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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: 11] [Impact Index Per Article: 11.0] [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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2
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Jamwal KD, Padhan RK, Sharma A, Sharma MK. Endoscopic ultrasound-guided coiling and glue is safe and superior to endoscopic glue injection in gastric varices with severe liver disease: a retrospective case control study. Clin Endosc 2023; 56:65-74. [PMID: 36594180 PMCID: PMC9902678 DOI: 10.5946/ce.2021.119] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 10/04/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND/AIMS Gastric varices (GV) are present in 25% of cirrhotic patients with high rates of rebleeding and mortality. Data on endoscopic ultrasound (EUS)-guided treatment in severe liver disease (model for end stage liver disease sodium [MELD-Na] >18 and Child-Turcotte-Pugh [CTP] C with GV) are scarce. Thus, we performed a retrospective comparison of endoscopic glue injection with EUS-guided therapy in cirrhotic patients with large GV. METHODS A retrospective study was performed in the tertiary hospitals of India. A total of 80 patients were recruited. The inclusion criteria were gastroesophageal varices type 2, isolated gastric varices type 1, bleeding within 6 weeks, size of GV >10 mm, and a MELD-Na >18. Treatment outcomes and complications of endoscopic glue injection and EUS-guided GV therapy were compared. RESULTS In this study, the patients' age, sex, liver disease severity (CTP, MELD-Na) and clinical parameters were comparable. The median number of procedures, injected glue volume, complications, and GV obturation were better in the EUS group, respectively. On subgroup analysis of the EUS method (e.g., direct gastric fundus vs. paragastric collateral [PGC] coil placement), PGC coil placement showed decreased coil requirement, less injected glue volume, decreased luminal coil extrusion, and increased successful GV obturation. CONCLUSION EUS-guided treatment is more efficient and safer, and requires a smaller number of treatment sessions, as compared to endoscopic treatment in severe liver disease patients with large GV. Furthermore, PGC coil placement increases the complete obliteration of GV.
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Affiliation(s)
- Kapil D. Jamwal
- Department of Gastroenterology, Artemis Hospitals, Gurugram, India,Institute of Liver and Biliary Sciences, New Delhi, India,Correspondence: Kapil D. Jamwal Department of Gastroenterology, Artemis Hospitals, Sector 51, Gurugram, Haryana 122001, India E-mail:
| | - Rajesh K. Padhan
- Department of Gastroenterology, Artemis Hospitals, Gurugram, India
| | - Atul Sharma
- Department of Gastroenterology, Artemis Hospitals, Gurugram, India
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Chooklin SM, Chuklin SS. Esophageal and stomach varices: physiological and anatomical features of formation. KLINICHESKAIA KHIRURGIIA 2022. [DOI: 10.26779/2522-1396.2022.7-8.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Esophageal and stomach varices: physiological and anatomical features of formation
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4
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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 2022; 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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5
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Cocchia R, Chianese S, Lombardi G, Romano L, Capone V, Amitrano L, Bennato R, Ranieri B, Russo G, Mauro C, Bossone E. Severe Stenosis of Mitral Bioprosthetic Valve Thrombosis in a Patient with HCV-Related Cirrhosis and Duodenal Variceal Bleeding: The Deadly Triad. Clin Pract 2022; 12:686-691. [PMID: 36136865 PMCID: PMC9498389 DOI: 10.3390/clinpract12050071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 08/02/2022] [Accepted: 08/24/2022] [Indexed: 11/16/2022] Open
Abstract
Bioprosthetic valve thrombosis (BPVT) is considered a relatively rare but life-threatening clinical entity. Thus, there is the need of high clinical suspicion in order to make a timely diagnosis and related appropriate therapeutic interventions. In this regard, the management of BPVT is high risk, whatever the option taken (surgery and/or systemic fibrinolysis). The presence of severe comorbidities—as decompensated cirrhosis—further complicates the clinical decision-making process, calling for a patient-tailored integrated multidisciplinary approach. We report a challenging case of a 45-year-old patient with mitral bioprosthetic valve thrombosis and hepatitis C virus (HCV)-related cirrhosis complicated by active duodenal variceal bleeding.
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Affiliation(s)
| | | | - Giovanni Lombardi
- Gastroenterology Unit, Antonio Cardarelli Hospital, 80131 Naples, Italy
| | - Luigia Romano
- Department of General and Emergency Radiology, Antonio Cardarelli Hospital, 80131 Naples, Italy
| | - Valentina Capone
- Cardiology Unit, Antonio Cardarelli Hospital, 80131 Naples, Italy
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Lucio Amitrano
- Gastroenterology Unit, Antonio Cardarelli Hospital, 80131 Naples, Italy
| | - Raffaele Bennato
- Gastroenterology Unit, Antonio Cardarelli Hospital, 80131 Naples, Italy
| | - Brigida Ranieri
- IRCCS SYNLAB SDN, Via Emanuele Gianturco, 80143 Naples, Italy
| | - Giuseppe Russo
- Chief Medical Officer, Antonio Cardarelli Hospital, 80131 Naples, Italy
| | - Ciro Mauro
- Cardiology Unit, Antonio Cardarelli Hospital, 80131 Naples, Italy
| | - Eduardo Bossone
- Cardiology Unit, Antonio Cardarelli Hospital, 80131 Naples, Italy
- Correspondence:
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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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7
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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: 1.0] [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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8
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Rudnick SR, Conway JD, Russo MW. Current state of endohepatology: Diagnosis and treatment of portal hypertension and its complications with endoscopic ultrasound. World J Hepatol 2021; 13:887-895. [PMID: 34552695 PMCID: PMC8422923 DOI: 10.4254/wjh.v13.i8.887] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/18/2021] [Accepted: 08/04/2021] [Indexed: 02/06/2023] Open
Abstract
The diagnosis and management of cirrhosis and portal hypertension (PH) with its complications including variceal hemorrhage, ascites, and hepatic encephalopathy continues to evolve. Although there are established “standards of care” in liver biopsy and measurement of PH, gastric varices remain an area without a universally accepted therapeutic approach. The concept of “Endo Hepatology” has been used to describe of the applications of endoscopic ultrasound (EUS) to these challenges. EUS-liver biopsy (EUS-LB) offers an alternative to percutaneous and transjuglar liver biopsy without compromising safety or efficacy, and with added advantages including the potential to reduce sampling error by allowing biopsies in both hepatic lobes. Furthermore, EUS-LB can be performed during the same procedure as EUS-guided portal pressure gradient (PPG) measurements, allowing for the collection of valuable diagnostic and prognostic data. EUS-guided PPG measurements provide an appealing alternative to the transjugular approach, with proposed advantages including the ability to directly measure portal vein pressure. In addition, EUS-guided treatment of gastric varices (GV) offers several possible advantages to current therapies. EUS-guided treatment of GV allows detailed assessment of the vascular anatomy, similar efficacy and safety to current therapies, and allows the evaluation of treatment effect through doppler ultrasound visualization. The appropriate selection of patients for these procedures is paramount to ensuring generation of useful clinical data and patient safety.
