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Tsuruoka M, Inoue J, Ouchi K, Uno K, Itami H, Ninomiya M, Iwata T, Sano A, Sato K, Onuki M, Sawahashi S, Koike T, Masamune A. A Case of Duodenal Variceal Rupture during Atezolizumab and Bevacizumab Treatment for Hepatocellular Carcinoma. Intern Med 2022; 62:1467-1472. [PMID: 36198602 DOI: 10.2169/internalmedicine.0629-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Duodenal varices are detected infrequently, and their rupture is very rare. We encountered an 87-year-old man who developed duodenal varices rupture during chemotherapy with atezolizumab and bevacizumab (ATZ/BV) for hepatocellular carcinoma. We identified massive bleeding of a ruptured varix in the horizontal portion of the duodenum with emergency esophagogastroduodenoscopy (EGD). Successful hemostasis was achieved by endoscopic injection sclerotherapy with Histoacryl. Although ATZ/BV can cause esophageal varices rupture, there have been no cases of duodenal varices rupture. We should take care to check the duodenal varices as well as esophagogastric varices before ATZ/BV treatment.
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Affiliation(s)
- Mio Tsuruoka
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Jun Inoue
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Keishi Ouchi
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Kaname Uno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Hideaki Itami
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Masashi Ninomiya
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Tomoaki Iwata
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Akitoshi Sano
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Kosuke Sato
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Masazumi Onuki
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Satoko Sawahashi
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Tomoyuki Koike
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
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Jansson-Knodell CL, Calderon G, Weber R, Ghabril M. Small Intestine Varices in Cirrhosis at a High-Volume Liver Transplant Center: A Retrospective Database Study and Literature Review. Am J Gastroenterol 2021; 116:1426-36. [PMID: 33734116 DOI: 10.14309/ajg.0000000000001204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/22/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Esophageal varices are a well-characterized sequela of portal hypertension; however, less is known about varices arising in ectopic locations. We aimed to describe bleeding small intestine varices (SIV) in patients with cirrhosis and compare characteristics and outcomes to published case reports. METHODS We performed an institutional chart review using billing codes and natural language processing between 2008 and 2019. Inclusion criteria were adult patients with cirrhosis and SIV verified by endoscopy, video capsule, or imaging. Patients with noncirrhotic portal hypertension and stomal varices were excluded. We examined demographic and clinical factors, characteristics of SIV, bleeding, intervention, and outcomes in our series and collated data from published cases identified during a literature review. RESULTS We identified 71 patients with cirrhosis and SIV (18 bled). The literature search yielded 76 cases with bleeding SIV. Our series and published cases were matched for age, sex, liver disease etiology, and SIV location. Length of stay and transfusion requirements were similar. Aggregate initial treatments (number, hemostasis rate) included medical (n = 7, 57%), endoscopic (n = 48, 56%), interventional radiology (n = 31, 77%), and surgery (n = 8, 87%). Hospital and overall mortality rates were higher in our series (22% and 38%) compared with the published cases (5.3% and 18.4%), respectively (P = 0.02 and P = 0.07). DISCUSSION A quarter of patients with cirrhosis and SIV experience bleeding, with high transfusion requirements, frequent need for secondary interventions, and high mortality. These findings highlight the need for a multidisciplinary approach and second-line therapeutic modalities in the timely management of bleeding SIV in cirrhosis.
