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Shetty AS, Fraum TJ, Ludwig DR, Itani M, Rajput MZ, Strnad BS, Konstantinoff KS, Chang AL, Kapoor S, Parwal U, Balfe DM, Mellnick VM. Imaging of the Inferior Mesenteric Vasculature. Radiographics 2024; 44:e240047. [PMID: 39446611 DOI: 10.1148/rg.240047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2024]
Abstract
The inferior mesenteric artery (IMA) and inferior mesenteric vein (IMV) supply and drain blood from the distal colon and rectum, respectively. Routinely imaged at cross-sectional imaging of the abdomen and pelvis, these vessels play a vital role in gastrointestinal tract health but may be neglected due to their diminutive caliber relative to other mesenteric vessels and potential lack of inclusion in routine search patterns. The authors describe and illustrate normal and abnormal appearances of the IMA and IMV and findings that are diagnostic of primary vascular abnormalities or can offer diagnostic clues. After the embryologic features, normal anatomy, and anatomic variants of the IMA and IMV are reviewed, various manifestations of IMA and IMV abnormalities, such as aneurysm and pseudoaneurysm, stenosis, occlusion, dissection, hemorrhage, arteriovenous malformations and fistulas, tumoral invasion, vasculitis, and perivascular lymphatic dilatation, are explored with use of case examples. The role of the IMA and IMV as collateral vasculature, including the clinical scenarios of superior mesenteric arterial occlusion, aortic endoleak, and portosystemic venous shunt, are discussed. Finally, diagnostic clues that the inferior mesenteric vessels and adjacent soft tissues can provide, including mesenteric venous gas, compression or displacement from bowel volvulus or internal hernias, lymphadenopathy, and venous flow artifacts, are highlighted. The authors provide a comprehensive reference for radiologists who evaluate the IMA and IMV on cross-sectional images and shine a spotlight on these neglected but important vessels. ©RSNA, 2024 Supplemental material is available for this article.
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Affiliation(s)
- Anup S Shetty
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd, Campus Box 8131, St. Louis, MO 63110
| | - Tyler J Fraum
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd, Campus Box 8131, St. Louis, MO 63110
| | - Daniel R Ludwig
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd, Campus Box 8131, St. Louis, MO 63110
| | - Malak Itani
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd, Campus Box 8131, St. Louis, MO 63110
| | - Mohamed Z Rajput
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd, Campus Box 8131, St. Louis, MO 63110
| | - Benjamin S Strnad
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd, Campus Box 8131, St. Louis, MO 63110
| | - Katerina S Konstantinoff
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd, Campus Box 8131, St. Louis, MO 63110
| | - Andrew L Chang
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd, Campus Box 8131, St. Louis, MO 63110
| | - Suraj Kapoor
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd, Campus Box 8131, St. Louis, MO 63110
| | - Utkarsh Parwal
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd, Campus Box 8131, St. Louis, MO 63110
| | - Dennis M Balfe
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd, Campus Box 8131, St. Louis, MO 63110
| | - Vincent M Mellnick
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd, Campus Box 8131, St. Louis, MO 63110
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Kóder G, Dinya T, Tóth D, Damjanovich L, Ágoston L, Tanyi M. Rare case of successfully operated idiopathic colonic varicosity. Int J Surg Case Rep 2024; 123:110196. [PMID: 39181031 PMCID: PMC11388158 DOI: 10.1016/j.ijscr.2024.110196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 08/15/2024] [Accepted: 08/17/2024] [Indexed: 08/27/2024] Open
Abstract
INTRODUCTION Ectopic gastrointestinal varicosities are defined as dilated portosystemic collateral veins that may localize anywhere in the gastrointestinal tract outside the gastroesophageal region. Ectopic colonic varices can be considered idiopathic when other etiology that related to portal hypertension or portal vein thrombosis have been excluded. CASE PRESENTATION A forty-five-year-old female patient has been under treatment for histopathologically confirmed ulcerative colitis since the age of 17. In her forties, the patient developed worsening hematochezia leading to severe anemia. Routine colonoscopy was performed which confirmed extensive rectosigmoid varices. A thorough investigation did not confirm any underlying causes, such as portal hypertension or cirrhosis. DISCUSSION The selective percutaneous transhepatic mesenteric angiography, which is recommended as a diagnostic and therapeutic option, was not performed because the interventional radiologists did not consider embolization feasible. Laparoscopic rectosigmoid resection with high ligation of the inferior mesenteric vein led to complete remission of hematochezia. The final histological examination confirmed ectopic rectum and sigmoid varices, and ulcerative colitis was ruled out. CONCLUSIONS Lower gastrointestinal bleeding from the colonic varices is very rare, with only a few cases reported in the literature. In the idiopathic form, the prognosis is very good, given the absence of other underlying diseases causing portal hypertension. Ectopic varices present a clinical challenge as they are difficult to diagnose and localize. There are currently no clear guidelines for diagnosis and therapy, and recommendations are based on different case reports. Idiopathic cases can be treated effectively by resection of the affected bowel segment.
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Affiliation(s)
- Gergely Kóder
- Department of Surgery, Faculty of General Medicine, University of Debrecen, Debrecen, Móricz Zsigmond körút 22, Hungary.
| | - Tamás Dinya
- Department of Surgery, Faculty of General Medicine, University of Debrecen, Debrecen, Móricz Zsigmond körút 22, Hungary
| | - Dezső Tóth
- Department of Surgery, Faculty of General Medicine, University of Debrecen, Debrecen, Móricz Zsigmond körút 22, Hungary
| | - László Damjanovich
- Department of Surgery, Faculty of General Medicine, University of Debrecen, Debrecen, Móricz Zsigmond körút 22, Hungary
| | - Lóránt Ágoston
- Prestige Private Hospital, Lujza u. 16, Nyíregyháza 4405, Hungary
| | - Miklós Tanyi
- Department of Surgery, Faculty of General Medicine, University of Debrecen, Debrecen, Móricz Zsigmond körút 22, Hungary
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Shalaby S, Nicoară-Farcău O, Perez-Campuzano V, Olivas P, Torres S, García-Pagán JC, Hernández-Gea V. Transjugular Intrahepatic Portosystemic Shunt (TIPS) for Treatment of Bleeding from Cardiofundal and Ectopic Varices in Cirrhosis. J Clin Med 2024; 13:5681. [PMID: 39407741 PMCID: PMC11476950 DOI: 10.3390/jcm13195681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 07/26/2024] [Accepted: 09/21/2024] [Indexed: 10/20/2024] Open
Abstract
Acute variceal bleeding in cirrhosis represents a critical clinical event that significantly impacts patient prognosis, with mortality rates increasing further after a second episode. This underscores the need for immediate intervention and optimal prophylaxis. The creation of a transjugular intrahepatic portosystemic shunt (TIPS) has been proven to be highly effective for managing esophageal variceal bleeding. However, the use of TIPS for managing cardiofundal gastric varices and ectopic varices remains debated due to their unique vascular anatomy and the limited data available. These varices, although less prevalent than esophageal varices, are complex and heterogeneous vascular shunts between the splanchnic venous system and the systemic veins. Indeed, while endoscopic therapy with tissue adhesives is widely endorsed for achieving hemostasis in active hemorrhage, there is no consensus regarding the optimal approach for secondary prophylaxis. Recent research emphasizes the efficacy of endovascular techniques over endoscopic treatments, such as TIPS and endovascular variceal embolization techniques. This review examines the use of TIPS in managing acute variceal bleeding in patients with cirrhosis, focusing specifically on cardiofundal gastric varices and ectopic varices, discussing optimal patient care based on the latest evidence, aiming to improve outcomes for this challenging subset of patients.