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Affiliation(s)
- Sean R Rudnick
- Section on Gastroenterology & Hepatology, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Jason D Conway
- Section on Gastroenterology & Hepatology, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Mark W Russo
- Department of Hepatology, Atrium Health, Carolinas Medical Center, Charlotte, NC 28204, United States
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9
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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: 15] [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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10
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Schmidt SC, Möller J, Bürgel N, Radke C, Beyer L, Marusch F. Minimally invasive accessory splenectomy for recurrent gastric variceal bleeding due to left-sided portal hypertension: report of the first case. J Surg Case Rep 2021; 2021:rjab008. [PMID: 33604020 PMCID: PMC7877905 DOI: 10.1093/jscr/rjab008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 01/06/2021] [Indexed: 02/06/2023] Open
Abstract
Upper gastrointestinal bleeding from esophagogastric varices is a common scenario, especially in patients with portal hypertension induced by liver cirrhosis or other diseases with thrombosis of the splenic vein. However, accessory spleen as pathophysiological cause of a regional, left-sided portal hypertension and consecutive development of isolated gastric varices is rare. We report a case of recurrent gastric variceal bleeding resulting from sinistral portal hypertension associated with an accessory spleen in a patient who had traumatic splenectomy many decades before. The accessory spleen is an extremely rare cause for the development of regional, left-sided portal hypertension leading to isolated gastric varices. Minimally invasive splenectomy is a safe and efficient treatment option.
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Affiliation(s)
- S C Schmidt
- Department for Hepato-Pancreato-Biliary Surgery, Ernst von Bergmann Clinic, Potsdam, Germany
| | - J Möller
- Department for Hepato-Pancreato-Biliary Surgery, Ernst von Bergmann Clinic, Potsdam, Germany
| | - N Bürgel
- Department for Gastroenterology and Infectiology, Ernst von Bergmann Clinic, Potsdam, Germany
| | - C Radke
- Institute for Pathology, Ernst von Bergmann Clinic, Potsdam, Germany
| | - L Beyer
- Department for Radiology, Ernst von Bergmann Clinic, Potsdam, Germany
| | - F Marusch
- Clinic for General-, Visceral-, Vascular- and Thoracic Surgery, Ernst von Bergmann Clinic, Potsdam, Germany
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11
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Kim HW, Yoon JS, Yu SJ, Kim TH, Seol JH, Kim D, Jung JY, Jeong PH, Kwon H, Lee HS, Lee SH, Choi JS, Park SJ, Jee SR, Lee YJ, Seol SY. Percutaneous Trans-splenic Obliteration for Duodenal Variceal bleeding: A Case Report. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2020; 76:331-336. [PMID: 33361709 DOI: 10.4166/kjg.2020.123] [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: 08/15/2020] [Revised: 09/08/2020] [Accepted: 09/15/2020] [Indexed: 06/12/2023]
Abstract
Duodenal varices are a serious complication of portal hypertension. Bleeding from duodenal varices is rare, but when bleeding does occur, it is massive and can be fatal. Unfortunately, the optimal therapeutic modality for duodenal variceal bleeding is unclear. This paper presents a patient with duodenal variceal bleeding that was managed successfully using percutaneous trans-splenic variceal obliteration (PTVO). A 56-year-old man with a history of alcoholic cirrhosis presented with a 6-day history of melena. Emergency esophagogastroduodenoscopy revealed a large, bluish mass with a nipple sign in the second portion of the duodenum. Coil embolization of the duodenal varix was performed via a trans-splenic approach (i.e., PTVO). The patient no longer complained of melena after treatment. The duodenal varix was no longer visible at the follow-up esophagogastroduodenoscopy performed three months after PTVO. The use of PTVO might be a viable option for the treatment of duodenal variceal bleeding.