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Yipeng W, Cong L, Sizhe W, Chenkai H, Anjiang W, Xuan Z. Effectiveness and safety of endoscopic treatment for duodenal variceal bleeding: a systematic review. Eur J Gastroenterol Hepatol 2021; 33:461-469. [PMID: 32576766 PMCID: PMC7908861 DOI: 10.1097/meg.0000000000001819] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023]
Abstract
Duodenal varix is a rare condition that involves massive bleeding, diagnostic difficulties, and a high rate of rebleeding and mortality. The purpose of this study was to systematically review endoscopic treatment for duodenal variceal bleeding to evaluate its effectiveness and safety. We searched PubMed, Embase, Web of Science, and the Cochrane Library up to 21 November 2019. Ninety-two studies containing 156 patients were finally included, and individual data from 101 patients (mean age: 52.67 ± 13.82 years, male: 64.4%) were collected and further analyzed. We used an analysis of variance and χ2 or Fisher's exact tests to analyze individual data from 101 patients. The cause of duodenal variceal bleeding was cirrhosis-related intrahepatic portal hypertension (IPH) in 76.2% of patients. The overall rates of initial hemostasis and treatment success of endoscopic treatment for duodenal variceal bleeding were 89.1 and 81.2%, respectively. The median duration of follow-up was 4.5 (1.0, 12.0) months. The overall rates of rebleeding and mortality were 8.9 and 13.9%, respectively. Among a variety of endoscopic treatments available, only the initial hemostasis rate was significantly different between the endoscopic injection sclerotherapy and endoscopic tissue adhesive (ETA) groups (72.7 vs. 94.7%, P = 0.023); differences in treatment success, rebleeding, mortality, and adverse events were not statistically significant among the four groups. Endoscopic intervention is a feasible, well tolerated, and effective modality for the treatment of duodenal variceal bleeding. Among the variety of endoscopic treatments available, ETA with cyanoacrylate may be preferable for duodenal variceal bleeding.
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Affiliation(s)
- Wan Yipeng
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Liu Cong
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Wan Sizhe
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Huang Chenkai
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Wang Anjiang
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Zhu Xuan
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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Cai Y, Chen XB, Mai DH, Wu P, Chen YH, Chen H. Multidetector computed tomography three-dimensional and multiplanar reconstruction diagnosis of a rare cause of gastrointestinal bleeding: A case report. World J Gastrointest Surg 2021; 13:87-95. [PMID: 33552396 PMCID: PMC7830075 DOI: 10.4240/wjgs.v13.i1.87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/30/2020] [Accepted: 12/10/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Anastomosis of the testicular vein with the superior mesenteric vein rarely causes severe gastrointestinal bleeding. To date, there have been few studies describing its appearance on medical imaging. Here, we present multidetector computed tomography three-dimensional and multiplanar reconstruction (MPR) images of a typical digital subtraction angiography showing proven ectopic bleeding and provide the first review of the image performance.
CASE SUMMARY A 68-year-old man who had been rushed to the hospital with a four-day history of melena and fainting underwent multiple esophagogastroduodenoscopy procedures that failed to identify the source of bleeding. We used MPR combined with three-dimensional reconstruction images, and found that the testicular vein had anastomosed with the superior mesenteric vein, and they clustered together in the jejunal vessel wall, which caused severe gastrointestinal bleeding. Digital subtraction angiography confirmed the location of bleeding. After transfusion and embolization therapy, the patient’s condition improved.
CONCLUSION Computed tomography-MPR combined with three-dimensional images offers significant value in the localization and qualitative assessment of rare gastrointestinal hemorrhage. The features of multiphase spiral scanning can improve the accuracy of the diagnosis.
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Affiliation(s)
- Yong Cai
- Department of Diagnostic Imaging, Maoming People’s Hospital, Maoming 525000, Guangdong Province, China
| | - Xiao-Bo Chen
- Department of Diagnostic Imaging, Maoming People’s Hospital, Maoming 525000, Guangdong Province, China
| | - Da-Hai Mai
- Department of Oncology, Maoming People's Hospital, Maoming 525000, Guangdong Province, China
| | - Ping Wu
- Department of Gastroenterology, Maoming People's Hospital, Maoming 525000, Guangdong Province, China
| | - Yong-Hai Chen
- Department of Diagnostic Imaging, Maoming People’s Hospital, Maoming 525000, Guangdong Province, China
| | - Hua Chen
- Department of Oncology, Maoming People's Hospital, Maoming 525000, Guangdong Province, China
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Lee JH, Wu CS, Huang JH. Endoscopic Sclerotherapy with a Large Volume of High Concentration of Cyanoacrylate for Jejunal Variceal Bleeding bys Single-Balloon Enteroscopy. ACTA ACUST UNITED AC 2018; 54:E68. [PMID: 30344299 DOI: 10.3390/medicina54050068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 09/04/2018] [Accepted: 09/06/2018] [Indexed: 12/14/2022]
Abstract
Jejunal varices are a rare manifestation of portal hypertension, and they are associated with a high mortality and poor prognosis when bleeding occurs. A bleeding jejunal varix is much more challenging to diagnose and manage because of its anatomic location. Herein, we describe the case of a 62-year-old man with active jejunal variceal bleeding who presented with massive hematochezia and hypovolemic shock. He was treated successfully with a high volume and concentration of a glue mixture as endoscopic sclerotherapy using single-balloon enteroscopy in the intensive care unit. Enteroscopic sclerotherapy is an effective option for jejunal variceal bleeding.
