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Kato A, Mashiba T, Tateishi Y, Oda R, Funakoshi H, Iwanami K, Motomura Y. Disseminated tuberculosis following invasive procedures for peripancreatic lymph node tuberculosis with portal vein obstruction: a case report. Clin J Gastroenterol 2022; 15:673-679. [PMID: 35334085 DOI: 10.1007/s12328-022-01624-6] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/09/2022] [Indexed: 11/28/2022]
Abstract
Peripancreatic tuberculous lymphadenopathy can mimic pancreatic cancer on imaging. There have only a few reports on varices from portal vein obstruction due to abdominal tuberculous lymphadenopathy. Iatrogenic disseminated tuberculosis is also rare. Herein, we present a rare case of peripancreatic tuberculous lymphadenopathy with ruptured duodenal varices due to portal vein obstruction. The patient presented to our hospital with hematemesis. Computed tomography revealed a peripancreatic mass. Duodenal varices rupture from portal vein obstruction due to pancreatic cancer were initially suspected. The patient underwent portal vein stenting for portal vein obstruction and endoscopic ultrasound-guided fine-needle aspiration for diagnosis, which revealed granulomas indicative of tuberculosis. The patient was discharged once because fine-needle aspiration did not lead to a definitive diagnosis of tuberculosis. Subsequently, he developed disseminated tuberculosis. Peripancreatic tuberculous lymphadenopathy can cause ectopic varices with portal vein obstruction. Tuberculosis should also be included in the differential diagnosis in the case of portal vein obstruction, to facilitate early treatment and avoid unnecessary surgery. Furthermore, fine-needle aspiration or portal vein stenting for tuberculous lesions can cause disseminated tuberculosis. Since a diagnosis might not be made until after several fine-needle aspirations have been conducted, careful follow-up is necessary after the procedure for such lesions.
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Affiliation(s)
- Aya Kato
- Department of Gastroenterology, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32, Todaijima, Urayasu, Chiba, 279-0001, Japan.
| | - Takahisa Mashiba
- Department of General Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32, Todaijima, Urayasu, Chiba, 279-0001, Japan
| | - Yoshinori Tateishi
- Department of Infectious Disease, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32, Todaijima, Urayasu, Chiba, 279-0001, Japan
| | - Rentaro Oda
- Department of Infectious Disease, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32, Todaijima, Urayasu, Chiba, 279-0001, Japan
| | - Hiraku Funakoshi
- Department of Interventional Radiology, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32, Todaijima, Urayasu, Chiba, 279-0001, Japan
| | - Keiichi Iwanami
- Department of Rheumatology, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32, Todaijima, Urayasu, Chiba, 279-0001, Japan
| | - Yasuaki Motomura
- Department of Gastroenterology, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32, Todaijima, Urayasu, Chiba, 279-0001, Japan
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Fukuda K, Sasaki T, Hirasawa T, Matsueda K, Nakao E, Mie T, Furukawa T, Yamada Y, Takeda T, Kasuga A, Matsuyama M, Ozaka M, Sasahira N. A case of percutaneous transhepatic portal vein stent placement and endoscopic injection sclerotherapy for duodenal variceal rupture occurring during chemotherapy for unresectable perihilar cholangiocarcinoma. Clin J Gastroenterol 2020; 13:1150-6. [PMID: 32897499 DOI: 10.1007/s12328-020-01213-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 08/13/2020] [Indexed: 10/23/2022]
Abstract
Duodenal varices are ectopic varices that are rare but can involve any site along the digestive tract outside the gastroesophageal region. Ectopic variceal bleeding is generally massive and life threatening; the mortality rate is approximately 40%. Up to 17% of ectopic varices occur in the duodenum. However, duodenal varices pose a significant therapeutic challenge due to the lack of standard treatment guidelines. We report a case of duodenal variceal bleeding secondary to portal vein stenosis in a 77-year-old woman receiving chemotherapy for unresectable perihilar cholangiocarcinoma. The patient presented with melena, nausea, vomiting and unstable vital signs suggestive of hemorrhagic shock. Emergency esophagogastroduodenoscopy revealed large nodular varices with a ruptured erosion on top in the superior duodenal angle, and variceal bleeding had stopped by the time of the procedure. Subsequent computed tomography showed the development of portosystemic collaterals; therefore, we performed percutaneous portal vein stent placement to reduce portal vein pressure. Since persistent bleeding was suspected, we also performed endoscopic injection sclerotherapy and achieved successful hemostasis with an improvement in liver function. This case revealed that a combination of portal vein stent placement and endoscopic injection sclerotherapy might be an effective therapy for duodenal variceal bleeding caused by portal vein stenosis.
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Chikamori F, Ito S. Bacterial meningitis after incomplete retrograde obliteration for duodenal varices with encephalopathy: A case report. Radiol Case Rep 2020; 15:1781-5. [PMID: 32793317 DOI: 10.1016/j.radcr.2020.07.029] [Citation(s) in RCA: 1] [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: 06/29/2020] [Revised: 07/10/2020] [Accepted: 07/11/2020] [Indexed: 11/25/2022] Open
Abstract
We report a case of bacterial meningitis in a 72-year-old female with nonalcoholic steatohepatitis who underwent incomplete retrograde obliteration for duodenal varices with encephalopathy. Two months after incomplete retrograde obliteration, she became febrile, drowsy, and was transported to hospital. Her serum ammonia level was normal. Endoscopy revealed that previously embolized coil was partially migrated into the duodenal lumen. Cerebrospinal fluid examination confirmed the diagnosis of bacterial meningitis. She was treated with intravenous antibiotics. As there was a risk of bleeding, trans-ileocolic vein obliteration of duodenal varices was attempted. The patient slowly recovered and was discharged. This case indicated two problems could occur by coil migration after incomplete retrograde obliteration for duodenal varices with encephalopathy. One was bacterial meningitis and the other was risk of bleeding from duodenal varices. We conclude that cerebrospinal fluid examination is recommended for patients with high fever and abnormal mental status after incomplete retrograde obliteration, and immediate complete obliteration should be attempted for a risk of bleeding.