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Affiliation(s)
- Hyun Woo Kim
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Jun Sik Yoon
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Seung Jung Yu
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Tae Heon Kim
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Jae Heon Seol
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Dan Kim
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Jun Young Jung
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Pyeong Hwa Jeong
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Hoon Kwon
- Department of Radiology, Pusan National University Hospital, Busan, Korea
| | - Hong Sub Lee
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Sang Heon Lee
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Jung Sik Choi
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Sung Jae Park
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Sam Ryong Jee
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Youn Jae Lee
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
| | - Sang Yong Seol
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Kore
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12
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Philips CA, Ahamed R, Rajesh S, George T, Mohanan M, Augustine P. Beyond the scope and the glue: update on evaluation and management of gastric varices. BMC Gastroenterol 2020; 20:361. [PMID: 33126847 PMCID: PMC7602314 DOI: 10.1186/s12876-020-01513-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/23/2020] [Indexed: 02/08/2023] Open
Abstract
Gastric varices are encountered less frequently than esophageal varices. Nonetheless, gastric variceal bleeding is more severe and associated with worse outcomes. Conventionally, gastric varices have been described based on the location and extent and endoscopic treatments offered based on these descriptions. With improved understanding of portal hypertension and the dynamic physiology of collateral circulation, gastric variceal classification has been refined to include inflow and outflow based hemodynamic pathways. These have led to an improvement in the management of gastric variceal disease through newer modalities of treatment such as endoscopic ultrasound-guided glue-coiling combination therapy and the emergence of highly effective endovascular treatments such as shunt and variceal complex embolization with or without transjugular intrahepatic portosystemic shunt (TIPS) placement in patients who are deemed ‘difficult’ to manage the traditional way. Furthermore, the decisions regarding TIPS and additional endovascular procedures in patients with gastric variceal bleeding have changed after the emergence of ‘portal hypertension theories’ of proximity, throughput, and recruitment. The hemodynamic classification, grounded on novel theories and its cognizance, can help in identifying patients at baseline, in whom conventional treatment could fail. In this exhaustive review, we discuss the conventional and hemodynamic diagnosis of gastric varices concerning new classifications; explore and illustrate new ‘portal hypertension theories’ of gastric variceal disease and corresponding management and shed light on current evidence-based treatments through a ‘new’ algorithmic approach, established on hemodynamic physiology of gastric varices.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit and Monarch Liver Laboratory, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India.
| | - Rizwan Ahamed
- Gastroenterology and Advanced G.I Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
| | - Sasidharan Rajesh
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
| | - Tom George
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
| | - Meera Mohanan
- Anaesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
| | - Philip Augustine
- Gastroenterology and Advanced G.I Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
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Liu M, Li W, Li P, Ma F, Xue H. Ectopic duodenal variceal bleed successfully treated with TIPS and 2 years follow-up: A Case Report. Radiol Case Rep 2020; 15:1570-1574. [PMID: 32685071 PMCID: PMC7355383 DOI: 10.1016/j.radcr.2020.04.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/18/2020] [Accepted: 04/18/2020] [Indexed: 12/24/2022] Open
Abstract
Duodenal varices are an uncommon presentation of portal hypertension and can result in significant gastrointestinal bleeding with a high mortality. Diagnosis can be difficult and therapeutic options limited. We present a case of upper gastrointestinal bleeding in a woman aged 54 years with primary biliary cholangitis who was ultimately diagnosed with ectopic duodenal variceal bleed, which was successfully treated with transjugular intrahepatic portosystemic shunt. Transjugular intrahepatic portosystemic shunt provide an effective treatment for ectopic duodenal variceal bleed caused by liver cirrhosis, though interventional radiologists need to remain aware of and vigilant for the complications and risks of this treatment option.
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Shi Q, Zhou C, Liu J, Qian K, Liu Y, Song S, Xiong B. Transjugular intrahepatic portosystemic shunt for repeated bleeding of hemorrhoids caused by severe portal hypertension with ectopic varices: A case report. J Interv Med 2020; 3:157-160. [PMID: 34805928 PMCID: PMC8562226 DOI: 10.1016/j.jimed.2020.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Severe portal hypertension is life-threatening and can bring adverse complications such as ascites, gastroesophageal varices, and edema. It can, even cause variceal hemorrhage, which may lead to a high risk of death. There is a rare incidence in bleeding of hemorrhoids caused by severe ectopic varices. Case presentation We report the case of a female patient with a 20-year history of hepatitis B virus infection who presented with repeated bleeding of hemorrhoids caused by severe portal hypertension with ectopic varices that is connection between the superior mesenteric vein and rectal venous plexus. Laboratory results revealed a hemoglobin level of 74 g/L. Finally, the patient was successfully treated with transjugular intrahepatic portosystemic shunt (TIPSS) placement without variceal embolization after a multidisciplinary comprehensive opinion. In the two-month follow-up period, the patient had failed to develop hepatic encephalopathy or hematochezia, and computed tomography venography (CTV) indicated that the stent was unobstructed and ascites disappeared. Conclusions TIPSS placement is effective for the case, and we hope this case can help improve clinicians’ awareness of hemorrhoidal bleeding with severe portal hypertension. Portal hypertension should also be considered during the diagnosis and treatment, as opposed to hemorrhoidal bleeding alone. Moreover, abdominal CTV is recommended as an effective imaging examination method to determine the stent status after operation.