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Khor V, Soon Y, Aung L. A case report of bleeding from a duodenal varix: Rare cause of upper gastrointestinal bleeding. Int J Surg Case Rep 2018; 49:205-208. [PMID: 30029079 PMCID: PMC6077164 DOI: 10.1016/j.ijscr.2018.06.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 06/25/2018] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Ectopic variceal bleeding is uncommon, accounts for 2-5% of variceal bleeding, of which 17% is in duodenum. PRESENTATION OF CASE 62-year-old lady with newly diagnosed liver cirrhosis on admission, presented with severe upper gastrointestinal bleeding (UGIB), was ultimately diagnosed with bleeding duodenal varices with single-balloon enteroscopy, after multiple oesophagogastroduodenoscopies (OGDs) and CT scans which failed to identify the varices. She was treated successfully with duodenectomy. DISCUSSION Endoscopy and CT angiography remain the diagnostic modalities of choice. However, diagnosis can be difficult as evidenced by three OGDs and two CTMAs yielding negative findings in this case. Endoscopic diagnosis is challenging and often delayed due to its rarity and unusual location. CONCLUSION Ectopic variceal bleeding is a rare but important cause of UGIB. Diagnosis is challenging and management of this condition should take a multidisciplinary approach, involving experienced gastroenterologists, interventional radiologists and surgeons. Endoscopic ligation or sclerotherapy is the first-line of treatment.
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Affiliation(s)
- Vincent Khor
- MOH Holdings Singapore, 1 Maritime Square, #11-25 HarbourFront Centre, 099235, Singapore; Department of General Surgery, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, 609606, Singapore.
| | - Yuen Soon
- Department of General Surgery, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, 609606, Singapore
| | - Lwin Aung
- Department of General Surgery, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, 609606, Singapore
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Abstract
PURPOSE OF REVIEW The objective is to provide an overview on the cause of small bowel bleeding. We discuss the role of small bowel endoscopy in the management of small bowel bleeding and provide an outline of pharmacotherapy that can be additionally beneficial. RECENT FINDINGS Small bowel capsule endoscopy (SBCE) is the initial diagnostic investigation of choice in small bowel bleeding. Computed tomography (CT) can be helpful in the context of small bowel tumours. Device-assisted enteroscopy (DAE) enables several therapeutic procedures such as argon plasma coagulation (APC) and haemoclip application. It can also guide further management with histology or by marking culprit lesions with India ink. A persistent rate of rebleeding despite APC is increasingly being reported. Pharmacotherapy has an emerging role in the management of small bowel bleeding. Somatostatin analogues are a well tolerated class of drugs that can play an additional role in the management of refractory bleeding secondary to small bowel angioectasias. SUMMARY SBCE is useful in determining the cause of small bowel bleeding. DAE offers an endoscopic therapeutic approach to small bowel bleeding replacing surgery and intraoperative enteroscopy. Pharmacotherapy, in addition to endotherapy, can play an important role in the management of multifocal, recurring bleeding small bowel lesions.
