.3% ( n = 14). No patient experienced any intra- or post-operative complications. Rebleed rates after initial PATVO in patients who achieved early clinical success was as follows: 3-month, 0% ( n = 0); 6-month, 20% ( n = 2); 12-month, 20% ( n = 2). Rebleed rates after all PATVO procedures (including patients undergoing repeat procedures) that achieved early clinical success were as follows: 3-month, 0% ( n = 0); 6-month, 14% ( n = 2; 12-month, 14% ( n = 2). All patients with re-bleeding required reintervention with either PATVO, transjugular intrahepatic portosystemic shunt (TIPS) or both. Conclusion PATVO can be safely performed to treat bleeding from parastomal and small bowel EVs. In patients who present with recurrent bleeding despite PATVO, TIPS with/without embolization of bleeding varices remains a valid option as described by the literature.
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Affiliation(s)
| | - Zain Badar
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, University Health Network/University of Toronto, Toronto, ON, Canada
| | - Victoria Giglio
- Department of Radiology, Juravinski Hospital, McMaster University, Hamilton, ON, Canada
| | | | - George Markose
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Sabarinath Nair
- Department of Surgery, McMaster University, Hamilton, ON, Canada
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31
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Sallout D, Tatro E, Adler DG. Managing gastric varices. Frontline Gastroenterol 2022; 13:535-542. [PMID: 36250174 PMCID: PMC9559633 DOI: 10.1136/flgastro-2021-101834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/11/2022] [Indexed: 02/04/2023] Open
Abstract
Gastric varices (GV) are a type of ectopic varix, which is a natural portosystemic shunt occurring in response to an increase in intrahepatic vascular resistance, mostly commonly from portal hypertension. GV are present in up to 20% of patients with portal hypertension. Although oesophageal varices are more common than GV, and oesophageal variceal bleeding (EVB) happens more often than gastric variceal bleeding (GVB), GVB tends to be more severe, to have higher associated hospital costs, length of stay, higher rebleeding rates and have higher mortality. Mortality rates associated with variceal bleeding range from 6% in EVB to 20%-55% in GVB. Risk factors for GV haemorrhage include location, size, severity of liver failure, presence of variceal red spots, and presence of HCC (hepatocellular carcinoma). This manuscript will review endoscopic and non-endoscopic treatment of GV.
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Affiliation(s)
- Deema Sallout
- The University of Utah Department of Internal Medicine, Salt Lake City, Utah, USA
| | - Eric Tatro
- The University of Utah Department of Internal Medicine, Salt Lake City, Utah, USA
| | - Douglas G Adler
- Endoscopy, Center for Advanced Therapeutic Endoscopy, Denver, Colorado, USA
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32
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Broussard KA, Rockey DC. Bleeding ectopic varices: clinical presentation, natural history, and outcomes. J Investig Med 2022; 70:1280-1284. [PMID: 35246467 DOI: 10.1136/jim-2021-002021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2022] [Indexed: 11/03/2022]
Abstract
Bleeding complications from ectopic varices are often difficult to manage. We aimed to study the natural history and outcomes of bleeding ectopic varices to better understand appropriate clinical management. This retrospective cohort study included patients admitted to the hospital with bleeding ectopic or esophageal varices from 2010 through 2019. Study subjects were identified through searching the Medical University of South Carolina's electronic medical record, and complete demographic, clinical, and procedural data were abstracted. 25 patients with gastrointestinal bleeding from ectopic varices and a matched group of 50 patients with bleeding esophageal varices were identified. Bleeding ectopic varices were identified in the following locations: duodenum (n=5), jejunum/ileum (n=5), colon (n=2), rectum (n=6), and anastomotic sites (n=7). Model for End-Stage Liver Disease scores (patients with cirrhosis), need for intensive care unit admission, and administration of octreotide and antibiotics were significantly higher in patients with esophageal variceal bleeding than those with ectopic varices. All-cause 1-year mortality of patients with ectopic varices was significantly lower than those with bleeding esophageal varices (8% vs 35%, p<0.05). Patients with ectopic varices and cirrhosis bled at lower hepatic venous pressure gradients than patients with bleeding esophageal varices (17 mm Hg vs 24 mm Hg, p<0.01). Transjugular intrahepatic portosystemic shunts (TIPS) were performed in two-thirds of patients with ectopic varices and one patient rebled due to TIPS dysfunction. The clinical features of patients with ectopic varices and those with esophageal varices were similar, but patients with ectopic varices had significantly lower 1-year mortality after bleeding events.