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Affiliation(s)
- Sarah Shalaby
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
| | - Oana Nicoară-Farcău
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Hepatology Department, Regional Institute of Gastroenterology and Hepatology “Octavian Fodor”, “Iuliu Hatieganu” University of Medicine and Pharmacy, 3rd Medical Clinic, 400394 Cluj-Napoca, Romania
| | - Valeria Perez-Campuzano
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
| | - Pol Olivas
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
| | - Sonia Torres
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
- Departament de Medicina i Ciències de la Salut, Universitat de Barcelona, 08036 Barcelona, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
- Departament de Medicina i Ciències de la Salut, Universitat de Barcelona, 08036 Barcelona, Spain
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Matsubara Y, Tsuboi A, Hirata I, Sumioka A, Takasago T, Tanaka H, Yamashita K, Hiyama Y, Takigawa H, Murakami E, Tsuge M, Urabe Y, Oka S. Predictive factors of portal hypertensive enteropathy exacerbations based on long-term outcomes. BMC Gastroenterol 2024; 24:287. [PMID: 39187770 PMCID: PMC11346274 DOI: 10.1186/s12876-024-03377-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 08/14/2024] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND Portal hypertensive enteropathy (PHE) is a small-bowel lesion observed in patients with portal hypertension. The clinical significance of endoscopic findings in PHE remains unclear. We aimed to clarify the clinical significance and predictive factors of capsule endoscopic findings in patients with PHE based on long-term outcomes. METHODS This retrospective study enrolled 55 patients with PHE (33 males and 22 females; median age, 64 years; range, 23-87) followed for > 3 years using capsule endoscopy (CE) between February 2009 and May 2023. We evaluated the clinical factors affecting PHE exacerbations and the effects of PHE exacerbations on gastrointestinal bleeding by comparing exacerbated and unchanged PHE groups. RESULTS Overall, 3 (5%) patients showed improvement, 33 (60%) remained unchanged, and 19 (35%) showed exacerbation on follow-up CE. In the exacerbated group, the rates of worsened fibrosis-4 index, exacerbated esophageal varices, and exacerbated portal hypertensive gastropathy were significantly higher than those in the unchanged group (21%, 32%, and 42% vs. 3%, 6%, and 12%, respectively; P < 0.05), and the rate of splenectomy was significantly lower in the exacerbated group than in the unchanged group (5% vs. 39%, respectively; P < 0.01). In multivariate analysis, exacerbation of esophageal varices and absence of splenectomy were significantly associated with PHE exacerbation. The rate of gastrointestinal bleeding after follow-up CE was significantly high in the exacerbated group (log-rank, P = 0.037). CONCLUSIONS Exacerbation of esophageal varices and splenectomy were significantly associated with exacerbation of PHE. Exacerbated PHE requires specific attention to prevent gastrointestinal bleeding.
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Affiliation(s)
- Yuka Matsubara
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akiyoshi Tsuboi
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
- Department of Gastroenterology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Issei Hirata
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akihiko Sumioka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takeshi Takasago
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hidenori Tanaka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Ken Yamashita
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuichi Hiyama
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hidehiko Takigawa
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Eisuke Murakami
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masataka Tsuge
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuji Urabe
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shiro Oka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Tabet Aoul A, Mupparuju V, Cirillo J, Chandrupatla S, Jordan J, Castano M, Oyesanmi O. Use of TC-325 Hemostatic Powder as a Rescue Monotherapy for Management of Rectal Variceal Bleed. ACG Case Rep J 2024; 11:e01391. [PMID: 38903452 PMCID: PMC11188910 DOI: 10.14309/crj.0000000000001391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 05/07/2024] [Indexed: 06/22/2024] Open
Abstract
The use of the endoscopic hemostatic powder TC-325 as a rescue monotherapy or as an adjunct agent in achieving hemostasis has been studied in upper gastrointestinal variceal bleeds and nonvariceal lower gastrointestinal bleeds with promising results. In this report, we describe a case of a successful use of TC-325 as rescue monotherapy to manage rectal variceal bleeding in a patient with alcohol-related cirrhosis with no report of bleeding recurrence and no side effects within the first 7 days, 30 days, or 6 months.
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Affiliation(s)
- Amel Tabet Aoul
- Department of Internal Medicine, HCA Healthcare Florida Citrus Hospital Florida, Inverness, FL
| | - Vamsee Mupparuju
- Division of Gastroenterology, Department of Internal Medicine, HCA Healthcare Florida Citrus Hospital Florida, Inverness, FL
| | - Jonathan Cirillo
- Department of Internal Medicine, HCA Healthcare Florida Citrus Hospital Florida, Inverness, FL
| | - Sreekanth Chandrupatla
- Division of Gastroenterology, Department of Internal Medicine, HCA Healthcare Florida Citrus Hospital Florida, Inverness, FL
| | - Jeffrey Jordan
- Department of Internal Medicine, HCA Healthcare Florida Citrus Hospital Florida, Inverness, FL
| | - Maria Castano
- Department of Internal Medicine, HCA Healthcare Florida Citrus Hospital Florida, Inverness, FL
| | - Olugbenga Oyesanmi
- Department of Internal Medicine, HCA Healthcare Florida Citrus Hospital Florida, Inverness, FL
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Dhar J, Samanta J. Endoscopic ultrasound-guided vascular interventions: An expanding paradigm. World J Gastrointest Endosc 2023; 15:216-239. [PMID: 37138933 PMCID: PMC10150286 DOI: 10.4253/wjge.v15.i4.216] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/09/2023] [Accepted: 03/15/2023] [Indexed: 04/14/2023] Open
Abstract
Endoscopic ultrasound (EUS) has expanded its arena from a mere diagnostic modality to an essential therapeutic tool in managing gastrointestinal (GI) diseases. The proximity of the GI tract to the vascular structures in the mediastinum and the abdomen has facilitated the growth of EUS in the field of vascular interventions. EUS provides important clinical and anatomical information related to the vessels' size, appearance and location. Its excellent spatial resolution, use of colour doppler with or without contrast enhancement and ability to provide images "real-time" helps in precision while intervening vascular structures. Additionally, structures such as venous collaterals or varices can be dealt with optimally using EUS. EUS-guided vascular therapy with coil and glue combination has revolutionized the management of portal hypertension. It also helps to avoid radiation exposure in addition to being minimally invasive. These advantages have led EUS to become an upcoming modality to complement traditional interventional radiology in the field of vascular interventions. EUS-guided portal vein (PV) access and therapy is a new kid on the block. EUS-guided portal pressure gradient measurement, injecting chemotherapy in PV and intrahepatic portosystemic shunt has expanded the horizons of endo-hepatology. Lastly, EUS has also forayed into cardiac interventions allowing pericardial fluid aspiration and tumour biopsy with experimental data on access to valvular apparatus. Herein, we provide a comprehensive review of the expanding paradigm of EUS-guided vascular interventions in GI bleeding, portal vein access and its related therapeutic interventions, cardiac access, and therapy. A synopsis of all the technical details involving each procedure and the available data has been tabulated, and the future trends in this area have been highlighted.
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Affiliation(s)
- Jahnvi Dhar
- Gastroenterology, Sohana Multispeciality Hospital, Mohali 140308, India
| | - Jayanta Samanta
- Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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Barath S, Kheradia D, Gopalkrishnan SP, R. RK, K. MRP. Review of Applied Anatomy, Hemodynamics, and Endovascular Management of Ectopic Varices. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2021. [DOI: 10.1055/s-0041-1730868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
AbstractPortal hypertension leads to the opening up of collateral pathways to bypass the occlusion or resistance in the portal system. Ectopic varices are formed by such collaterals at many various sites along the gastrointestinal tract other than the usual location, that is, gastroesophageal region. Early diagnosis of ectopic varices needs strong clinical suspicion and contrast-enhanced computed tomography scan as endoscopy may often fail to pinpoint a source. In contrast to gastric varices where the understanding of the disease, as well as endovascular management, is widely studied and documented, the same is not true for ectopic varices due to low incidence. Understanding the applied anatomy and hemodynamic classification is important to decide the most suitable therapy. Interventional radiological procedures are aimed at either decompressing the varices or obliterating them and depend on the patency of the portal system, underlying etiology, and local expertise.