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Bhagani S, Winters C, Moreea S. Duodenal variceal bleed: an unusual cause of upper gastrointestinal bleed and a difficult diagnosis to make. BMJ Case Rep 2017; 2017:bcr-2016-218669. [PMID: 28242804 PMCID: PMC5337649 DOI: 10.1136/bcr-2016-218669] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
We present a case of recurrent upper gastrointestinal (GI) bleeding in a man aged 57 years with primary biliary cholangitis who was ultimately diagnosed with an isolated duodenal variceal bleed, which was successfully treated with histoacryl glue injection. Duodenal varices are an uncommon presentation of portal hypertension and can result in significant GI bleeding with a high mortality. Diagnosis can be difficult and therapeutic options limited. Endoscopic variceal sclerotherapy with histoacryl glue provides an effective treatment, though endoscopists need to remain aware of and vigilant for the serious complications of this treatment option.
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Affiliation(s)
- Shradha Bhagani
- Department of Gastroenterology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Conchubhair Winters
- Department of Gastroenterology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Sulleman Moreea
- Department of Gastroenterology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
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Temel T, Aktas A, Ozgenel SM, Özakyol A. Complete Eradication of Bleeding Duodenal Varices with Endoscopic Polydocanol Sclerotherapy. Euroasian J Hepatogastroenterol 2016; 6:176-178. [PMID: 29201754 PMCID: PMC5578590 DOI: 10.5005/jp-journals-10018-1194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 06/08/2016] [Indexed: 11/23/2022] Open
Abstract
Bleeding from duodenal varices is a rare complication of portal hypertension, occurring in only 0.4% of these patients and is often life-threatening because of the difficulty in diagnosis and treatment. Treatment options include surgical procedures and endoscopic and endovascular treatments. A 48-year-old female cirrhotic patient was admitted to our clinic with upper gastrointestinal (GI) tract bleeding. Endoscopic examination revealed nonbleeding Lm, Cb, RC (+), F3-F3-F2 esophageal and nodular-bleeding-oozing duodenal varices. Esophageal varices were eradicated with band ligation at two sessions. After one session of 2% polydocanol sclerotheraphy, no signs of bleeding were determined. Complete eradication was achieved after five sessions and 1 year apart from the initial treatment duodenal varices were eradicated. Although duodenal varices are rare, they are frequently fatal. There are limited data regarding optimal treatment. Successful treatment depends both on patient factors (hepatic synthetic function, comorbidities, size/location of the varices) and center expertise. Long-term eradication is variable and may depend on the cause and extensiveness of the ectopic varices.
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Affiliation(s)
- Tuncer Temel
- Department of Gastroenterology, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Abdülvahhap Aktas
- Department of Internal Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Safak Meric Ozgenel
- Department of Gastroenterology, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Aysegül Özakyol
- Department of Gastroenterology, Eskisehir Osmangazi University, Eskisehir, Turkey
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Hashimoto R, Sofue K, Takeuchi Y, Shibamoto K, Arai Y. Successful balloon-occluded retrograde transvenous obliteration for bleeding duodenal varices using cyanoacrylate. World J Gastroenterol 2013; 19:951-954. [PMID: 23429766 PMCID: PMC3574895 DOI: 10.3748/wjg.v19.i6.951] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2012] [Accepted: 10/30/2012] [Indexed: 02/06/2023] Open
Abstract
A 76-year-old woman with hepatitis C cirrhosis presented with tarry stools and hematemesis. An endoscopy demonstrated bleeding duodenal varices in the second portion of the duodenum. Contrast-enhanced computed tomography revealed markedly tortuous varices around the wall in the duodenum. Several afferent veins appeared to have developed, and the right ovarian vein draining into the inferior vena cava was detected as an efferent vein. Balloon-occluded retrograde transvenous obliteration (BRTO) of the varices using cyanoacrylate was successfully performed in combination with the temporary occlusion of the portal vein. Although no previous publications have used cyanoacrylate as an embolic agent for BRTO to control bleeding duodenal varices, this strategy can be considered as an alternative procedure to conventional BRTO using ethanolamine oleate when numerous afferent vessels that cannot be embolized are present.
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