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Affiliation(s)
- Kent A Broussard
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Don C Rockey
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina, USA
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33
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Hori A, Watanabe Y, Takahashi K, Tonouchi T, Kimura N, Setsu T, Ikarashi S, Kamimura H, Yokoyama J, Terai S. A rare case of duodenal variceal bleeding due to extrahepatic portal vein obstruction successfully treated with endoscopic injection sclerotherapy. Clin J Gastroenterol 2022; 15:617-622. [PMID: 35378714 DOI: 10.1007/s12328-022-01627-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 03/15/2022] [Indexed: 10/18/2022]
Abstract
Primary extra-hepatic portal vein obstruction (EHPVO) is a disease that develops ectopic varices due to portal hypertension and obstruction of the portal vein. Since bleeding from ectopic varices is life-threatening, the management of ectopic varices is important for patients with primary EHPVO. Here, we report a case of duodenal variceal bleeding in a patient with primary EHPVO. A 39-year-old man was diagnosed with F2-shaped duodenal varices (DV) due to primary EHPVO and was first treated with endoscopic variceal ligation for temporary hemostasis. We then performed angiography to understand the detailed hemodynamics and subsequently conducted endoscopic injection sclerotherapy (EIS) with a sclerosing agent containing N-butyl-2-cyanoacrylate for further hemostasis. After the treatment, dynamic computed tomography and endoscopic ultrasound revealed that the blood flow to the causative DV disappeared, although the DV itself remained. The patient was discharged without any re-bleeding or adverse events. Since treatment for DV due to primary EHPVO differs depending on hemodynamics (hepatofugal or hepatopetal blood flow), evaluating detailed hemodynamics for optimal treatment selection is crucial. Although EIS for this patient was not a radical treatment, it was effective in managing acute bleeding from the DV. This case will serve as a reference for successful treatment in future cases.
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Affiliation(s)
- Ashu Hori
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Yusuke Watanabe
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.
- Division of Preemptive Medicine for Digestive Disease and Healthy Active Life, School of Medicine, Niigata University, 1-757 Asahimachi-dori, Chuo-ku, Niigata, 951-8510, Japan.
| | - Kazuya Takahashi
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
- Division of Network Medicine for Digestive Diseases, School of Medicine, Niigata University, Niigata, Japan
| | - Takahumi Tonouchi
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Naruhiro Kimura
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Toru Setsu
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Satoshi Ikarashi
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Hiroteru Kamimura
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
- Division of Network Medicine for Digestive Diseases, School of Medicine, Niigata University, Niigata, Japan
| | - Junji Yokoyama
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
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Vulasala SSR, Onteddu NKR, Kalva SP, Smolinski-Zhao S. Expanding Indications of TIPS in the Management of Portal Hypertension Complications. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2022. [DOI: 10.1055/s-0042-1748818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2022] Open
Abstract
AbstractTransjugular intrahepatic portosystemic shunt (TIPS) is a nonsurgical intervention to reduce portal pressure by creating a low-resistance channel between the portal and systemic circulations. It is a well-accepted treatment for gastroesophageal varices and refractory ascites. This review aims to discuss the evidence-based applications of TIPS in other complications of portal hypertension beyond gastroesophageal varices and refractory ascites.
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Affiliation(s)
- Sai Swarupa Reddy Vulasala
- Department of Radiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Nirmal Kumar Reddy Onteddu
- Division of Hospital Medicine, Department of Internal Medicine, Flowers Hospital, Dothan, Alabama, United States
| | - Sanjeeva Prasad Kalva
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Sara Smolinski-Zhao
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, United States
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Singh H, Selvarajan L, Ong SY, Ali S, Sharif K, Mirza D, Gupte G. Late Bleeding Episodes Following Intestinal Transplantation: It Is Not Always Rejection or Infection. JPGN REPORTS 2022; 3:e174. [PMID: 37168923 PMCID: PMC10158307 DOI: 10.1097/pg9.0000000000000174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 12/23/2021] [Indexed: 05/13/2023]
Abstract
Ectopic varices have been reported in 5% of children presenting with variceal bleeding and are defined as portosystemic venous collaterals occurring anywhere in the abdomen except in the cardioesophageal region. The liver-intestinal transplant or isolated liver-intestinal transplant patient presenting several years post-transplant with ectopic variceal bleeding as a consequence of portal hypertension is a seldom reported complication. Etiologies such as rejection or infection are a more common source of bleeding, and only after excluding these can differentials such as portal hypertension secondary to a blocked portacaval shunt or native liver disease be considered.