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Affiliation(s)
- Qin Shi
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Chen Zhou
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Jiacheng Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Kun Qian
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Yiming Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Songlin Song
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Bin Xiong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
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Magaz M, Baiges A, Hernández-Gea V. Precision medicine in variceal bleeding: Are we there yet? J Hepatol 2020; 72:774-784. [PMID: 31981725 DOI: 10.1016/j.jhep.2020.01.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 12/14/2022]
Abstract
Variceal bleeding is one of the most feared complications of portal hypertension in patients with cirrhosis because of its deleterious impact on prognosis. Adequate management of patients at risk of developing variceal bleeding includes the prevention of the first episode of variceal bleeding and rebleeding, and is crucial in modifying prognosis. The presence of clinically significant portal hypertension is the main factor determining the risk of development of varices and other liver-related decompensations; therefore, it should be carefully screened for and monitored. Treating patients with clinically significant portal hypertension based on their individual risk of portal hypertension-related bleeding undoubtedly improves prognosis. The evaluation of liver haemodynamics and liver function can stratify patients according to their risk of bleeding and are no question useful tools to guide therapy in an individualised manner. That said, recent data support the idea that tailoring therapy to patient characteristics may effectively impact on prognosis and increase survival in all clinical scenarios. This review will focus on evaluating the available evidence supporting the use of individual risk characteristics for clinical decision-making and their impact on clinical outcome and survival. In primary prophylaxis, identification and treatment of patients with clinically significant portal hypertension improves decompensation-free survival. In the setting of acute variceal bleeding, the risk of failure and rebleeding can be easily predicted, allowing for early escalation of treatment (i.e. pre-emptive transjugular intrahepatic portosystemic shunt) which can improve survival in appropriate candidates. Stratifying the risk of recurrent variceal bleeding based on liver function and haemodynamic response to non-selective beta-blockers allows for tailored treatment, thereby increasing survival and avoiding adverse events.
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Affiliation(s)
- Marta Magaz
- Unidad de Hemodinámica Hepática, Servicio de Hepatología, Hospital Clínic, Universidad de Barcelona, Instituto de Investigaciones Biomédicas Augusto Pi Suñer (IDIBAPS), Barcelona, Spain
| | - Anna Baiges
- Unidad de Hemodinámica Hepática, Servicio de Hepatología, Hospital Clínic, Universidad de Barcelona, Instituto de Investigaciones Biomédicas Augusto Pi Suñer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
| | - Virginia Hernández-Gea
- Unidad de Hemodinámica Hepática, Servicio de Hepatología, Hospital Clínic, Universidad de Barcelona, Instituto de Investigaciones Biomédicas Augusto Pi Suñer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain.
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Bleeding from gastrointestinal ectopic varices is not associated with haemorrhage from oesophageal or gastric varices. GASTROENTEROLOGY REVIEW 2020; 15:60-64. [PMID: 32215130 PMCID: PMC7089859 DOI: 10.5114/pg.2020.93632] [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: 12/05/2018] [Accepted: 05/27/2019] [Indexed: 11/21/2022]
Abstract
Introduction Ectopic varices are those that appear in a different region of the gastroesophageal junction. Bleeding from ectopic varices is rare but is usually massive and deadly. Aim To identify the possible factors that cause bleeding from ectopic varices in patients with portal hypertension. Material and methods A cross-sectional and retrospective study; the data were collected between January 2004 and June 2014. We included patients with portal hypertension and gastrointestinal ectopic varices diagnosed by endoscopy. Results We found 31 patients with gastrointestinal ectopic varices. Of these, 25 had liver cirrhosis, and six showed non-cirrhotic portal hypertension. There were 16 men and 15 women in the study. The median age of the patients was 60 years (range minimum–maximum of 27 to 80 years). Nineteen (61%) patients had rectal varices, 10 (32%) had duodenal varices, 1 (3%) had ileal varices, and 1 (3%) had colonic varices. We found bleeding in 4 (13%) of the 31 patients with ectopic varices; two belonged to the cirrhosis group, and the other two were from the non-cirrhotic portal hypertension group. Three of the 4 patients with bleeding from gastrointestinal ectopic varices had exhibited haemorrhage from oesophageal varices (odds ratio = 4.09, 95% CI: 0.37–44.78, p = 0.249), but none of them showed bleeding from gastric varices. Conclusions Bleeding from gastrointestinal ectopic varices is not necessarily associated with bleeding from oesophageal or gastric varices.
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Rodrigues SG, Mendoza YP, Bosch J. Beta-blockers in cirrhosis: Evidence-based indications and limitations. JHEP Rep 2020; 2:100063. [PMID: 32039404 PMCID: PMC7005550 DOI: 10.1016/j.jhepr.2019.12.001] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 11/29/2019] [Accepted: 12/03/2019] [Indexed: 02/07/2023] Open
Abstract
Non-selective beta-blockers (NSBBs) are the mainstay of treatment for portal hypertension in the setting of liver cirrhosis. Randomised controlled trials demonstrated their efficacy in preventing initial variceal bleeding and subsequent rebleeding. Recent evidence indicates that NSBBs could prevent liver decompensation in patients with compensated cirrhosis. Despite solid data favouring NSBB use in cirrhosis, some studies have highlighted relevant safety issues in patients with end-stage liver disease, particularly with refractory ascites and infection. This review summarises the evidence supporting current recommendations and restrictions of NSBB use in patients with cirrhosis.
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Key Words
- ACLF
- ACLF, acute-on-chronic liver failure
- AKI, acute kidney injury
- ALD, alcohol-related liver disease
- ARD, absolute risk difference
- AV, atrioventricular
- EBL, endoscopic band ligation
- GOV, gastroesophageal varices
- HRS, hepatorenal syndrome
- HVPG, hepatic venous pressure gradient
- IGV, isolated gastric varices
- IRR, incidence rate ratio
- ISMN, isosorbide mononitrate
- MAP, mean arterial pressure
- NASH, non-alcoholic steatohepatitis
- NNH, number needed to harm
- NNT, number needed to treat
- NR, not reported
- NSBBs
- NSBBs, non-selective beta-blockers
- OR, odds ratio
- PH, portal hypertension
- PHG, portal hypertensive gastropathy
- RCT, randomised controlled trials
- RR, risk ratio
- SBP, spontaneous bacterial peritonitis
- SCL, sclerotherapy
- TIPS, transjugular intrahepatic portosystemic shunt
- ascites
- cirrhosis
- portal hypertension
- spontaneous bacterial peritonitis
- varices
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Affiliation(s)
- Susana G. Rodrigues
- Swiss Liver Center, UVCM, Inselspital, Bern University Hospital, Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Yuly P. Mendoza
- Swiss Liver Center, UVCM, Inselspital, Bern University Hospital, Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Jaime Bosch
- Swiss Liver Center, UVCM, Inselspital, Bern University Hospital, Department of Biomedical Research, University of Bern, Bern, Switzerland
- Corresponding author. Address: Swiss Liver Center, UVCM, Inselspital, Bern University Hospital, Department of Biomedical Research, University of Bern, Bern, Switzerland.