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Affiliation(s)
- Sitaram Barath
- Interventional Radiology Subdivision, Department of Radiology, Geetanjali Medical College & Hospital, Udaipur, Rajasthan, India
| | | | | | - Rahul K. R.
- Government Medical College, Kozhikode, Kerala, India
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Role of interventional radiology in intractable bleeding rectal varices. Abdom Radiol (NY) 2021; 46:1163-1170. [PMID: 32940757 DOI: 10.1007/s00261-020-02746-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/21/2020] [Accepted: 09/03/2020] [Indexed: 10/23/2022]
Abstract
In the setting of portal hypertension, intractable bleeding from anorectal varices is a rare occurrence. In this review, clinical presentation and management of this dilemma are presented in a case-based fashion. Bleeding may occur in the absence of prior history of cirrhosis or gastroesophageal varices and measurement of hepatic venous pressure gradient and liver biopsy could help to establish the diagnosis. Successful treatment outcome necessitates tailoring treatment to the patient's anatomy and imaging findings. A multidisciplinary algorithmic approach is also proposed to aid clinicians in this regard.
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Maeda H, Kageyama K, Yamamoto A, Jogo A, Sohgawa E, Matsushita K, Asano K, Yonezawa H, Nota T, Murai K, Ogawa S, Miki Y. Usefulness of coil-assisted retrograde transvenous obliteration II (CARTO-II) for the treatment of ascending colonic varix: a case report. CVIR Endovasc 2020; 3:90. [PMID: 33275189 PMCID: PMC7718362 DOI: 10.1186/s42155-020-00187-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/30/2020] [Indexed: 12/17/2022] Open
Abstract
Background Colonic varices are rare among ectopic varices. A previous report demonstrated that once bleeding from colonic varices occurs, it can be fatal. Several treatments for colonic varices exist, including surgical, endoscopic, and endovascular treatments; however, management of colonic varices has not been standardized. For colonic varices, minimally invasive therapies would be desirable. Balloon-occluded retrograde transvenous obliteration (B-RTO) is one of the treatment options for colonic varices to prevent their rupture. Two cases of successful conventional B-RTO for these varices have already been reported. However, B-RTO using coil-assisted retrograde transvenous obliteration II (CARTO-II) procedure for these varices has not been reported. Case presentation A 71-year-old male patient had liver cirrhosis caused by hepatitis C virus infection. A varix was located at the ascending colon, which was coincidentally found on colonic endoscopy. Contrast-enhanced computed tomography (CT) showed that the feeder vein was the ileocolic vein and that the main draining vein was the right renal vein. Physicians concluded that treatment was required to avoid the risk of death from massive bleeding due to varix rupture. However, endoscopic and surgical treatments were difficult due to the anatomical location of the varix and the high risk of operative compilations, respectively. This ascending colonic varix was treated by balloon-occluded retrograde transvenous obliteration (B-RTO) using coil-assisted retrograde transvenous obliteration II (CARTO-II) procedure via the right renal vein. There were no complications during the procedure and no recurrences for 36 months during long-term follow-up. Conclusions CARTO-II can be one of the effective treatment techniques for ascending colonic varices.
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Affiliation(s)
- Hiroyuki Maeda
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Ken Kageyama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan.
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Etsuji Sohgawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Kazuki Matsushita
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Kazuo Asano
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Hiroki Yonezawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Takehito Nota
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Kazuki Murai
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Satoyuki Ogawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
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Staudenmann DA, Kaffes AJ, Saxena P. Endoscopic Ultrasound-Guided Vascular Procedures: A Review. Clin Endosc 2020; 53:519-524. [PMID: 33027582 PMCID: PMC7548160 DOI: 10.5946/ce.2020.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 09/03/2020] [Indexed: 12/02/2022] Open
Abstract
Since the 1980s, endoscopic ultrasound has advanced from being purely diagnostic to an interventional modality. The gastrointestinal tract offers an exceptional window for assessing the vascular structures in the mediastinum and in the abdomen. This has led to a rapidly growing interest in endoscopic ultrasound-controlled vascular interventions as a minimally invasive alternative to surgical and radiological procedures.
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Affiliation(s)
- Dominic A Staudenmann
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Arthur J Kaffes
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia.,The University of Sydney, Sydney, Australia
| | - Payal Saxena
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia.,The University of Sydney, Sydney, Australia
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11
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Giurazza F, Corvino F, Cavaglià E, Silvestre M, Cangiano G, Amodio F, De Magistris G, Niola R. Emborrhoid in patients with portal hypertension and chronic hemorrhoidal bleeding: preliminary results in five cases with a new coiling release fashion “Spaghetti technique”. Radiol Med 2020; 125:1008-1011. [DOI: 10.1007/s11547-020-01194-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/02/2020] [Indexed: 02/07/2023]
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12
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Gardner IH, Siddharthan RV, Tsikitis VL. Benign anorectal disease: hemorrhoids, fissures, and fistulas. Ann Gastroenterol 2019; 33:9-18. [PMID: 31892792 PMCID: PMC6928486 DOI: 10.20524/aog.2019.0438] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 10/04/2020] [Indexed: 12/20/2022] Open
Abstract
Hemorrhoids, anal fissures, and fistulas are common benign anorectal diseases that have a significant impact on patients’ lives. They are primarily encountered by primary care providers, including internists, gastroenterologists, pediatricians, gynecologists, and emergency care providers. Most complex anorectal disease cases are referred to colorectal surgeons. Knowledge of these disease processes is essential for proper treatment and follow up. Hemorrhoids and fissures frequently benefit from non-operative treatment; they may, however, require surgical procedures. The treatment of anorectal abscess and fistulas is mainly surgical. The aim of this review is to examine the etiology, diagnosis, medical, and surgical treatment for these benign anorectal diseases.
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Affiliation(s)
- Ivy H Gardner
- Department of General Surgery, Division of Gastrointestinal and General Surgery Portland, Oregon Health and Science University, OR, USA
| | - Ragavan V Siddharthan
- Department of General Surgery, Division of Gastrointestinal and General Surgery Portland, Oregon Health and Science University, OR, USA
| | - Vassiliki Liana Tsikitis
- Department of General Surgery, Division of Gastrointestinal and General Surgery Portland, Oregon Health and Science University, OR, USA
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13
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Shalaby H, El-Meghawry ES, Al-Azhary S, Elfayoumy KN, Zeid ESA. Portal hypertensive colopathy in Egyptian cirrhotic patients: an endoscopic study. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2018. [DOI: 10.4103/ejim.ejim_42_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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14
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Goenka MK, Shah BB, Rai VK, Jajodia S, Goenka U. Mucosal Changes in the Small Intestines in Portal Hypertension: First Study Using the Pillcam SB3 Capsule Endoscopy System. Clin Endosc 2018; 51:563-569. [PMID: 30300988 PMCID: PMC6283757 DOI: 10.5946/ce.2018.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 07/18/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND/AIMS To evaluate patients with portal hypertension (PH) of varied etiologies for portal hypertensive enteropathy (PHE) using the PillCam SB3 capsule endoscopy (CE) system. METHODS Consecutive patients with PH presenting with unexplained anemia and/or occult gastrointestinal bleeding were evaluated using the PillCam SB3 CE system. Abnormal findings were categorized as vascular or non-vascular. The patients with ongoing bleeding caused by PHE were treated. The correlation of the CE scores of PHE with the clinical, laboratory, and endoscopic features was determined. RESULTS Of the 43 patients included in the study, 41 (95.3%) showed PHE findings. These included varices (67.4%), red spots (60.5%), erythema (44.2%), villous edema (46.5%), telangiectasia (16.3%), and polyps (16.3%). The CE scores varied from 0 to 8 (mean±standard deviation, 4.09±1.8). Five patients (11.6%) showed evidence of ongoing or recent bleeding due to PHE. Three of these five patients underwent endotherapy, and one patient underwent radiological coil placement. CONCLUSION The PillCam SB3 CE system revealed a high prevalence of PHE in the patients with PH. Using this system, evidence of bleeding due to PHE was found in a small but definite proportion of the patients.