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Affiliation(s)
- Harveen Singh
- From the Liver Unit, Birmingham Children’s Hospital, Birmingham, United Kingdom
| | - Lakshmi Selvarajan
- From the Liver Unit, Birmingham Children’s Hospital, Birmingham, United Kingdom
| | - Sik-Yong Ong
- From the Liver Unit, Birmingham Children’s Hospital, Birmingham, United Kingdom
| | - Sajeed Ali
- University of Cambridge School of Medicine, Cambridge, United Kingdom
| | - Khalid Sharif
- From the Liver Unit, Birmingham Children’s Hospital, Birmingham, United Kingdom
| | - Darius Mirza
- From the Liver Unit, Birmingham Children’s Hospital, Birmingham, United Kingdom
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Girish Gupte
- From the Liver Unit, Birmingham Children’s Hospital, Birmingham, United Kingdom
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Recurrent Ileal Variceal Bleeding as a Diagnostic and Therapeutic Challenge. Case Rep Gastrointest Med 2022; 2022:7072961. [PMID: 35529673 PMCID: PMC9072047 DOI: 10.1155/2022/7072961] [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: 01/14/2022] [Revised: 03/28/2022] [Accepted: 04/20/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Massive ileal variceal bleeding is a rare intricate condition that needs rapid management and treatment. The absence of randomized clinical trials in this field leads to a lack of evidence-based diagnostic and therapeutical approaches. We present a case report describing imaging, endoscopic, and surgical procedures leading to the diagnosis and resolution of severe ileal variceal bleeding. Case Report. We admitted a 63-year-old patient for recurrent anemia and ongoing bleeding from the gastrointestinal tract presenting as enterorrhagia. We were not able to elucidate the source by endoscopic, angiographic, or nuclear imaging methods. As a last resort, we carried out a surgical procedure with peroperative enteroscopy and subsequent resection of the affected part of the intestine. Conclusion We present a patient with a case of ileal variceal bleeding, which required extensive diagnostic and therapeutic effort with a unique peroperative enteroscopic approach.
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Transhepatic Coil Embolization for Ectopic Varices After Pediatric Liver-intestine Transplantation. Transplantation 2022; 106:e240-e241. [PMID: 35333849 DOI: 10.1097/tp.0000000000003985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Johnson LN, Moran SK, Bhargava P, Revels JW, Moshiri M, Rohrmann CA, Mansoori B. Fluoroscopic Evaluation of Duodenal Diseases. Radiographics 2022; 42:397-416. [PMID: 35179986 DOI: 10.1148/rg.210165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The duodenum can be affected by a variety of abnormalities because of its development during embryogenesis and its dual intra- and retroperitoneal location. If small bowel embryogenesis is disturbed, congenital errors occur. Although some congenital variants may be asymptomatic and inconsequential to the patient, other anomalies can result in life-threatening emergencies such as malrotation, leading to midgut volvulus. Many infectious processes affect the duodenum, including duodenal ulcers and opportunistic infection in patients with HIV/AIDS or Crohn disease. Small bowel malignancies are uncommon but important to recognize, because the duodenum can be involved in polyposis syndromes or the development of primary adenocarcinoma, neuroendocrine tumors, lymphoma, and metastasis. Although endoscopy is currently the most used diagnostic method to assess the lumen of the upper gastrointestinal tract, fluoroscopy is a valuable adjunct technique and the study of choice for many diseases, specifically those for which anatomic and functional information is required. Fluoroscopy is also commonly used postoperatively to assess for complications such as obstruction and extraluminal leaks. Compared with endoscopy, fluoroscopy is an inexpensive and noninvasive technique that provides salient anatomic information and allows delineation of the duodenal mucosa and assessment of real-time duodenal motility. The authors examine the broad spectrum of conditions that can involve the duodenum, including congenital, infectious, inflammatory, and neoplastic abnormalities, and review their typical appearances at fluoroscopy. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Lisa N Johnson
- From the Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA 98195-7115 (L.N.J., S.K.M., P.B., M.M., C.A.R., B.M.); Department of Radiology, University of New Mexico, Albuquerque, NM (J.W.R.); and Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.)