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KASL clinical practice guidelines for liver cirrhosis: Varices, hepatic encephalopathy, and related complications. Clin Mol Hepatol 2020; 26:83-127. [PMID: 31918536 PMCID: PMC7160350 DOI: 10.3350/cmh.2019.0010n] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 02/06/2023] Open
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Park SJ, Kim YH, Kang UR, Ji SW. Successful Treatment of Duodenal Variceal Bleeding with Coil-Assisted Retrograde Transvenous Obliteration: A Case Report. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2020; 81:231-236. [PMID: 36238109 PMCID: PMC9432092 DOI: 10.3348/jksr.2020.81.1.231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/22/2019] [Accepted: 06/03/2019] [Indexed: 11/17/2022]
Abstract
십이지장 정맥류는 간경화증에 의한 문맥압 고혈압 환자에서 발생할 수 있으며, 치명적인 심한 상부 위장관 출혈을 일으킬 수 있으나 아직까지 명확한 치료 지침이 정립되어 있지는 않다. 일차적으로 내시경으로 치료를 시도하고 지혈 실패 시 목정맥경유간속문맥전신순환연결술, 풍선 혹은 혈관 마개를 이용한 역행성 경정맥 폐색술, 피부간경유 폐색술 등과 같은 중재적 치료를 고려할 수 있다. 저자들은 내시경적 치료에 실패한 십이지장 정맥류 출혈 환자에게 저하된 간 기능과 해부학적인 구조의 제한으로 인해 코일을 이용한 역행성 경정맥 폐색술을 시행하여 성공적으로 치료한 1예를 경험하였기에 이를 보고하고자 한다.
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Affiliation(s)
- Se Jin Park
- Department of Radiology, Daegu Catholic University College of Medicine, Daegu, Korea
| | - Young Hwan Kim
- Department of Radiology, Daegu Catholic University College of Medicine, Daegu, Korea
| | - Ung Rae Kang
- Department of Radiology, Daegu Catholic University College of Medicine, Daegu, Korea
| | - Seung Woo Ji
- Department of Radiology, CHA Gumi Medical Center, CHA University, Gumi, Korea
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Balloon Retrograde Transvenous Obliteration Versus Endoscopic Cyanoacrylate in Bleeding Gastric Varices: Comparison of Rebleeding and Mortality with Extended Follow-up. J Vasc Interv Radiol 2019; 30:187-194. [PMID: 30717949 DOI: 10.1016/j.jvir.2018.12.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 12/05/2018] [Accepted: 12/06/2018] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To assess short- and long-term mortality and rebleeding with endoscopic cyanoacrylate (EC) versus balloon-occluded retrograde transvenous obliteration (BRTO). MATERIALS AND METHODS A retrospective cohort comparison was conducted of 90 EC patients and 71 BRTO patients from 1997 through 2015 with portal hypertension who presented due to endoscopically confirmed bleeding cardiofundal gastric varices. Patients underwent either endoscopic intra-varix injection of 4-carbon-n-butyl-2-cyanoacrylate or sclerosis with sodium tetradecyl sulfate with balloon occlusion for primary variceal treatment. RESULTS Seventy-one BRTO patients and 90 EC patients, of whom 89% had cirrhosis and 35% were women, were included, with a respective average Model for End-Stage Liver Disease (MELD) score of 13.4 and 14.4, respectively. Mortality at 6 weeks was 14.4% for EC patients and 13.1% for BRTO patients (Kaplan-Meier/Wilcoxon, P = .85). No long-term mortality difference was observed (Cox hazard ratio [HR] = 0.89, P = .64). Also, 5.1% of EC patients and 3.5% of BRTO patients (Kaplan-Meier/Wilcoxon, P = .62) rebled at 6 weeks, but at 1 year, 22.0% of EC patients and 3.5% of BRTO patients had rebled (Kaplan-Meier/Wilcoxon, P < .01). Lower rates of long-term rebleeding were found with BRTO (Cox HR = 0.25, P = .03). No difference was seen in the rate of new portal hypertensive complications (Cox HR = 1.21, P = .464). However, 16/71 patients who underwent BRTO had simultaneous transjugular intrahepatic portosystemic shunt. Age, sex, MELD score, and presence of cirrhosis were the primary predictors of mortality. One death in the EC group and 5 deaths in the BRTO group were deemed to be procedurally related (chi-square, P = .088). CONCLUSIONS BRTO is associated with a lower rate of rebleeding but no change in mortality.