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Affiliation(s)
| | - Bhavik Bharat Shah
- Institute of Gastro-Sciences, Apollo Gleneagles Hospitals, Kolkata, India
| | - Vijay Kumar Rai
- Institute of Gastro-Sciences, Apollo Gleneagles Hospitals, Kolkata, India
| | - Surabhi Jajodia
- Department of Clinical Imaging and Interventional Radiology, Apollo Gleneagles Hospitals, Kolkata, India
| | - Usha Goenka
- Department of Clinical Imaging and Interventional Radiology, Apollo Gleneagles Hospitals, Kolkata, India
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15
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Ishiyama S, Shiode J, Yoshioka M, Nasu J, Fujiwara A, Itoh M, Fujii M, Saitoh S, Kanetoh M, Oka H. A case of early colorectal cancer with rectal varices treated with endoscopic variceal ligation. Clin J Gastroenterol 2018; 12:10-14. [PMID: 30109571 DOI: 10.1007/s12328-018-0893-x] [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: 06/04/2018] [Accepted: 08/11/2018] [Indexed: 11/24/2022]
Abstract
Rectal varices are ectopic varices that occur in patients with portal hypertension and cause abrupt gastrointestinal bleeding. Endoscopic variceal ligation is a minimally invasive treatment used for patients with bleeding from rectal varices. Endoscopic treatment of colorectal tumors accompanied by rectal varices has been rarely reported. It is very important to control bleeding during treatment. The patient was a 76-year-old man who had a chief complaint of bloody stools. A flat-elevated-type neoplastic lesion measuring about 20 mm was found above the rectal varices. After performing endoscopic variceal ligation for rectal varices around the lesion, the lesion was resected en bloc by endoscopic submucosal dissection. Bleeding was controlled during the procedure; the patient was discharged 7 days after the endoscopic treatment, and there was no postoperative bleeding. Colonoscopy performed 90 days after the procedure showed scar formation in the wound area and no remnant lesion. The implementation of preoperative endoscopic variceal ligation enabled us to control bleeding during endoscopic treatment in a case of early colorectal cancer accompanied by rectal varices.
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Affiliation(s)
- Shuhei Ishiyama
- Internal Medicine, Okayama Saiseikai General Hospital, 2-25 Kokutaichou, Kita-ku, Okayama, 700-8511, Japan.
| | - Junji Shiode
- Internal Medicine, Okayama Saiseikai General Hospital, 2-25 Kokutaichou, Kita-ku, Okayama, 700-8511, Japan
| | - Masao Yoshioka
- Internal Medicine, Okayama Saiseikai General Hospital, 2-25 Kokutaichou, Kita-ku, Okayama, 700-8511, Japan
| | - Junichirou Nasu
- Internal Medicine, Okayama Saiseikai General Hospital, 2-25 Kokutaichou, Kita-ku, Okayama, 700-8511, Japan
| | - Akiko Fujiwara
- Internal Medicine, Okayama Saiseikai General Hospital, 2-25 Kokutaichou, Kita-ku, Okayama, 700-8511, Japan
| | - Mamoru Itoh
- Internal Medicine, Okayama Saiseikai General Hospital, 2-25 Kokutaichou, Kita-ku, Okayama, 700-8511, Japan
| | - Masakuni Fujii
- Internal Medicine, Okayama Saiseikai General Hospital, 2-25 Kokutaichou, Kita-ku, Okayama, 700-8511, Japan
| | - Shusuke Saitoh
- Internal Medicine, Okayama Saiseikai General Hospital, 2-25 Kokutaichou, Kita-ku, Okayama, 700-8511, Japan
| | - Mitsuhiro Kanetoh
- Internal Medicine, Okayama Saiseikai General Hospital, 2-25 Kokutaichou, Kita-ku, Okayama, 700-8511, Japan
| | - Hisanori Oka
- Internal Medicine, Okayama Saiseikai General Hospital, 2-25 Kokutaichou, Kita-ku, Okayama, 700-8511, Japan
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16
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Wu X, Xuan W, Song L. Transjugular intrahepatic portosystemic stent shunt placement and embolization for hemorrhage associated with rupture of anorectal varices. J Int Med Res 2018; 46:1666-1671. [PMID: 29338471 PMCID: PMC6091825 DOI: 10.1177/0300060517730720] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Portal hypertension can lead to ectopic varices, which occur most frequently in the rectum. Rectal variceal bleeding in patients with portal hypertension is rare but can be life-threatening if not diagnosed and treated in a timely manner. However, no specific treatment guidelines have been established for rectal variceal bleeding. We herein report a case involving a woman with portal hypertension due to autoimmune liver disease who was successfully treated with a transjugular intrahepatic portosystemic stent shunt and variceal embolization. We recommend treatment of refractory ectopic variceal bleeding with a transjugular intrahepatic portosystemic stent shunt in combination with embolization.
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Affiliation(s)
- Xiuyan Wu
- Department of Medical Oncology, The Second Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Wei Xuan
- Department of Medical Oncology, The Second Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Lei Song
- Department of Medical Oncology, The Second Hospital of Dalian Medical University, Dalian, Liaoning, China
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17
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Affiliation(s)
- Idan Levy
- Paul May and Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California
| | - Kenneth F Binmoeller
- Paul May and Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California
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18
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19
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Kim YH, Lee YS, Yoon YS, Hong S, Kim WY, Kim JH, Park YC. Rectal ectopic variceal bleeding during liver transplantation -A case report-. Anesth Pain Med (Seoul) 2017. [DOI: 10.17085/apm.2017.12.2.165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Yun-hee Kim
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Yoon-Sook Lee
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Yong-sang Yoon
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Soonyoung Hong
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Woon Young Kim
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Jae Hwan Kim
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Young-cheol Park
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Ansan, Korea
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20
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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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21
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Abdel-Aal AK, Dawoud N, Moustafa AS, Hamed MF, Saddekni S. Percutaneous Transhepatic Embolization of Bleeding Rectal Varices Using A New Embolic And Sclerotic Mixture Augmented By Amplatzer Vascular Plug 2. J Radiol Case Rep 2016; 10:44-51. [PMID: 27761198 PMCID: PMC5065273 DOI: 10.3941/jrcr.v10i9.2580] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
We report a case of 59-year-old female with non-alcoholic-steato-hepatitis (NASH) induced cirrhosis, who presented with hematochezia. The patient had a history of bleeding esophageal varices treated with endoscopic variceal ligation (EVL). Colonoscopy showed large rectal varices which were the source of her lower gastrointestinal bleeding (LGIB). Since endoscopic treatment for LGIB are limited, and because the patient had portal vein thrombosis which contraindicated transjugular intrahepatic portosystemic shunt (TIPS), we performed percutaneous transhepatic embolization of her rectal varices using a new mixture of embolic and sclerotic agents, followed by Amplatzer plug 2 (AVP 2). To our knowledge, the use of this new mixture with the AVP 2 in the rectal varices treatment has not been previously published in literature. Our case provides an alternative treatment modality that can be used for rectal varices treatment, when TIPS and endoscopic management fails or is contraindicated.