| | - Shamus K Moran
- From the Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA 98195-7115 (L.N.J., S.K.M., P.B., M.M., C.A.R., B.M.); Department of Radiology, University of New Mexico, Albuquerque, NM (J.W.R.); and Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.)
| | - Puneet Bhargava
- From the Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA 98195-7115 (L.N.J., S.K.M., P.B., M.M., C.A.R., B.M.); Department of Radiology, University of New Mexico, Albuquerque, NM (J.W.R.); and Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.)
| | - Jonathan W Revels
- From the Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA 98195-7115 (L.N.J., S.K.M., P.B., M.M., C.A.R., B.M.); Department of Radiology, University of New Mexico, Albuquerque, NM (J.W.R.); and Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.)
| | - Mariam Moshiri
- From the Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA 98195-7115 (L.N.J., S.K.M., P.B., M.M., C.A.R., B.M.); Department of Radiology, University of New Mexico, Albuquerque, NM (J.W.R.); and Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.)
| | - Charles A Rohrmann
- From the Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA 98195-7115 (L.N.J., S.K.M., P.B., M.M., C.A.R., B.M.); Department of Radiology, University of New Mexico, Albuquerque, NM (J.W.R.); and Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.)
| | - Bahar Mansoori
- From the Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA 98195-7115 (L.N.J., S.K.M., P.B., M.M., C.A.R., B.M.); Department of Radiology, University of New Mexico, Albuquerque, NM (J.W.R.); and Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.)
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Tamai Y, Tanaka H, Fujimori M, Iwasa M, Nakagawa H. Successful endoscopic cyanoacrylate injection therapy for ruptured duodenal varices immediately after balloon-occluded retrograde transvenous obliteration. JGH Open 2021; 5:1401-1403. [PMID: 34950785 PMCID: PMC8674538 DOI: 10.1002/jgh3.12683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 11/11/2022]
Abstract
We present a rare case of acute duodenal variceal rupture after B-RTO that was successfully treated with endoscopic CA injection therapy. A 74-year-old Japanese woman was transferred to our hospital due to progressive general malaise and hematemesis. Gastroduodenoscopy (GDS) showed duodenal varices without active bleeding in the second portion of duodenum. Balloon-occluded retrograde transvenous obliteration (B-RTO) was carried out to prevent duodenal variceal rebleeding. Good pooling of ethanolamine oleate with iopamidol (EOI) was observed in duodenal varices using balloon catheters. However, massive melena was observed immediately after B-RTO. Emergent GDS revealed a white plug on the treated varix, thus endoscopic cyanoacrylate (CA) injection therapy was performed. We speculated that the injection of EOI increased the pressure in the duodenal varices which resulted in rupture of duodenal varices. B-RTO was effective therapy to prevent duodenal variceal rebleeding, but postprocedural monitoring is required as illustrated by this case. We suggest that careful monitoring and backup system for endoscopy are required during or after B-RTO.
