Gallbladder varices: diagnosis in children with portal hypertension on duplex sonography

Gallbladder varices in a pediatric patient after roux-en-Y gastric bypass

This is a case with associated radiologic images for a pediatric patient who developed portomesenteric and splenic vein thrombosis (PMSVT) after Roux-en-Y gastric bypass with subsequent development of portal cavernoma and gallbladder varices (GBV). This case highlights both the importance of post-operative prophylactic anti-coagulation after gastric bypass and detailed imaging following a diagnosis of PMSVT. This case is relevant for pediatric surgeons as they are performing this operation more frequently with the increase in pediatric obesity.

Case Report: Gallbladder Varices in a Patient with Portal Vein Thrombosis Secondary to Hepatocellular Carcinoma

Gallbladder varices are a rare form of collateralization that develop in patients with portal hypertension. We present here a case of gallbladder varices accurately diagnosed by contrast enhanced CT imaging of the abdomen and confirmed by Color Doppler Sonography. A 76-year-old patient with hepatocellular carcinoma developed portal vein thrombosis due to tumor extension during the course of treatment and was incidentally discovered to have gallbladder varices. While most commonly asymptomatic, gallbladder varices are associated with increased risk of massive bleeding, either spontaneously or during cholecystectomy. As a result, the existence of such varices should be well documented if the patient is to undergo any abdominal surgical procedures. In addition, because of a particular association with portal vein thrombosis, patients with portal hypertension that are found to possess gallbladder varices should be evaluated for portal vein thrombosis.

Jejunal varix bleeding with extrahepatic portal vein obstruction after pylorus-preserving pancreatoduodenectomy: report of two cases

We present 2 patients showing afferent jejunal varix bleeding around hepaticojejunostomy caused by extrahepatic portal vein obstruction after pylorus-preserving pancreatoduodenectomy (PPPD). The case 1 was a 58-year-old woman who had recurrent anemia and hematochezia 3 years after undergoing PPPD. On the portography, the main portal vein was obliterated and collaterals around hepaticojejunostomy were developed. After percutaneous transhepatic balloon dilatation and stent placement through the obliterated portal vein, jejunal varices had disappeared and thereafter no bleeding occurred for 32 months. The case 2 was a 71-year-old man who had frequent melena 7 years after PPPD. Portal stent insertion was first tried, but failed due to severe stenosis of the main portal vein. Therefore, meso-caval shunt operation was attempted in order to reduce the variceal flow. Although an episode of a small amount of melena occurred one month after the shunt operation, there was no occurrence of bleeding for the next 8 months. For the treatment of jejunal varices, a less invasive approach, such as the angiographic intervention of stent insertion, balloon dilatation, or embolization is recommended first. Surgical operations, such as a shunt or resection of the jejunal rim, could be considered when noninvasive approaches have failed.

Gallbladder wall variceal haemorrhage with associated rupture: a rare cause of mortality in the cirrhotic patient

Gallbladder wall varices are unusual ectopic varices, which occur in the setting of portal hypertension, usually but not universally associated with portal vein thrombosis. Rupture of these varices may lead to life-threatening intra abdominal haemorrhage and is associated with a high mortality rate. We report a case of gallbladder wall variceal haemorrhage in a cirrhotic patient with patent transjugular intrahepatic portosystemic shunt, which resulted in death.

Ultrasonographic assessment of the gallbladder in 21 children with portal vein thrombosis

BACKGROUND

Portal vein thrombosis (PVT) is one of the most frequent causes of portal hypertension (PH) during childhood. Portal systemic collateral vessels occur at several locations, including the gallbladder (GB).

OBJECTIVE

To evaluate the GB in patients with PVT using US to assess GB wall thickness and its function, and the incidence of lithiasis and varices.

MATERIALS AND METHODS

A prospective study was done on 21 children and young adults whose ages ranged from 17 months to 20 years and 10 months (mean age: 11 years and 7 months). A control group was matched for age and sex. All of the patients and controls fasted for at least 6 h prior to the US examination. The GB measurements included anterior wall thickness. These measurements were obtained before the ingestion and then 30 and 60 min after the ingestion of a meal containing at least 25 g of fat. The rate of GB contractility was calculated based on these results. The presence of varices in the GB wall was detected by the characteristic serpentine shape of the intramural vessels and by the venous flow using pulse duplex and color Doppler imaging. The presence of biliary lithiasis was confirmed by shadowing. The chi-square test, the exact Fisher test and the Mann-Whitney test were used to compare the results.

RESULTS

Biliary lithiasis occurred in 3 (14.2%) of the 21 patients. The GB wall was thickened in 13 (61.9%) of the 21 patients, which corresponded with the number of patients with GB varices. The wall dimensions of all the controls were within normal limits. In patients with PVT; GB contractility was lower than in the 21 patients used as control and resulted in a significant difference in all of the measurements.

CONCLUSION

GB varices are very common in children with PVT, and it is noted especially in patients whose GB wall was thickened and in whom the GB contractility was reduced. Lithiasis could be a consequence of the decreased contractility of GB.

Color Doppler sonographic evaluation of spontaneous portosystemic shunts and inversion of portal venous flow in patients with cirrhosis

PURPOSE

The aim of the study was to evaluate the usefulness of color Doppler sonography in the detection of spontaneous portosystemic shunts and abnormal blood flow direction in the portal vein in patients with cirrhosis.

METHODS

Patients were 67 men and 42 women (mean age, 53 +/- 14 years) with cirrhosis confirmed by liver biopsy. All patients underwent abdominal gray-scale and color Doppler sonographic evaluations to detect the presence of spontaneous portosystemic shunts and to analyze portal vein blood flow direction.

RESULTS

Spontaneous portosystemic shunts were found in 41 patients (38%), most often as splenorenal shunts (21%) and patent umbilical veins (14%). Less frequent were gastric collaterals, gallbladder varices, collaterals to thrombotic portal veins, mesoiliac shunts, and portorenal shunts to the right kidney. The presence of shunts was associated with that of esophageal varices (p < 0.01), ascites (p < 0.01), and inversion of portal flow (p < 0. 001) but not with splenomegaly. The direction of portal venous flow was normal (hepatopetal) in 80 patients (73%), hepatofugal in 10 (9%), and bidirectional in 7 (6%); 12 patients (11%) had partial portal vein thrombosis.

CONCLUSIONS

Portosystemic shunts and the direction of portal venous flow are important features in the sonographic diagnosis of portal hypertension.