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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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Anegawa G, Sumi K, Miyoshi A, Kitahara K, Satou S. A novel surgical technique for bleeding duodenal varices after failure of balloon-occluded retrograde transvenous obliteration: a case report. Surg Case Rep 2016; 2:65. [PMID: 27411533 PMCID: PMC4943917 DOI: 10.1186/s40792-016-0192-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 03/24/2016] [Accepted: 06/21/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Duodenal varices are a low-frequency cause of gastrointestinal bleeding; however, greater than 40 % mortality has been reported after the initial bleeding episode. CASE PRESENTATION This report describes a 72-year-old woman with bleeding duodenal varices treated by surgery after failure of balloon-occluded retrograde transvenous obliteration (B-RTO). The patient presented with profuse melena. Emergent upper endoscopy was immediately performed, and bleeding duodenal varices in the second portion of the duodenum were seen. Endoscopic band ligation was attempted first followed by B-RTO; however, the combined procedures failed. Laparotomy under general anesthesia was then performed, and the venous collaterals were cannulated using an 18-gauge needle. Following intraoperative angiography, the venous collateral was ligated on the peripheral side of the needle entry point, and ethanolamine oleate was injected into the afferent collateral vessel. Endoscopic examination on postoperative day 4 showed embolization of the duodenal varices. The patient was discharged on postoperative day 11. CONCLUSIONS This technique is simple and effective, and we believe it is a potential alternative surgical treatment for duodenal varices with portal hypertension.
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Affiliation(s)
- Go Anegawa
- Department of Surgery, Saga-Ken Medical Centre Koseikan, 400 Kase-machi Nakabaru, Saga, 840-8571, Japan.
| | - Kenji Sumi
- Department of Surgery, Saga-Ken Medical Centre Koseikan, 400 Kase-machi Nakabaru, Saga, 840-8571, Japan
| | - Atsushi Miyoshi
- Department of Surgery, Saga-Ken Medical Centre Koseikan, 400 Kase-machi Nakabaru, Saga, 840-8571, Japan
| | - Kenji Kitahara
- Department of Surgery, Saga-Ken Medical Centre Koseikan, 400 Kase-machi Nakabaru, Saga, 840-8571, Japan
| | - Seiji Satou
- Department of Surgery, Saga-Ken Medical Centre Koseikan, 400 Kase-machi Nakabaru, Saga, 840-8571, Japan
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Steevens C, Abdalla M, Kothari TH, Kaul V, Kothari S. Massive duodenal variceal bleed; complication of extra hepatic portal hypertension: Endoscopic management and literature review. World J Gastrointest Pharmacol Ther 2015; 6:248-252. [PMID: 26558159 PMCID: PMC4635165 DOI: 10.4292/wjgpt.v6.i4.248] [Citation(s) in RCA: 3] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 06/29/2015] [Accepted: 08/31/2015] [Indexed: 02/06/2023] Open
Abstract
Bleeding from duodenal varices is reported to be a catastrophic and often fatal event. Most of the cases in the literature involve patients with underlying cirrhosis. However, approximately one quarter of duodenal variceal bleeds is caused by extrahepatic portal hypertension and they represent a unique population given their lack of liver dysfunction. The authors present a case where a 61-year-old male with history of remote crush injury presented with bright red blood per rectum and was found to have bleeding from massive duodenal varices. Injection sclerotherapy with ethanolamine was performed and the patient experienced a favorable outcome with near resolution of his varices on endoscopic follow-up. The authors conclude that sclerotherapy is a reasonable first line therapy and review the literature surrounding the treatment of duodenal varices secondary to extrahepatic portal hypertension.
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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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Abstract
Although often considered together, gastric and ectopic varices represent complications of a heterogeneous group of underlying diseases. Commonly, these are known to arise in patients with cirrhosis secondary to portal hypertension; however, they also arise in patients with noncirrhotic portal hypertension, most often secondary to venous thrombosis of the portal venous system. One of the key initial assessments is to define the underlying condition leading to the formation of these portal-collateral pathways to guide management. In the authors' experience, these patients can be grouped into distinct although sometimes overlapping conditions, which can provide a helpful conceptual basis of management.
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Affiliation(s)
- Zachary Henry
- Division of Gastroenterology and Hepatology, University of Virginia Health System, PO Box 800708, Charlottesville, VA 22908-0708, USA
| | - Dushant Uppal
- Division of Gastroenterology and Hepatology, University of Virginia Health System, PO Box 800708, Charlottesville, VA 22908-0708, USA
| | - Wael Saad
- Division of Vascular and Interventional Radiology, University of Virginia Health System, PO Box 800170, Charlottesville, VA 22908, USA
| | - Stephen Caldwell
- Division of Gastroenterology and Hepatology, University of Virginia Health System, PO Box 800708, Charlottesville, VA 22908-0708, USA.
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