Preaortic esophageal veins: CT appearance

Esophageal varices in dogs: A retrospective case series

Background

Esophageal varices (EV) are abnormally dilated veins in the esophagus caused by alterations of blood flow or pressure. Esophageal variceal hemorrhage is a major complication of hepatic disease in humans, but a lack of information exists regarding associated adverse events in dogs.

Objective

To describe the clinical manifestations and associated etiologies and outcomes of dogs with EV.

Animals

Twenty‐five client‐owned dogs with EV diagnosed via computed tomography (CT), endoscopy, or fluoroscopy.

Methods

Retrospective case series. Cases were identified by review of the hospital imaging records database between 2010 and 2020. Signalment, clinical signs, and outcomes were documented. When present, additional collateral vasculature was also recorded. Cases were subcategorized into suspected etiology based upon the anatomic location or absence of an attributable underlying disease process, as well as the direction of blood flow.

Results

Twenty‐four of 25 cases were identified via CT, with a prevalence of 0.012% (24/1950 total studies). Presenting clinical signs were nonspecific, and more likely because of the underlying cause as opposed to complications secondary to EV themselves. Etiologic anatomic locations were similar in occurrence between the abdomen (N = 14) and thorax (N = 11). All cases with an abdominal etiologic location had presumed or confirmed portal hypertension and 9/11 cases with a thoracic etiologic location had pulmonary, caval, or systemic hypertension. No cases died or were euthanized as a direct result of EV or associated hemorrhage.

Conclusions and Clinical Importance

Esophageal varices are rarely reported in dogs and commonly identified concurrently with portal, pulmonary, and caval hypertension. Hemorrhage is not a common clinical manifestation of EV.

Study of the association between hemorrhage and the position of hemorrhagic stigmata in patients with esophageal varices

The aim of the present study was to investigate the predilection position of hemorrhagic stigmata (HS) in patients with esophageal variceal hemorrhage and provide guidance on endoscopic therapy for esophageal varices. The clinical characteristics, particularly the endoscopic manifestations of HS, in the patients who presented with gastroesophageal variceal hemorrhage and cirrhosis between January 2003 and December 2013 at our hospital were summarized and patients were grouped according to the distance of the lesion site to incisors at 35-40 and ~30 cm. The association between the location of HS and active hemorrhage was assessed. The location of hemorrhage and HS at 35-40 cm from the incisors was more common in esophageal varices patients, followed by the location at ~30 cm from the incisors (P<0.0001). The incidence of HS in esophageal varices patients in the 35-40 cm group was significantly higher than that in the ~30 cm group except for HS at 9:00 position (P<0.0001). The highest incidence of HS in the ~30 cm group was at the 3:00 position, followed by the 12:00, 6:00 and 9:00 position. Among them, there were significant differences between the 3:00 and 6:00 position, the 3:00 and 9:00 position, and the 9:00 and 12:00 position (P<0.05). The order in the 35-40 cm group was similar to that in the ~30 cm group and the incidence of HS at the 9:00 position was lowest (P<0.05). A certain association between the point of location of HS and hemorrhage was identified. HS located at 35-40 cm from the lesion site to incisors was identified to be most likely to bleed, followed by that located at ~30 cm. In addition, the incidence of HS at 9:00 position was found to be lower than that in the other positions. Therefore, HS located at ~30 cm and 35-40 cm from the lesion site to incisors should be paid attention to and the 3:00, 12:00 and 6:00 rather than the 9:00 position should be prioritized during endoscopic treatment, particularly in emergency situations.

Characteristics of paraesophageal varices: A study with 64-row multidetector computed tomography portal venography

AIM: To identify the characteristics of morphology, location and collateral circulation involved in paraesophageal varices (para-EV) of portal hypertension patients with 64-row multidetector computed tomography (MDCT).

METHODS: Fifty-two of 501 patients with portal hypertensive cirrhosis accompanied with esophageal varices were selected for 64-row MDCT examination after the observation of para-EV. The CT protocol included unenhanced, arterial and portal phases with a slice thickness of 0.625 mm and a scanning field of 2 cm above the bifurcation to the lower edge of kidney. The CT portal venography (CTPV) was reformatted on AW4.3 workstation. The characteristics of origination, location, morphology and collateral circulation in para-EV were observed.