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Zhang K, Sun X, Wang G, Zhang M, Wu Z, Tian X, Zhang C. Treatment outcomes of percutaneous transhepatic variceal embolization versus transjugular intrahepatic portosystemic shunt for gastric variceal bleeding. Medicine (Baltimore) 2019; 98:e15464. [PMID: 31045824 PMCID: PMC6504295 DOI: 10.1097/md.0000000000015464] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
There have been few studies comparing percutaneous transhepatic variceal embolization (PTVE) and transjugular intrahepatic portosystemic shunt (TIPS) for the prevention of recurrent gastric variceal bleeding (GVB).Compare the outcomes of these 2 procedures in patients with GVB.A total of 74 cirrhosis patients with GVB who underwent TIPS and modified PTVE were enrolled. The rebleeding and mortality rates, portal vein pressure (PVP) variation, and rates of hepatic encephalopathy (HE) were compared between the 2 groups.A total of 43 PTVE and 31 TIPS patients were enrolled in this study. The difference of rebleeding rate in the 2 groups was not statistically significant (P = .190). The difference of early rebleeding rates and cumulative rebleeding-free rates were all not statistically significant (P = .256, P = .200). The difference of mortality rates in the 2 groups was not statistically significant (χ = 1.206, P = .272). The rate of HE in TIPS group was statistically higher than that in PTVE group (P < .0001).Both PTVE and TIPS were effective for preventing rebleeding of GVs. There were no significant differences in rebleeding and mortality rates. The incidence of HE after TIPS was higher than PTVE.
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Affiliation(s)
- Kai Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
| | - Xiaoyan Sun
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
| | - Guangchuan Wang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
| | - Mingyan Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
| | - Zhe Wu
- Department of Gastroenterology, Ningbo Medical Center Lihuili Hospital, Ningbo, China
| | - Xiangguo Tian
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
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Nett A, Binmoeller KF. Endoscopic Management of Portal Hypertension-related Bleeding. Gastrointest Endosc Clin N Am 2019; 29:321-337. [PMID: 30846156 DOI: 10.1016/j.giec.2018.12.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Gastrointestinal bleeding as a sequela of portal hypertension can be catastrophic and fatal. Endoscopic and endosonographic therapy play a critical role in management of such bleeding- both for hemostasis of active bleeding and bleeding prophylaxis. Variceal band ligation is established as the standard intervention for esophageal varices. For other sources of portal hypertension-related bleeding, or for salvage therapy for esophageal varices, a variety of endoscopic techniques are available. Endoscopic ultrasound may be used to enhance endoscopic management, particularly for gastric and ectopic varices.
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Affiliation(s)
- Andrew Nett
- Interventional Endoscopy Services, California Pacific Medical Center, 2351 Clay Street, 6th Floor Suite 600, San Francisco, CA 94115, USA.
| | - Kenneth F Binmoeller
- Interventional Endoscopy Services, California Pacific Medical Center, 2351 Clay Street, 6th Floor Suite 600, San Francisco, CA 94115, USA
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Sørensen M, Larsen LP, Villadsen GE, Aagaard NK, Grønbæk H, Keiding S, Vilstrup H. β-Blockers Improve Presinusoidal Portal Hypertension. Dig Dis Sci 2018; 63:3153-3157. [PMID: 30003386 PMCID: PMC6182445 DOI: 10.1007/s10620-018-5186-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 06/25/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Presinusoidal portal hypertension is a clinically important cause of gastric and gastroesophageal varices. Whereas β-blockers have an established prophylactic role against bleeding from esophageal and gastric varices in portal hypertension due to cirrhosis, the effect on presinusoidal portal hypertension is unknown. AIMS To evaluate the hemodynamic effect of β-blockers in non-cirrhotic patients with presinusoidal portal hypertension. METHODS We measured the blood pressure gradient from spleen pulp to free hepatic vein in 12 patients with presinusoidal portal hypertension by combined hepatic vein catheterization and spleen pulp puncture while on and off β-blocker treatment (random sequence). RESULTS The β-blockers reduced the gradient from a mean off-treatment value of 32 mm Hg to a on-treatment value of 26 mm Hg (P < 0.05) with a reduction of at least 20% in five patients (42%). CONCLUSIONS β-blocker treatment caused a clinically significant reduction in the pressure gradient from spleen pulp to the free hepatic vein. This finding supports the recommendation for prophylactic β-blockage in patients with presinusoidal portal hypertension.
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Affiliation(s)
- Michael Sørensen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99; C116, 8000 Aarhus, Denmark
| | - Lars P. Larsen
- Department of Radiology, Aarhus University Hospital, 8000 Aarhus, Denmark
| | - Gerda E. Villadsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99; C116, 8000 Aarhus, Denmark
| | - Niels K. Aagaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99; C116, 8000 Aarhus, Denmark
| | - Henning Grønbæk
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99; C116, 8000 Aarhus, Denmark
| | - Susanne Keiding
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99; C116, 8000 Aarhus, Denmark
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99; C116, 8000 Aarhus, Denmark
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Bittencourt PL, Strauss E, Farias AQ, Mattos AAD, Lopes EP. VARICEAL BLEEDING: UPDATE OF RECOMMENDATIONS FROM THE BRAZILIAN ASSOCIATION OF HEPATOLOGY. ARQUIVOS DE GASTROENTEROLOGIA 2017; 54:349-355. [PMID: 28977116 DOI: 10.1590/s0004-2803.201700000-79] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 08/11/2017] [Indexed: 12/18/2022]
Abstract
Since the publication of the Brazilian Association of Hepatology recommendations for the prevention and treatment of variceal bleeding in 2010, new evidence-based data were reported in the literature. This has changed our current management for portal hypertension. This review updates the previous recommendations. It takes the new prognostic staging of cirrhosis into account allowing tailored treatment for advanced fibrosis, compensated or decompensated cirrhosis. An organizing panel of five experts reviewed all recommendations according to available data, which were subsequently scrutinized by all members of the Brazilian Association of Hepatology using a web-based approach. The accepted recommendations are presented in this manuscript.