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Affiliation(s)
- Yasuyuki Tamai
- Department of Gastroenterology and Hepatology Mie University Graduate School of Medicine Tsu Mie Japan
| | - Hideaki Tanaka
- Department of Gastroenterology and Hepatology Mie University Graduate School of Medicine Tsu Mie Japan
| | - Masashi Fujimori
- Department of Radiology Mie University Graduate School of Medicine Tsu Mie Japan
| | - Motoh Iwasa
- Department of Gastroenterology and Hepatology Mie University Graduate School of Medicine Tsu Mie Japan
| | - Hayato Nakagawa
- Department of Gastroenterology and Hepatology Mie University Graduate School of Medicine Tsu Mie Japan
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40
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Zumblick M, Stathopoulos P, Gress TM, Mahnken AH, Denzer UW. Interdisziplinäres Komplikationsmanagement bei Leberzirrhose. DER GASTROENTEROLOGE 2021; 16:463-468. [DOI: 10.1007/s11377-021-00575-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/25/2021] [Indexed: 01/05/2025]
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41
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Wongjarupong N, Said HS, Huynh RK, Golzarian J, Lim N. Hemoperitoneum From Bleeding Intra-Abdominal Varices: A Rare, Life-Threatening Cause of Abdominal Pain in a Patient With Cirrhosis. Cureus 2021; 13:e18955. [PMID: 34815901 PMCID: PMC8605961 DOI: 10.7759/cureus.18955] [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] [Accepted: 10/21/2021] [Indexed: 11/05/2022] Open
Abstract
We report the case of a 54-year-old male with alcoholic cirrhosis who presented several times to the emergency department (ED) with right upper quadrant abdominal pain. Ten days after his initial presentation, the patient represented with hypotension and anemia. An abdominal CT angiogram identified hemorrhage from an ectopic varix successfully treated with emergent glue embolization of mesenteric, omental, and periumbilical varices. Intraperitoneal bleeding from ectopic varices in cirrhosis patients is a rare, life-threatening condition. Consideration and recognition of ectopic variceal hemorrhage in patients with cirrhosis can facilitate prompt life-saving treatment in a population susceptible to significant morbidity and mortality.
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Affiliation(s)
- Nicha Wongjarupong
- Internal Medicine, University of Minnesota, Minneapolis, USA.,Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, USA
| | - Hamdi S Said
- Gastroenterology and Hepatology, University of Minnesota, Minneapolis, USA
| | - Richie K Huynh
- Medicine, M Health Fairview Woodwinds Hospital, Woodbury, USA
| | - Jafar Golzarian
- Interventional Radiology, University of Minnesota, Minneapolis, USA
| | - Nicholas Lim
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, USA
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42
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Smith MJ, Daly D, Wong SW. Parastomal variceal bleeding. ANZ J Surg 2021; 92:1510-1511. [PMID: 34672073 DOI: 10.1111/ans.17301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 09/27/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Matthew Jacob Smith
- Department of General Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Daniel Daly
- Department of General Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Shing Wai Wong
- Department of General Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
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Tarasconi A, Perrone G, Davies J, Coimbra R, Moore E, Azzaroli F, Abongwa H, De Simone B, Gallo G, Rossi G, Abu-Zidan F, Agnoletti V, de'Angelis G, de'Angelis N, Ansaloni L, Baiocchi GL, Carcoforo P, Ceresoli M, Chichom-Mefire A, Di Saverio S, Gaiani F, Giuffrida M, Hecker A, Inaba K, Kelly M, Kirkpatrick A, Kluger Y, Leppäniemi A, Litvin A, Ordoñez C, Pattonieri V, Peitzman A, Pikoulis M, Sakakushev B, Sartelli M, Shelat V, Tan E, Testini M, Velmahos G, Wani I, Weber D, Biffl W, Coccolini F, Catena F. Anorectal emergencies: WSES-AAST guidelines. World J Emerg Surg 2021; 16:48. [PMID: 34530908 PMCID: PMC8447593 DOI: 10.1186/s13017-021-00384-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/16/2021] [Indexed: 02/06/2023] Open
Abstract
Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.
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Affiliation(s)
- Antonio Tarasconi
- Emergency Surgery Department, Parma University Hospital, Parma, Italy.