RESULTS: Among the 52 cases of para-EV, 50 showed the originations from the posterior branch of left gastric vein, while the others from the anterior branch. Fifty cases demonstrated their locations close to the esophageal-gastric junction, and the other two cases were extended to the inferior bifurcation of the trachea. The circuitous pattern was observed in 16 cases, while reticulated pattern was seen in 36 cases. Collateral circulation identified 4 cases of single periesophageal varices (peri-EV) communication, 3 cases of single hemiazygous vein, one case of single inferior vena cava, 41 cases of mixed type (collateral communications of at least 2 of above mentioned types) and 3 cases of undetermined communications. Among all the cases, 43 patients showed the communications between para-EV and peri-EV, while hemiazygous vein (43 cases) and inferior vena cava (5 cases) were also involved.

CONCLUSION: Sixty-four-row multidetector computed tomography portal venography could display the location, morphology, origin, and collateral types of para-EV, which provides important and referable information for clinical management and disease prognosis.

Portosystemic shunt on CT during arterial portography: prevalence in patients with and without liver cirrhosis

BACKGROUND

To review various portosystemic shunts (PS) and to evaluate their prevalence by CT during arterial portography (CTAP) using a multidetector-row CT (MDCT).

METHODS

CTAP of 116 patients (liver cirrhosis 70 patients, non-liver cirrhosis 46 patients) was retrospectively reviewed. CTAP was performed with the catheter placed in the superior mesenteric artery using MDCT. Axial CT images of 0.625- and 3.75- or 2.5-mm thickness were obtained. Multiplanar reformation images and maximum intensity projection images were subjected to review.

RESULTS

A part of the veins in the ileocecal region drained into the right renal vein or the inferior vena cava (IVC) via the right gonadal vein in 57 patients (81%). A part of the veins of the ascending colon drained via the right renal capsular vein into the IVC in 37 patients (53%). In 46 patients without liver cirrhosis, the right gonadal and right renal capsular veins were opacified on CTAP in 22 patients (48%) and 20 patients (43%), respectively.

CONCLUSIONS

Portosystemic shunts in retroperitoneum were frequently recognized on CTAP images in patients with liver cirrhosis. The right gonadal vein and the right renal capsular vein were the most frequent routes of the portosystemic shunts. They may exist in physiological condition.

[Esophageal disease: is cross sectional imaging contributive?]

For a long time, esophagography and endoscopy were the major diagnostic tests used for evaluation of the esophagus. Now, the development of computed tomography, endosonography and MR imaging has permitted more comprehensive evaluation of esophageal diseases. Cross sectional imaging is essential to evaluate the relationship between esophageal lesions and adjacent mediastinal structures and to evaluate the thickness of the esophageal wall.

CT demonstration of dilated thoracoabdominal veins in patients with arteriovenous fistulas or grafts for hemodialysis

PURPOSE

The purpose of this article was to describe the CT finding of dilated thoracoabdominal veins in patients with renal failure who have arteriovenous fistulas or grafts (AVF/G) for hemodialysis.

MATERIALS AND METHODS

The authors retrospectively identified nine women and nine men on hemodialysis with a mean age of 62 (range, 20-88) years. Inclusion criteria for the series were functioning AVF/G, imaging with chest or abdominal CT, and access to clinical charts. Each clinical chart was evaluated for AVF/G function, diagnosis of cirrhosis or central venous obstruction, hepatitis B and C serology, and liver function as reflected by serum SGOT/SGPT. Each CT was reviewed for evidence of cirrhosis as follows: nodular liver contour, prominent left and caudate lobes, splenomegaly, and ascites. The CT scans were also evaluated for the presence of dilated thoracic or abdominal veins. The contrast-enhanced scans were evaluated for obstruction of the visualized central veins.