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Affiliation(s)
| | | | - Alberto Queiroz Farias
- Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
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Laparotomy-Assisted Endoscopic Injection of Jejunal Varices for Overt Small Bowel Bleeding. ACG Case Rep J 2017; 4:e79. [PMID: 28670593 PMCID: PMC5482908 DOI: 10.14309/crj.2017.79] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 05/05/2017] [Indexed: 12/22/2022] Open
Abstract
A 54-year old male liver transplant recipient with Roux-en-Y choledochojejunostomy was admitted for symptomatic anemia. Despite endoscopies and a bleeding scan, active bleeding was not visualized. Angiography and abdominal computed tomography demonstrated possible jejunal varices at the choledochojejunal anastomosis. Double-balloon enteroscopy demonstrated varices with overlying clots in the Roux limb at the anastomosis. Due to the extensive loop formation and unstable position of the endoscope, therapeutic intervention could not be performed. Operative enterotomy and intraoperative endoscopy were subsequently required. A varix in the jejunum with venous flow on Doppler was injected twice with cyanoacrylate and successfully obturated.
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Gulamhusein AF, Kamath PS. The epidemiology and pathogenesis of gastrointestinal varices. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017. [DOI: 10.1016/j.tgie.2017.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Fagiuoli S, Bruno R, Debernardi Venon W, Schepis F, Vizzutti F, Toniutto P, Senzolo M, Caraceni P, Salerno F, Angeli P, Cioni R, Vitale A, Grosso M, De Gasperi A, D'Amico G, Marzano A. Consensus conference on TIPS management: Techniques, indications, contraindications. Dig Liver Dis 2017; 49:121-137. [PMID: 27884494 DOI: 10.1016/j.dld.2016.10.011] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 09/27/2016] [Accepted: 10/17/2016] [Indexed: 12/11/2022]
Abstract
The trans jugular intrahepatic Porto systemic shunt (TIPS) is no longer viewed as a salvage therapy or a bridge to liver transplantation and is currently indicated for a number of conditions related to portal hypertension with positive results in survival. Moreover, the availability of self-expandable polytetrafluoroethylene (PTFE)-covered endoprostheses has dramatically improved the long-term patency of TIPS. However, since the last updated International guidelines have been published (year 2009) new evidence have come, which have open the field to new indications and solved areas of uncertainty. On this basis, the Italian Association of the Study of the Liver (AISF), the Italian College of Interventional Radiology-Italian Society of Medical Radiology (ICIR-SIRM), and the Italian Society of Anesthesia, Analgesia and Intensive Care (SIAARTI) promoted a Consensus Conference on TIPS. Under the auspices of the three scientific societies, the consensus process started with the review of the literature by a scientific board of experts and ended with a formal consensus meeting in Bergamo on June 4th and 5th, 2015. The final statements presented here were graded according to quality of evidence and strength of recommendations and were approved by an independent jury. By highlighting strengths and weaknesses of current indications to TIPS, the recommendations of AISF-ICIR-SIRM-SIAARTI may represent the starting point for further studies.
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Affiliation(s)
- Stefano Fagiuoli
- Gastroenterologia Epatologia e Trapiantologia, Papa Giovanni XXIII Hospital, Bergamo, Italy.
| | - Raffaele Bruno
- Dept. of Infectious Diseases, Hepatology Outpatients Unit, University of Pavia-Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Wilma Debernardi Venon
- Gastroepatologia, AOU Città della Salute e della Scienza, Molinette Hospital, Torino, Italy
| | - Filippo Schepis
- Department of Gastroenterology University of Modena and Reggio Emilia, Italy
| | - Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Pierluigi Toniutto
- Medical Liver Transplant Section, Department of Medical Sciences Experimental and Clinical, Internal Medicine, University of Udine, Italy
| | - Marco Senzolo
- Unità di Trapianto Multiviscerale, Gastroenterologia, Dipartimento di Scienze Chirurgiche e Gastroenterologiche, Università-Ospedale di Padova, Italy
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Francesco Salerno
- Department of Internal Medicine, Policlinico IRCCS San Donato, University of Milan, Italy
| | - Paolo Angeli
- Internal Medicine and Hepatology Department of Medicine (DIMED), University of Padova, Italy
| | - Roberto Cioni
- Dipartimento di Radiologia Diagnostica e Interventistica, UO di Radiologia Interventistica, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Alessandro Vitale
- U.O.C. di Chirurgia Epatobiliare e del Trapianto Epatico, Azienda Ospedaliera Università di Padova, Italy
| | - Maurizio Grosso
- Department of Radiology S. Croce and Carle Hospital Cuneo, Italy
| | - Andrea De Gasperi
- 2° Servizio Anestesia e Rianimazione-Ospedale Niguarda Ca Granda, Milan, Italy
| | | | - Alfredo Marzano
- Gastroepatologia, AOU Città della Salute e della Scienza, Molinette Hospital, Torino, Italy
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Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology 2017; 65:310-335. [PMID: 27786365 DOI: 10.1002/hep.28906] [Citation(s) in RCA: 1216] [Impact Index Per Article: 173.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 10/20/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Guadalupe Garcia-Tsao
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT.,Department of Medicine, VA-CT Healthcare System, West Haven, CT
| | - Juan G Abraldes
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Annalisa Berzigotti
- Hepatology, Inselspital, University Clinic of Visceral Surgery and Medicine (UVCM), University of Bern, Switzerland
| | - Jaime Bosch
- Hepatology, Inselspital, University Clinic of Visceral Surgery and Medicine (UVCM), University of Bern, Switzerland.,Hospital Clinic, Barcelona, Spain.,Liver Unit, Hepatic Hemodynamic Laboratory, Institute of Biomedical Research, August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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Garcia MC, Ahlenstiel G, Mahajan H, van der Poorten D. Small bowel varices secondary to chronic superior mesenteric vein thrombosis in a patient with heterozygous Factor V Leiden mutation: a case report. J Med Case Rep 2015; 9:210. [PMID: 26423996 PMCID: PMC4589920 DOI: 10.1186/s13256-015-0705-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 09/02/2015] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Bleeding ectopic small bowel varices pose a clinical dilemma for the physician, given their diagnostic obscurity and the lack of evidence-based medicine to guide therapy. They often occur in the context of portal hypertension, secondary to either liver disease or extrahepatic causes. Rarely is their presence associated with chronic superior mesenteric vein thrombosis and hereditary coagulopathies. CASE PRESENTATION A 74-year-old white woman, with a heterozygous Factor V Leiden mutation and no underlying liver disease or portal hypertension, presented over the course of 13 months for recurrent episodes of melena and per rectal bleeding. An initial endoscopy showed a clean-based chronic gastric ulcer, while colonoscopies showed multiple, non-bleeding angioectasias which were treated with argon plasma coagulation. Subsequent video capsule endoscopy and double balloon enteroscopy revealed red wale marks overlying engorged submucosal veins in her distal ileum, consistent with ectopic varices. A chronic superior mesenteric vein thrombus, found via computed tomography venogram, was the cause of the ileal varices. She underwent curative surgical resection of the affected bowel, with no re-bleeding episodes 17 months post-surgery, despite needing lifelong anticoagulation for recurrent venous thromboembolisms. CONCLUSIONS Clinicians should consider ectopic varices in patients who present with obscure gastrointestinal bleeding, even in the absence of portal hypertension or liver disease. In those with a known thrombophilia, patients should be screened for splanchnic thrombosis, which may precipitate ectopic varices.