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Affiliation(s)
- Ahmed Kamel Abdel-Aal
- Department of Radiology, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
- Department of Radiology, Cairo University, Cairo, Egypt
| | - Nabila Dawoud
- Department of Radiology, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
| | - Amr Soliman Moustafa
- Department of Radiology, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
- Department of Radiology, Zagazig University, Zagazig, Egypt
| | - Maysoon F Hamed
- Department of Family medicine, University of Alabama, Tuscaloosa, Alabama, USA
| | - Souheil Saddekni
- Department of Radiology, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
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22
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Enteroscopic Management of Ectopic Varices in a Patient with Liver Cirrhosis and Portal Hypertension. Case Reports Hepatol 2016; 2016:2018642. [PMID: 27595025 PMCID: PMC4995326 DOI: 10.1155/2016/2018642] [Citation(s) in RCA: 4] [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: 04/12/2016] [Accepted: 07/19/2016] [Indexed: 12/12/2022] Open
Abstract
Portal hypertension and liver cirrhosis may predispose patients to varices, which have a propensity to bleed and cause significant morbidity and mortality. These varices are most commonly located in the gastroesophageal area; however, rarely ectopic varices may develop in unusual locations outside of this region. Haemorrhage from these sites can be massive and difficult to control; thus early detection and management may be lifesaving. We present a case of occult gastrointestinal bleeding in a patient with underlying alcoholic liver disease where an ectopic varix was ultimately detected with push enteroscopy.
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23
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Abstract
Symptomatic hemorrhoid disease is one of the most prevalent ailments associated with significant impact on quality of life. Management options for hemorrhoid disease are diverse, ranging from conservative measures to a variety of office and operating-room procedures. In this review, the authors will discuss the anatomy, pathophysiology, clinical presentation, and management of hemorrhoid disease.
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Affiliation(s)
- Zhifei Sun
- Department of Surgery, Duke University, Durham, North Carolina
| | - John Migaly
- Department of Surgery, Duke University, Durham, North Carolina
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24
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Komekami Y, Konishi F, Makita K, Mijin T, Onogawa A, Chochi T, Lee C, Yoshida T, Maeda T, Mitsusada M, Hasegawa S. Rectal arterio-venous malformation (AVM) with bleeding of an internal hemorrhoid. Clin J Gastroenterol 2016; 9:22-6. [DOI: 10.1007/s12328-016-0629-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 01/28/2016] [Indexed: 11/30/2022]
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Al Khalloufi K, Laiyemo AO. Management of rectal varices in portal hypertension. World J Hepatol 2015; 7:2992-2998. [PMID: 26730278 PMCID: PMC4691702 DOI: 10.4254/wjh.v7.i30.2992] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 10/13/2015] [Accepted: 12/11/2015] [Indexed: 02/06/2023] Open
Abstract
Rectal varices are portosystemic collaterals that form as a complication of portal hypertension, their prevalence has been reported as high as 94% in patients with extrahepatic portal vein obstruction. The diagnosis is typically based on lower endoscopy (colonoscopy or sigmoidoscopy). However, endoscopic ultrasonography has been shown to be superior to endoscopy in diagnosing rectal varices. Color Doppler ultrasonography is a better method because it allows the calculation of the velocity of blood flow in the varices and can be used to predict the bleeding risk in the varices. Although rare, bleeding from rectal varices can be life threatening. The management of patients with rectal variceal bleeding is not well established. It is important to ensure hemodynamic stability with blood transfusion and to correct any coagulopathy prior to treating the bleeding varices. Endoscopic injection sclerotherapy has been reported to be more effective in the management of active bleeding from rectal varices with less rebleeding rate as compared to endoscopic band ligation. Transjugular intrahepatic portsystemic shunt alone or in combination with embolization is another method used successfully in control of bleeding. Balloon-occluded retrograde transvenous obliteration is an emerging procedure for management of gastric varices that has also been successfully used to treat bleeding rectal varices. Surgical procedures including suture ligation and porto-caval shunts are considered when other methods have failed.
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Abstract
The continued need to develop minimally invasive alternatives to surgical and radiologic interventions has driven the development of endoscopic ultrasound (EUS)-guided treatments. EUS has now stepped into the therapeutic arena. EUS provides the unique advantage of both real-time imaging and access to structures within and adjacent to the gastrointestinal (GI) tract. Hence, EUS-guided therapeutic techniques continue to evolve in several directions enabling a variety of minimally invasive therapies for pancreatic and biliary pathologies. Furthermore, the close proximity of the GI tract to vascular structures in the mediastinum and abdomen permits EUS-guided vascular access and therapy. Studies have demonstrated several EUS-guided vascular interventions by using standard endoscopic accessories and available tools from the interventional radiology armamentarium. This article provides an overview of the literature including clinical and nonclinical studies for the management of nonvariceal and variceal GI bleeding, formation of intrahepatic portosystemic shunts (IPSS), and EUS-guided cardiac access and therapy.
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Affiliation(s)
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
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27
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Li SL, Jing FY, Ma LL, Guo LL, Na F, An SL, Ye Y, Yang JM, Bao M, Kang D, Sun XL, Deng YJ. Myofibrotic malformation vessels: unique angiodysplasia toward the progression of hemorrhoidal disease. DRUG DESIGN DEVELOPMENT AND THERAPY 2015; 9:4649-56. [PMID: 26316703 PMCID: PMC4541538 DOI: 10.2147/dddt.s90209] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background The etiology and pathogenesis of hemorrhoids is unclear, although hemorrhoids are a worldwide disease in men and women, with peak prevalence at 45–65 years of age. Hemorrhoidal cushions as the anal venous plexi are normal anatomical structures from infancy. This study attempts to reveal the angiodysplasia and other pathological changes in association with different degrees of symptomatic hemorrhoids. Materials and methods A total of 281 patients with internal hemorrhoids from degree I to IV underwent hemorrhoidectomy. The vascular changes were analyzed by microscopic assessment and software analysis, with Masson’s trichrome, CD34, and smooth muscle actin. Results The hemorrhoidal tissues exhibited abnormal vessels in the mucosae and submucosae that we termed them as myofibrotic malformation vessels (MMVs). MMVs are not ascribed to arteries or veins because they exhibit enlarged and tortuous lumens with smooth muscle dysplasia and fibrotic deposition in the walls without overlying mucosal ulceration. The muscularis mucosae also showed smooth muscle dysplasia and fibrosis, even if it were interrupted by the intruding MMVs. The statistical data indicated that the severity of all the changes correlate positively with the progression of hemorrhoids (P<0.001). Hemorrhoidal patients are prone for reoccurrence even with prolapsing hemorrhoid when compared with the conventional hemorrhoidectomy. Multiple logistic regression analysis showed that MMVs in mucosal propria, mean thickness of mucosal muscularis layer, and fibrotic changes in MMV were independent risk factors for MMVs in hemorrhoidal disease. Conclusion MMVs and muscularis mucosae dysplasia reciprocally contribute to hemorrhoidal exacerbation. The novel findings of this study propose that the characteristic features of MMVs and muscularis mucosae dysplasia of the anorectal tube ultimately cause symptomatic hemorrhoids, which could affect the clinical management of hemorrhoidal disease through the use of surgery to target the malformed vessels.