| | - Gennaro Perrone
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Raul Coimbra
- Riverside University Health System Medical Center, Loma Linda University School of Medicine, Riverside, CA, USA
| | - Ernest Moore
- Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO, USA
| | - Francesco Azzaroli
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Hariscine Abongwa
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Belinda De Simone
- Department of Metabolic, Digestive and Emergency Surgery, Centre Hospitalier Intercommunal de Poissy et Saint Germain en Laye, Poissy, France
| | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Giorgio Rossi
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, AUSL Romagna, M.Bufalini Hospital, Cesena, Italy
| | - Gianluigi de'Angelis
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Gastroenterology and Endoscopy Unit, Hospital of Parma, Parma, Italy
| | - Nicola de'Angelis
- Minimally Invasive and Robotic Digestive Surgery Unit, Regional General Hospital F. Miulli, Bari, Ital - Université Paris Est, UPEC, Creteil, France
| | - Luca Ansaloni
- Department of Emergency and general Surgery, Pavia University Hospital, Pavia, Italy
| | - Gian Luca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Paolo Carcoforo
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Marco Ceresoli
- General Surgery, Monza University Hospital, Monza, Italy
| | - Alain Chichom-Mefire
- Faculty of Health Sciences, Department of Surgery, University of Buea, Buea, Cameroon
| | - Salomone Di Saverio
- General surgery 1st unit, Department of General Surgery, University of Insubria, Varese, Italy
| | - Federica Gaiani
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Gastroenterology and Endoscopy Unit, Hospital of Parma, Parma, Italy
| | - Mario Giuffrida
- Department of Medicine and Surgery, General Surgery Unit, University Hospital of Parma, Parma, Italy
| | - Andreas Hecker
- Department of General & Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Kenji Inaba
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, USA
| | - Michael Kelly
- Department of General Surgery, Albury Hospital, Albury, Australia
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | | | - Andrey Litvin
- Department of Surgical Disciplines, Regional Clinical Hospital, Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Carlos Ordoñez
- Department of Surgery, Fundacion Valle del Lili - Universidad del Valle, Cali, Colombia
| | | | - Andrew Peitzman
- University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, PA, USA
| | - Manos Pikoulis
- 3rd Department of Surgery, National & Kapodistrian University of Athens, Athens, Greece
| | - Boris Sakakushev
- General Surgery Department, University Hospital St George, Plovdiv, Bulgaria
| | | | - Vishal Shelat
- Department of Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Edward Tan
- Department of Surgery, Department of Emergency Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Mario Testini
- Academic Unit of General Surgery "V. Bonomo" Department of Biomedical Sciences and Human Oncology, University of Bari, Bari, Italy
| | - George Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Imtiaz Wani
- Government Gousia Hospital, Srinagar, Kashmir, India
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Walter Biffl
- Department of Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, San Diego, CA, USA
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Fausto Catena
- General, Emergency and Trauma Surgery Dept., Bufalini Hospital, Cesena, Italy
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Massive duodenal variceal hemorrhage in a patient with prior Roux-en-Y gastric bypass. Radiol Case Rep 2021; 16:3304-3307. [PMID: 34484536 PMCID: PMC8403701 DOI: 10.1016/j.radcr.2021.08.002] [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: 07/31/2021] [Revised: 08/01/2021] [Accepted: 08/01/2021] [Indexed: 12/13/2022] Open
Abstract
Duodenal variceal bleeding is a rare form of variceal bleeding which may be fatal if left untreated. There are no specific guidelines available for their treatment. Medical management, surgical, endoscopic, and interventional radiological procedures have been utilized with varied outcomes. In this case summary we report the successful management of duodenal variceal bleeding in a patient with prior Roux-en-Y gastric bypass . The patient with history of cirrhosis presented with acute gastrointestinal bleeding. Esophagogastroduodenoscopy and colonoscopy could not locate the source of bleeding. Computed tomography of the abdomen demonstrated a large duodenal variceal complex. Interventional radiology (IR) treated the patient with a combination of percutaneous transhepatic embolization and subsequent transjugular intrahepatic portosystemic shunt . No recurrence of gastrointestinal bleeding was noted at follow up. This case demonstrates that percutaneous transhepatic embolization along with transjugular intrahepatic portosystemic shunt may be effective treatment of duodenal variceal bleeding.