RESULTS

Fifty percent (9 of 18) of patients had dilated thoracoabdominal veins involving the following sites: chest wall, internal mammary, inferior phrenic, left gastric, gastric, portal, periportal, preaortic, mesenteric, splenorenal, periumbilical, and omental. None of these patients had clinical or CT evidence of cirrhosis. Eighty-nine percent (eight of nine patients) had normal serum SGOT/SGPT. Hepatitis B serology was normal in all seven patients tested, and hepatitis C serology was normal in 86% (six of seven patients). Eighty-nine percent (eight of nine patients) had no clinical or CT evidence of central venous obstruction. Among the nine patients without dilated veins, none had the clinical diagnosis of cirrhosis, although 56% (five of nine) had one or more CT findings associated with cirrhosis. None was diagnosed with central venous obstruction. Sixty-seven percent (six of nine patients) of those tested had normal serum SGOT/SGPT. Hepatitis B serology was normal in 88% (seven of eight) and 63% (five of eight) of patients tested, respectively. The authors did not find statistically significant differences between the patients with and without dilated veins with respect to the above parameters.

CONCLUSION

Dilated thoracoabdominal veins were present in 50% of patients on hemodialysis with functioning AVF/G in this series. The venous dilatation appears to be independent of cirrhosis and central venous obstruction and is likely related to complex physiologic changes that are known to occur in patients on hemodialysis with functioning AVF/G.

Esophageal and gastric vasculature in children with extrahepatic portal hypertension: evaluation by intravenous CT portography

PURPOSE

To compare the findings related to esophageal/gastric varices and congestive gastropathy on intravenous computed tomography (CT) portography (CTP) and upper gastrointestinal endoscopy (UGIE) in children with extrahepatic portal venous obstruction (EHO) presented with hematemesis.

METHODS/MATERIALS

Fifty pediatric patients (age < 15 years) with EHO (initially diagnosed on abdominal ultrasound) presented with hematemesis and underwent UGIE and intravenous CTP using a helical CT scanner. Axial sections of 2 mm each were obtained with a collimation of 2 mm and a table feed of 3 mm. CTP findings on these axial sections were compared with UGIE (gold standard).

RESULTS

The sensitivity of CTP for detection of esophageal varices, gastric varices, and gastropathy was 32/33 (97%), 38/40 (95%), and 30/32 (93%), respectively. CTP showed false positivity as well, which was 5/17 (29%), 2/10 (20%), and 13/17 (76%) for esophageal varices, gastric varices, and gastropathy, respectively. On follow-up UGIE, the endoscopic features appeared in 14/19 (74%) of false positive patients. Therefore, false positivity for all the parameters on CTP when compared to the initial UGIE represented the changes in vasculature before they were endoscopically manifest.

CONCLUSIONS

CTP was likely to pick up changes in esophageal and gastric vasculature earlier than UGIE in children with EHO presented with hematemesis.

Diseases of the hepatopulmonary axis

Hepatopulmonary syndrome is the most widely recognized of the processes associated with end-stage liver disease. Chronic liver dysfunction is associated with pulmonary manifestations due to alterations in the production or clearance of circulating cytokines and other mediators. Hepatopulmonary syndrome results in hypoxemia due to pulmonary vasodilatation with significant arteriovenous shunting and ventilation-perfusion mismatch. Hepatic hydrothorax may develop in patients with cirrhosis and ascites. Rarely, pulmonary hypertension occurs in the setting of portal hypertension. A second group of disorders may primarily affect the lungs and liver (the hepatopulmonary axis). Among these are the congenital conditions alpha(1)-antitrypsin deficiency and cystic fibrosis. Autoimmune liver disease may be associated with lymphocytic interstitial pneumonitis, fibrosing alveolitis, intrapulmonary granulomas, and bronchiolitis obliterans with organizing pneumonia. Sarcoidosis affects the lung and liver in up to 70% of patients. Medications such as amiodarone can result in a characteristic radiologic appearance of pulmonary and hepatic toxic effects. Knowledge of these associations will assist the radiologist in forming a meaningful differential diagnosis and may influence treatment decisions.