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Affiliation(s)
- Sheng-Long Li
- Department of Anorectal Surgery, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China
| | - Fang-Yan Jing
- Department of Anorectal Surgery, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China ; Department of Pathology, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China ; Department of Pathology, School of Basic Medical Sciences, Zengcheng, Guangzhou, People's Republic of China
| | - Li-Li Ma
- Department of Pathology, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China ; Department of Pathology, School of Basic Medical Sciences, Zengcheng, Guangzhou, People's Republic of China
| | - Li-Li Guo
- Department of Pathology, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China ; Department of Pathology, School of Basic Medical Sciences, Zengcheng, Guangzhou, People's Republic of China
| | - Feng Na
- Department of Pathology, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China ; Department of Pathology, School of Basic Medical Sciences, Zengcheng, Guangzhou, People's Republic of China
| | - Sheng-Li An
- Department of Biostatistics, Southern Medical University, Zengcheng, Guangzhou, People's Republic of China
| | - Yan Ye
- Department of General Surgery, Xintang Hospital, Zengcheng, Guangzhou, People's Republic of China
| | - Jun-Ming Yang
- Department of Anorectal Surgery, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China
| | - Ming Bao
- Department of Anorectal Surgery, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China
| | - Dong Kang
- Department of Anorectal Surgery, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China
| | - Xiao-Lan Sun
- Department of Anorectal Surgery, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China
| | - Yong-Jian Deng
- Department of Pathology, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China ; Department of Pathology, School of Basic Medical Sciences, Zengcheng, Guangzhou, People's Republic of China
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Sato T. Treatment of ectopic varices with portal hypertension. World J Hepatol 2015; 7:1601-1605. [PMID: 26140080 PMCID: PMC4483542 DOI: 10.4254/wjh.v7.i12.1601] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 02/21/2015] [Accepted: 04/14/2015] [Indexed: 02/06/2023] Open
Abstract
Ectopic varices are unusual with portal hypertension and can involve any site along the digestive tract outside the gastroesophageal region. Hemorrhage from ectopic varices generally are massive and life threatening. Diagnosis of ectopic varices is difficult and subsequent treatment is also difficult; the optimal treatment has not been established. Recently, interventional radiology and endoscopic treatments have been carried out successfully for hemorrhage from ectopic varices.
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Mekaroonkamol P, Cohen R, Chawla S. Portal hypertensive enteropathy. World J Hepatol 2015; 7:127-138. [PMID: 25729469 PMCID: PMC4342596 DOI: 10.4254/wjh.v7.i2.127] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 10/28/2014] [Accepted: 11/19/2014] [Indexed: 02/06/2023] Open
Abstract
Portal hypertensive enteropathy (PHE) is a condition that describes the pathologic changes and mucosal abnormalities observed in the small intestine of patients with portal hypertension. This entity is being increasingly recognized and better understood over the past decade due to increased accessibility of the small intestine made possible by the introduction of video capsule endoscopy and deep enteroscopy. Though challenged by its diverse endoscopic appearance, multiple scoring systems have been proposed to classify the endoscopic presentation and grade its severity. Endoscopic findings can be broadly categorized into vascular and non-vascular lesions with many subtypes of both categories. Clinical manifestations of PHE can range from asymptomatic incidental findings to fatal gastrointestinal hemorrhage. Classic endoscopic findings in the setting of portal hypertension may lead to a prompt diagnosis. Occasionally histopathology and cross sectional imaging like computed tomography or magnetic resonance imaging may be helpful in establishing a diagnosis. Management of overt bleeding requires multidisciplinary approach involving hepatologists, endoscopists, surgeons, and interventional radiologists. Adequate resuscitation, reduction of portal pressure, and endoscopic therapeutic intervention remain the main principles of the initial treatment. This article reviews the existing evidence on PHE with emphasis on its classification, diagnosis, clinical manifestations, endoscopic appearance, pathological findings, and clinical management. A new schematic management of ectopic variceal bleed is also proposed.
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Yoshino K, Imai Y, Nakazawa M, Chikayama T, Ando S, Sugawara K, Hamaoka K, Inao M, Oka M, Mochida S. Therapeutic strategy for patients with bleeding rectal varices complicating liver cirrhosis. Hepatol Res 2014; 44:1088-94. [PMID: 24033909 DOI: 10.1111/hepr.12232] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 08/21/2013] [Accepted: 08/27/2013] [Indexed: 01/09/2023]
Abstract
AIM Although rupture of rectal varices is rarely encountered, it may provoke massive and fatal hemorrhage in patients with liver cirrhosis. We examined the clinical features of patients showing bleeding from rectal varices to establish a suitable therapeutic strategy for the lesions. METHODS Twelve cirrhotic patients with bleeding rectal varices were enrolled. Surgical suture, endoscopic variceal ligation (EVL) or balloon tamponade was performed to achieve the initial hemostasis. Then, the feeding and drainage vessels of the varices were evaluated by computed tomography, and additional procedures were undertaken: EVL was performed when the sizes of the varices and feeding vessels were small. In contrast, in patients with varices of large sizes, balloon-occluded retrograde transvenous obliteration (B-RTO) was performed when single or two drainage vessels were identified, while endoscopic injection sclerotherapy (EIS) using ethanolamine oleate was carried out for varices with three or more drainage vessels. RESULTS The Child-Pugh class was grade A in four, B in six and C in two patients. Eleven patients had received previous therapy for esophageal varices. Initial hemostasis was achieved by surgical suture in three patients, EVL in one patient and balloon tamponade in two patients. EVL, EIS and B-RTO were carried out as additional procedures in seven, three and one patient, respectively. Rebleeding from the rectal varices occurred in only one patient who underwent EVL as an additional procedure. CONCLUSION Bleeding from rectal varices was controlled satisfactorily by the therapeutic strategy of selecting EVL, EIS or B-RTO as an additional therapy according to the size and hemodynamics of the varices.
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Affiliation(s)
- Kiyoko Yoshino
- Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Iruma-gun, Japan
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31
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Cauchy F, Schwarz L, Brustia R, Sepulveda A, Perdigao F, Bernard D, Schielke A, Scatton O, Soubrane O. Laparoscopic division of a portosystemic shunt for recurrent life-threatening rectal variceal bleeding: report of a case. J Gastrointest Surg 2014; 18:842-4. [PMID: 24311294 DOI: 10.1007/s11605-013-2409-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 10/31/2013] [Indexed: 01/31/2023]
Abstract
In patients with severe portal hypertension related to liver cirrhosis, recanalization of umbilical veins may lead to both development and rupture of massive anorectal varices. In this setting, while transjugular intrahepatic portosystemic shunt (TIPS) is considered as the treatment of choice, the management of these patients remains unclear in case of contraindications to TIPS. Laparoscopic division of massive portosystemic shunts has been reported to yield beneficial effects in patients with isolated hepatic encephalopathy but has never been attempted in a context of life-threatening lower gastrointestinal bleeding. In the present case report, we both describe the operative technique of laparoscopic division of recanalized umbilical veins to treat recurrent massive haemorrhage following rupture of giant rectal varices in a 68-year-old Child C cirrhotic patient contraindicated to TIPS and report the postoperative course of the patient.