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Affiliation(s)
- Maria C Garcia
- Sydney Medical School, Westmead Clinical School, University of Sydney, Sydney, NSW, Australia.
| | - Golo Ahlenstiel
- Department of Gastroenterology and Hepatology, University of Sydney at Westmead Hospital, Westmead, NSW, Australia.
| | - Hema Mahajan
- Department of Anatomical Pathology, Westmead Hospital, Westmead, NSW, Australia.
| | - David van der Poorten
- Department of Gastroenterology and Hepatology, University of Sydney at Westmead Hospital, Westmead, NSW, Australia.
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Arora A, Rajesh S, Meenakshi YS, Sureka B, Bansal K, Sarin SK. Spectrum of hepatofugal collateral pathways in portal hypertension: an illustrated radiological review. Insights Imaging 2015; 6:559-72. [PMID: 26337049 PMCID: PMC4569600 DOI: 10.1007/s13244-015-0419-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 06/25/2015] [Accepted: 06/29/2015] [Indexed: 12/14/2022] Open
Abstract
The purpose of this article is to describe the various portosystemic collateral pathways pertinent to portal hypertension on multi-detector row computed tomography (MDCT) and their clinical relevance, with special emphasis on the uncommon ones. The knowledge and understanding of the various patterns of portosystemic collateral channels has important implications both for the clinician and the interventionist. MDCT with its advanced post processing capabilities can exquisitely demonstrate these vascular pathways to help in therapeutic decision making. Teaching points • Portosystemic collaterals are an important cause of bleeding and hepatic encephalopathy. • Radiologists should be familiar with the imaging findings to effectively identify them. • Pre-operative knowledge of portosystemic collaterals is essential to avoid inadvertent vascular injury.
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Affiliation(s)
- Ankur Arora
- Department of Radiology, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070, India.
| | - S Rajesh
- Department of Radiology, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070, India.
| | - Yamini S Meenakshi
- Department of Radiology, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070, India.
| | - Binit Sureka
- Department of Radiology, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070, India.
| | - Kalpana Bansal
- Department of Radiology, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070, India.
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver & Biliary Sciences, D-1, Vasant Kunj, New Delhi, 110070, India.
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Parikh K, Ali MA, Wong RCK. Unusual Causes of Upper Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am 2015; 25:583-605. [PMID: 26142040 DOI: 10.1016/j.giec.2015.02.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Upper gastrointestinal (GI) bleeding is an important clinical condition managed routinely by endoscopists. Diagnostic and therapeutic options vary immensely based on the source of bleeding and it is important for the gastroenterologist to be cognizant of both common and uncommon etiologies. The focus of this article is to highlight and discuss unusual sources of upper GI bleeding, with a particular emphasis on both the clinical and endoscopic features to help diagnose and treat these atypical causes of bleeding.
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Affiliation(s)
- Keyur Parikh
- Digestive Health Institute, Division of Gastroenterology and Liver Disease, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5066, USA
| | - Meer Akbar Ali
- Digestive Health Institute, Division of Gastroenterology and Liver Disease, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5066, USA
| | - Richard C K Wong
- Digestive Health Institute, Division of Gastroenterology and Liver Disease, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5066, USA.
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Affiliation(s)
- Juan G. Abraldes
- Cirrhosis Care Clinic (CCC) (JGA and PT), Liver Unit, Division of Gastroenterology and the Division of Pediatric Gastroenterology and Nutrition (JY)University of AlbertaEdmontonAlbertaCanada.
| | - Puneeta Tandon
- Cirrhosis Care Clinic (CCC) (JGA and PT), Liver Unit, Division of Gastroenterology and the Division of Pediatric Gastroenterology and Nutrition (JY)University of AlbertaEdmontonAlbertaCanada.
| | - Jason Yap
- Cirrhosis Care Clinic (CCC) (JGA and PT), Liver Unit, Division of Gastroenterology and the Division of Pediatric Gastroenterology and Nutrition (JY)University of AlbertaEdmontonAlbertaCanada.
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