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Kim J, Randhawa H, Sands D, Lambe S, Puglia M, Serrano PE, Pinthus JH. Muscle-Invasive Bladder Cancer in Patients with Liver Cirrhosis: A Review of Pertinent Considerations. Bladder Cancer 2021; 7:261-278. [PMID: 38993608 PMCID: PMC11181825 DOI: 10.3233/blc-211536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/09/2021] [Indexed: 11/15/2022]
Abstract
The incidence of liver cirrhosis is increasing worldwide. Patients with cirrhosis are generally at a higher risk of harbouring hepatic and non-hepatic malignancies, including bladder cancer, likely due to the presence of related risk factors such as smoking. Cirrhosis can complicate both the operative and non-surgical management of bladder cancer. For example, cirrhotic patients undergoing abdominal surgery generally demonstrate worse postoperative outcomes, and chemotherapy in patients with cirrhosis often requires dose reduction due to its direct hepatotoxic effects and reduced hepatic clearance. Multiple other considerations in the peri-operative management for cirrhosis patients with muscle-invasive bladder cancer must be taken into account to optimize outcomes in these patients. Unfortunately, the current literature specifically related to the treatment of cirrhotic bladder cancer patients remains sparse. We aim to review the literature on treatment considerations for this patient population with respect to perioperative, surgical, and adjuvant management.
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Affiliation(s)
- John Kim
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - David Sands
- Division of Urology, McMaster University, Hamilton, ON, Canada
| | - Shahid Lambe
- Division of Urology, McMaster University, Hamilton, ON, Canada
- McMaster Institute of Urology, St. Joseph’s Hospital, Hamilton, ON, Canada
| | - Marco Puglia
- Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada
| | | | - Jehonathan H. Pinthus
- Division of Urology, McMaster University, Hamilton, ON, Canada
- Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada
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Maruyama H, Shiina S. Collaterals in portal hypertension: anatomy and clinical relevance. Quant Imaging Med Surg 2021; 11:3867-3881. [PMID: 34341755 DOI: 10.21037/qims-20-1328] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 03/07/2021] [Indexed: 12/14/2022]
Abstract
Portal hypertension is a key pathophysiology of chronic liver diseases typified with cirrhosis or noncirrhotic portal hypertension. The development of collateral vessels is a characteristic feature of impaired portal hemodynamics. The paraumbilical vein (PUV), left gastric vein (LGV), posterior gastric vein (PGV), short gastric vein (SGV), splenorenal shunt (SRS), and inferior mesenteric vein (IMV) are major collaterals, and there are some rare collaterals. The degree and hemodynamics of collateral may affect the portal venous circulation and may compensate for the balance between inflow and outflow volume of the liver. Additionally, the development of collateral shows a relation with the liver function reserve and clinical manifestations such as esophageal varices (EV), gastric varices, rectal varices and the other ectopic varices, hepatic encephalopathy, and prognosis. Furthermore, there may be an interrelationship in the development between different collaterals, showing additional influences on the clinical presentations. Thus, the assessment of collaterals may enhance the understanding of the underlying pathophysiology of the condition of patients with portal hypertension. This review article concluded that each collateral has a specific function depending on the anatomy and hemodynamics and is linked with the relative clinical presentation in patients with portal hypertension. Imaging modalities may be essential for the detection, grading and evaluation of the role of collaterals and may help to understand the pathophysiology of the patient condition. Further investigation in a large-scale study would elucidate the basic and clinical significance of collaterals in patients with portal hypertension and may provide information on how to manage them to improve the prognosis as well as quality of life.
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Affiliation(s)
- Hitoshi Maruyama
- Department of Gastroenterology, Juntendo University, Tokyo, Japan
| | - Shuichiro Shiina
- Department of Gastroenterology, Juntendo University, Tokyo, 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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48
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Abstract
Portosystemic collateralization is usually seen in patients with portal hypertension. Bleeding from the ectopic varices is reportedly rare. We present a case of a 55-year-old gentleman who presented with complaints of bleeding from the umbilicus. On examination, he was tachycardic, hypotensive, and in hypovolemic shock. Bleeding was suspected to be from the umbilical varices. Contrast-enhanced computed tomography of the abdomen with abdominal angiography revealed a cirrhotic liver with partial thrombosis of the portal vein with collaterals in the perigastric, lower esophageal, peripancreatic, splenic and mesenteric, umbilical and paraumbilical collaterals with recanalization of the umbilical vein. The bleeder was identified to be the collateral at the umbilical region from the superior mesenteric vein. The patient was treated with a Doppler-guided injection of a sclerosant into the collateral, thereby achieving successful hemostasis.