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Affiliation(s)
- François Cauchy
- Department of Hepatobiliary and Liver Transplantation Surgery, Hôpital Saint-Antoine, Assistance publique-Hopitaux de Paris, Université Pierre et Marie Curie, Paris, France
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32
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Galati G, De Vincentis A, Ripetti V, La Vaccara V, Vespasiani-Gentilucci U, Mazzarelli C, Gallo P, Luppi G, Grasso RF, Picardi A. Haemorrhoidal disease in severe portal hypertension: a combined approach with transjugular intrahepatic portosystemic shunt (TIPS) and transanal haemorrhoidal dearterialization (THD). Arch Med Sci 2014; 10:195-6. [PMID: 24701234 PMCID: PMC3953988 DOI: 10.5114/aoms.2014.40746] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Revised: 02/04/2013] [Accepted: 02/05/2013] [Indexed: 12/19/2022] Open
Affiliation(s)
- Giovanni Galati
- Department of Clinical Medicine and Hepatology, Campus Bio-Medico University of Rome, Italy
| | - Antonio De Vincentis
- Department of Clinical Medicine and Hepatology, Campus Bio-Medico University of Rome, Italy
| | - Valter Ripetti
- Department of General Surgery, Campus Bio-Medico University of Rome, Italy
| | | | | | - Chiara Mazzarelli
- Department of Clinical Medicine and Hepatology, Campus Bio-Medico University of Rome, Italy
| | - Paolo Gallo
- Department of Clinical Medicine and Hepatology, Campus Bio-Medico University of Rome, Italy
| | - Giacomo Luppi
- Department of Interventional Radiology, Campus Bio-Medico University of Rome, Italy
| | | | - Antonio Picardi
- Department of Clinical Medicine and Hepatology, Campus Bio-Medico University of Rome, Italy
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33
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Treatment of bleeding rectal varices with transumbilical venous obliteration of the inferior mesenteric vein. Surg Laparosc Endosc Percutan Tech 2014; 23:e134-7. [PMID: 23752023 DOI: 10.1097/sle.0b013e31828031ec] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A 56-year-old male with alcohol-induced liver cirrhosis developed rectal varices. He had a prior history of treatment for esophageal varices with endoscopic variceal ligation. Despite the repeated treatment for rectal varices with endoscopic variceal ligation, endoscopic injection sclerotherapy, and surgery, the bleeding from the rectal varices could not be controlled. Multidetector-row computed tomography and 3D-angiography revealed the hemodynamic profile of the rectal varices. We next approached the rectal varices through the umbilical vein on the abdominal wall, and successfully embolized the varices continuing from the inferior mesenteric vein using coils and a 5% solution of ethanolamine oleate with iopamidol.
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34
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Kim KS, Suh GJ, Kwon WY. Successful Bridging Hemostasis Using a Sengstaken-Blakemore Tube in Massive Rectal Variceal Bleeding. Korean J Crit Care Med 2014. [DOI: 10.4266/kjccm.2014.29.3.237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Kyung Su Kim
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Gil Joon Suh
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Woon Yong Kwon
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
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35
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Maslekar S, Toh EW, Adair R, Bate JP, Botterill I. Systematic review of anorectal varices. Colorectal Dis 2013; 15:e702-10. [PMID: 24020839 DOI: 10.1111/codi.12417] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 06/18/2013] [Indexed: 12/13/2022]
Abstract
AIM Anorectal varices are an uncommon, but significant, source of bleeding in patients with portal hypertension. The aim of this article was to review systematically the available literature on the aetiology, clinical presentation and management of anorectal varices, and to suggest a simple treatment algorithm based on available evidence and local expertise. METHOD A systematic literature search was carried out to identify articles on anorectal varices, and the search strategy identified 57 relevant references. The inclusion criteria included a consecutive cohort of patients having treatment for anorectal varices with details of success rates and the number of different techniques used. Exclusion criteria included papers published in languages other than English with no English version and results not reported separately for anorectal varices. RESULTS Anorectal varices can occur in up to 89% of patients with portal hypertension, although the overall incidence in the general population is low. Diagnosis is best achieved with anoscopy or flexible sigmoidoscopy. The current evidence supports the use of local procedures, such as endoscopic band ligation, to arrest bleeding where feasible, with radiological or surgical procedures used in the event of failure. CONCLUSION As there are no large series on this pathology, we present a systematic approach for the patient with anorectal varices.
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Affiliation(s)
- S Maslekar
- The John Goligher Colorectal Unit, St James's University Hospital, Leeds, UK
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36
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Successful treatment of endoscopically unmanageable rectal varices by balloon-occluded antegrade transvenous sclerotherapy followed by microcoil embolization. J Vasc Interv Radiol 2013; 24:1399-403. [PMID: 23973026 DOI: 10.1016/j.jvir.2013.04.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 04/10/2013] [Accepted: 04/11/2013] [Indexed: 11/23/2022] Open
Abstract
The present report describes two cases of endoscopically unmanageable rectal varices that were treated by balloon-occluded antegrade transvenous sclerotherapy (BATS) followed by microcoil embolization. Follow-up endoscopy confirmed eradication of the rectal varices. Balloon-occluded rectal venography showed stasis of contrast material and sclerosing agent for 30 minutes in both cases of rectal varices, which indicated that the inflow vessel was a single dilated superior rectal vein without other minor inflow vessels. BATS appears to be a feasible therapeutic option for the treatment of rectal varices of this hemodynamic type.
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37
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Gastrointestinal Bleeding in Cirrhotic Patients with Portal Hypertension. ISRN HEPATOLOGY 2013; 2013:541836. [PMID: 27335828 PMCID: PMC4890899 DOI: 10.1155/2013/541836] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 06/29/2013] [Indexed: 02/06/2023]
Abstract
Gastrointestinal bleeding related to portal hypertension is a serious complication in patients with liver cirrhosis. Most patients bleed from esophageal or gastric varices, but bleeding from ectopic varices or portal hypertensive gastropathy is also possible. The management of acute bleeding has changed over the last years. Patients are managed with a combination of endoscopic and pharmacologic treatment. The endoscopic treatment of choice for esophageal variceal bleeding is variceal band ligation. Bleeding from gastric varices is treated by injection with cyanoacrylate. Treatment with vasoactive drugs as well as antibiotic treatment is started before or at the time point of endoscopy. The first-line treatment for primary prophylaxis of esophageal variceal bleeding is nonselective beta blockers. Pharmacologic therapy is recommended for most patients; band ligation is an alternative in patients with contraindications for or intolerability of beta blockers. Treatment options for secondary prophylaxis include variceal band ligation, beta blockers, a combination of nitrates and beta blockers, and combination of band ligation and pharmacologic treatment. A clear superiority of one treatment over the other has not been shown. Bleeding from portal hypertensive gastropathy or ectopic varices is less common. Treatment options include beta blocker therapy, injection therapy, and interventional radiology.
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38
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Moore JS, Seah AS, Hyman N. Management of hemorrhoids in unusual circumstances. SEMINARS IN COLON AND RECTAL SURGERY 2013. [DOI: 10.1053/j.scrs.2013.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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39
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EUS-Assisted Evaluation of Rectal Varices before Banding. Gastroenterol Res Pract 2013; 2013:619187. [PMID: 23781241 PMCID: PMC3678414 DOI: 10.1155/2013/619187] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 03/16/2013] [Indexed: 12/12/2022] Open
Abstract
Rectal varices are an important cause of bleed. The bleeding can be sometimes fatal. Endoscopic management is possible and is generally done in emergency situation. Rectal variceal banding is useful. Hemodynamic evaluation has shown that the blood flow in rectal varices is from above downwards; however, the site of banding of rectal varices is unclear. This case series shows that the rectal varices should be banded at the highest point of inflow.
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40
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Bach HH, Wang N, Eberhardt JM. Common anorectal disorders for the intensive care physician. J Intensive Care Med 2013; 29:334-41. [PMID: 23753241 DOI: 10.1177/0885066613485347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although anorectal disorders such as abscess, fissure, and hemorrhoids are typically outpatient problems, they also occur in the critically ill patient population, where their presentation and management are more difficult. This article will provide a brief review of anorectal anatomy, explain the proper anorectal examination, and discuss the current understanding and treatment concepts with regard to the most common anorectal disorders that the intensive care unit clinician is likely to face.
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Affiliation(s)
- Harold H Bach
- Division of Colon and Rectal Surgery, Department of Surgery, Loyola University Medical Center, Maywood, IL, USA Department of Molecular Pharmacology and Therapeutics, Loyola University Medical Center, Maywood, IL, USA
| | - Norby Wang
- Division of Colon and Rectal Surgery, Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Joshua M Eberhardt
- Division of Colon and Rectal Surgery, Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
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41
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Ko BS, Kim WT, Chang SS, Kim EH, Lee SW, Park WS, Kim YS, Nam SW, Lee DS, Kim JC, Kang SB. A case of ascending colon variceal bleeding treated with venous coil embolization. World J Gastroenterol 2013; 19:311-5. [PMID: 23345957 PMCID: PMC3547563 DOI: 10.3748/wjg.v19.i2.311] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 11/08/2012] [Accepted: 11/14/2012] [Indexed: 02/06/2023] Open
Abstract
A 38-year-old female with a history of alcoholic liver cirrhosis visited our hospital with a massive hematochezia. An esophagogastroduodenoscopy did not demonstrate any bleeding source, and a colonoscopy showed a massive hemorrhage in the ascending colon but without an obvious focus. The source of the bleeding could not be found with a mesenteric artery angiography. We performed an enhanced abdominal computed tomography, which revealed a distal ascending colonic varix, and assumed that the varix was the source of the bleeding. We performed a venous coil embolization and histoacryl injection to obliterate the colon varix. The intervention appeared to be successful because the vital signs and hemoglobin laboratory data remained stable and because the hematochezia was no longer observed. We report here on a rare case of colonic variceal bleeding that was treated with venous coil embolization.
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42
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Arai H, Kobayashi T, Takizawa D, Toyoda M, Takayama H, Abe T. Transileocolic vein obliteration for bleeding rectal varices with portal thrombus. Case Rep Gastroenterol 2013; 7:75-81. [PMID: 23626507 PMCID: PMC3617969 DOI: 10.1159/000348761] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
We report a case of rectal varices treated successfully with transileocolic vein obliteration (TIO). A 70-year-old man was admitted to our hospital for evaluation of fresh bloody stools in January 2011. Emergent colonoscopy revealed fresh blood in the rectum and tortuous rectal varices. Three-dimensional computed tomography was used as a non-invasive method for the identification of rectal varices and thrombus in the extrahepatic portal vein. Angiography demonstrated that rectal varices were supplied with backward blood flow by the inferior mesenteric vein. Transileocolic variceal obliteration was performed using coils and 5% ethanolamine oleate with iopamidol. Complete hemostasis was achieved without complications. We conclude that TIO is a safe and effective hemostatic measure for ruptured rectal varices with portal thrombus.
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Affiliation(s)
- Hirotaka Arai
- Department of Gastroenterology, Maebashi Red Cross Hospital, Maebashi, Japan
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43
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Akhter NM, Haskal ZJ. Diagnosis and management of ectopic varices. GASTROINTESTINAL INTERVENTION 2012. [DOI: 10.1016/j.gii.2012.08.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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44
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Affiliation(s)
- Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Chandan K N Kumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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45
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Moubarak E, Bouvier A, Boursier J, Lebigot J, Ridereau-Zins C, Thouveny F, Willoteaux S, Aubé C. Portosystemic collateral vessels in liver cirrhosis: a three-dimensional MDCT pictorial review. Abdom Radiol (NY) 2012; 37:746-66. [PMID: 22002160 DOI: 10.1007/s00261-011-9811-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE Portosystemic collateral vessels (PSCV) are a consequence of the portal hypertension that occurs in chronic liver diseases. Their prognosis is strongly marked by the risk of digestive hemorrhage and hepatic encephalopathy. MATERIALS AND METHODS CT was performed with a 16-MDCT scanner. Maximum intensity projection and volume rendering were systematically performed on a workstation to analyze PSCV. RESULTS We describe the PSCV according to their drainage into either the superior or the inferior vena cava. In the superior vena cave group, we found gastric veins, gastric varices, esophageal, and para-esophageal varices. In the inferior vena cava group, the possible PSCV are numerous, with different sub groups: gastro and spleno renal shunts, paraumbilical and abdominal wall veins, retroperitoneal shunts, mesenteric varices, gallbladder varices, and omental collateral vessels. Regarding clinical consequences esophageal and gastric varices are most frequently involved in digestive bleeding; splenorenal shunts often lead to hepatic encephalopathy; the paraumbilical vein is an acceptable derivation pathway for natural decompression of the portal system. CONCLUSION Knowledge of precise cartography of PSCV is essential to therapeutic decisions. MDCT is the best way to understand and describe the different types of PSCV.
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Affiliation(s)
- Elie Moubarak
- Department of Radiology, Angers University Hospital, Angers, France
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46
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Khaliq A, Dutta U, Kochhar R, Chalapathi A, Singh K. Massive lower gastrointestinal bleed due to rectal varix. Intern Emerg Med 2012; 7 Suppl 1:S57-9. [PMID: 22033787 DOI: 10.1007/s11739-011-0685-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Accepted: 07/22/2011] [Indexed: 12/31/2022]
Affiliation(s)
- Abdul Khaliq
- Department of Gastroenterology, PGIMER, Sector-12, Chandigarh, India.
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47
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Krystallis C, Masterton GS, Hayes PC, Plevris JN. Update of endoscopy in liver disease: More than just treating varices. World J Gastroenterol 2012; 18:401-11. [PMID: 22346246 PMCID: PMC3272639 DOI: 10.3748/wjg.v18.i5.401] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 06/02/2011] [Accepted: 06/09/2011] [Indexed: 02/06/2023] Open
Abstract
The management of complications in liver disease is often complex and challenging. Endoscopy has undergone a period of rapid expansion with numerous novel and specialized endoscopic modalities that are of increasing value in the investigation and management of the patient with liver disease. In this review, relevant literature search and expert opinions have been used to provide a brief overview and update of the current endoscopic management of patients with liver disease and portal hypertension. The main areas covered are safety of endoscopy in patients with liver disease, the use of standard endoscopy for the treatment of varices and the role of new endoscopic modalities such as endoscopic ultrasound, esophageal capsule, argon plasma coagulation, spyglass and endomicroscopy in the investigation and treatment of liver-related gastrointestinal and biliary pathology. It is clear that the role of the endoscopy in liver disease is well beyond that of just treating varices. As the technology in endoscopy expands, so does the role of the endoscopist in liver disease.
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48
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Clinical manifestations of portal hypertension. Int J Hepatol 2012; 2012:203794. [PMID: 23024865 PMCID: PMC3457672 DOI: 10.1155/2012/203794] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Revised: 07/20/2012] [Accepted: 07/25/2012] [Indexed: 02/07/2023] Open
Abstract
The portal hypertension is responsible for many of the manifestations of liver cirrhosis. Some of these complications are the direct consequences of portal hypertension, such as gastrointestinal bleeding from ruptured gastroesophageal varices and from portal hypertensive gastropathy and colopathy, ascites and hepatorenal syndrome, and hypersplenism. In other complications, portal hypertension plays a key role, although it is not the only pathophysiological factor in their development. These include spontaneous bacterial peritonitis, hepatic encephalopathy, cirrhotic cardiomyopathy, hepatopulmonary syndrome, and portopulmonary hypertension.
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49
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Almadi MA, Almessabi A, Wong P, Ghali PM, Barkun A. Ectopic varices. Gastrointest Endosc 2011; 74:380-8. [PMID: 21612777 DOI: 10.1016/j.gie.2011.03.1177] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Accepted: 03/14/2011] [Indexed: 12/13/2022]
Affiliation(s)
- Majid Abdulrahman Almadi
- Division of Gastroenterology, McGill University and the McGill University Health Centre, Montreal, Quebec, Canada
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50
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Anderson KL, Dean AJ. Foreign Bodies in the Gastrointestinal Tract and Anorectal Emergencies. Emerg Med Clin North Am 2011; 29:369-400, ix. [DOI: 10.1016/j.emc.2011.01.009] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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