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Affiliation(s)
- Nagarajan Raj Kumar
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Muhamed Tajudeen
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
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Naidoo SF, Obuch JC. Late Manifestation of Massive Jejunal and Cecal Varices Post Liver and Small Bowel Transplantation in a Patient With Microvillus Inclusion Disease. Cureus 2021; 13:e15884. [PMID: 34327104 PMCID: PMC8304195 DOI: 10.7759/cureus.15884] [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] [Accepted: 06/24/2021] [Indexed: 11/16/2022] Open
Abstract
We report the case of an 18-year-old male with a medical history of microvillous inclusion disease (MID) and notable surgical history of small bowel, liver, and pancreas transplant who presented with massive jejunal and cecal varices. Endoscopy findings demonstrated a large grape-like cluster, with subsequent CT angiography (CTA) showing other variceal lesions in the cecum. The patient was transferred to the original transplant center for recommended open surgical evaluation and combined interventional radiology (IR) embolization of varices. MID is a rare genetic disorder caused by mutations in the Myosin VB (MYO5B) gene leading to a lack of myosin Vb. Patients subsequently develop liver damage at birth, which necessitates a small bowel/liver transplant in childhood.
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Affiliation(s)
- Shiva F Naidoo
- Internal Medicine, Geisinger Health System, Wilkes-Barre, USA
| | - Joshua C Obuch
- Gastroenterology, Geisinger Health System, Wilkes-Barre, USA
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Chevallier O, Guillen K, Comby PO, Mouillot T, Falvo N, Bardou M, Midulla M, Aho-Glélé LS, Loffroy R. Safety, Efficacy, and Outcomes of N-Butyl Cyanoacrylate Glue Injection through the Endoscopic or Radiologic Route for Variceal Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:jcm10112298. [PMID: 34070534 PMCID: PMC8198169 DOI: 10.3390/jcm10112298] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 05/17/2021] [Accepted: 05/17/2021] [Indexed: 12/12/2022] Open
Abstract
We performed a systematic review and meta-analysis of published studies to assess the efficacy, safety, and outcomes of N-butyl cyanoacrylate (NBCA) injection for the treatment of variceal gastrointestinal bleeding (GIB). The MEDLINE/PubMed, EMBASE, and SCOPUS databases were searched for English-language studies published from January 1980 to December 2019 and including patients who had injection of NBCA for variceal GIB. Two independent reviewers extracted and evaluated the data from eligible studies. Exclusion criteria were sample size < 5, article reporting the use of NBCA with other embolic agents, no extractable data, and duplicate reports. NBCA was injected during endoscopy in 42 studies and through a direct percutaneous approach for stomal varices in 1 study. The study’s endpoints were: Technical success, 30-day rebleeding, and 30-day overall and major complications. The estimated overall rates were computed with 95% confidence intervals, based on each study rate, weighted by the number of patients involved in each study. In total, 43 studies with 3484 patients were included. The technical success rate was 94.1% (95% CI: 91.6–96.1%), the 30-day rebleeding rate was 24.2% (18.9–29.9%), and 30-day overall and major complications occurred in 15.9% (11.2–21.3%) and 5.3% (3.3–7.8%) of patients, respectively. For treating variceal GIB, NBCA injection is a safe and effective method that demonstrates high technical success rate and very low major complication rate.
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Affiliation(s)
- Olivier Chevallier
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (O.C.); (K.G.); (N.F.); (M.M.)
| | - Kévin Guillen
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (O.C.); (K.G.); (N.F.); (M.M.)
| | - Pierre-Olivier Comby
- Department of Neuroradiology and Emergency Radiology, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France;
| | - Thomas Mouillot
- Department of Gastroenterology and Hepatology, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (T.M.); (M.B.)
| | - Nicolas Falvo
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (O.C.); (K.G.); (N.F.); (M.M.)
| | - Marc Bardou
- Department of Gastroenterology and Hepatology, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (T.M.); (M.B.)
| | - Marco Midulla
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (O.C.); (K.G.); (N.F.); (M.M.)
| | - Ludwig-Serge Aho-Glélé
- Department of Biostatistics and Epidemiology, François-Mitterrand University Hospital, 14 Rue Paul, Gaffarel, BP 77908, 21079 Dijon, France;
| | - Romaric Loffroy
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (O.C.); (K.G.); (N.F.); (M.M.)
- Correspondence: ; Tel.: +33-380-293-358
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