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Dolu S, Arayici ME, Onem S, Buyuktorun I, Dongelli H, Bengi G, Akarsu M. Effectiveness of Double Balloon Enteroscopy in the Diagnosis and Treatment of Small Bowel Varices. Diagnostics (Basel) 2025; 15:336. [PMID: 39941266 PMCID: PMC11817830 DOI: 10.3390/diagnostics15030336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2024] [Revised: 01/28/2025] [Accepted: 01/30/2025] [Indexed: 02/16/2025] Open
Abstract
Background/Aims: Double balloon enteroscopy (DBE) is an innovative method for the diagnosis and management of small bowel (SB) diseases. SB varices are rare disorders, and their diagnosis and treatment can be challenging for clinicians. This study evaluates the use of double balloon enteroscopy (DBE) in diagnosing and treating small bowel varices. Materials and Methods: SB varices were detected in 28 out of 900 double balloon enteroscopy procedures over an 18-year period. Eleven cases of SB varices of various etiologies, diagnosed via DBE, are described. The characteristics of SB varices and endoscopic procedural details were evaluated. Results: A retrospective investigation of 750 patients identified eleven patients (eight males and three females; median age 59 years, range 40-80 years) with small bowel varices. The most common site of SB varices was the jejunum. At least one abdominopelvic surgical procedure had been previously performed on five patients. Endotherapy by DBE was administered to nine patients (seven emergent and two prophylactic). Post-endotherapy, three patients experienced bleeding that required re-endotherapy. Endoscopic therapy for small bowel varices included injection sclerotherapy in eight cases (six with cyanoacrylate and two with polidocanol) and injection sclerotherapy plus hemoclipping in one case. Conclusions: SB varices can present a diagnostic challenge for clinicians. DBE is a valuable tool for both the diagnosis and management of small bowel varices.
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Affiliation(s)
- Suleyman Dolu
- Department of Gastroenterology, Faculty of Medicine, Dokuz Eylül University, Izmir 35340, Turkey; (I.B.); (G.B.)
| | - Mehmet Emin Arayici
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Dokuz Eylül University, Izmir 35340, Turkey;
| | - Soner Onem
- Department of Gastroenterology, Samsun Training and Research Hospital, Samsun 55090, Turkey;
| | - Ilker Buyuktorun
- Department of Gastroenterology, Faculty of Medicine, Dokuz Eylül University, Izmir 35340, Turkey; (I.B.); (G.B.)
| | - Huseyin Dongelli
- Department of Internal Medicine, Faculty of Medicine, Dokuz Eylül University, Izmir 35340, Turkey;
| | - Goksel Bengi
- Department of Gastroenterology, Faculty of Medicine, Dokuz Eylül University, Izmir 35340, Turkey; (I.B.); (G.B.)
| | - Mesut Akarsu
- Private Gastroenterology Clinic, Izmir 35535, Turkey;
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2
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Majid Z, Yaseen T, Tasneem AA, Luck NH. Rectal varices vs hemorrhoids-diagnosis and management. World J Hepatol 2024; 16:1216-1218. [PMID: 39606165 PMCID: PMC11586752 DOI: 10.4254/wjh.v16.i11.1216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 09/01/2024] [Accepted: 10/15/2024] [Indexed: 11/06/2024] Open
Abstract
Rectal varices are an uncommon manifestation of portal hypertension. Although hemorrhoids can be seen in cirrhotic patients, distinguishing between rectal varices and hemorrhoids can be challenging. Furthermore, the underlying mechanism and treatment options vary. Hence, the correct identification is of utmost important. Through this letter, we highlight the features of both and listed the distinguishing points between the two etiologies.
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Affiliation(s)
- Zain Majid
- Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi 74200, Pakistan.
| | - Taha Yaseen
- Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi 74200, Pakistan
| | - Abbas Ali Tasneem
- Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi 74200, Pakistan
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3
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Ogawa S, Yamamoto A, Jogo A, Kageyama K, Sohgawa E, Ohira G, Kimura K, Tanaka S, Amano R, Takemura S, Ishizawa T, Miki Y. Embolization with or without portal vein stenting for bleeding ectopic jejunal varices in hepatopetal portal collaterals due to extrahepatic portal vein occlusion or stenosis after hepatobiliary and pancreatic surgery. Jpn J Radiol 2024; 42:1342-1351. [PMID: 38935221 PMCID: PMC11522060 DOI: 10.1007/s11604-024-01616-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 06/17/2024] [Indexed: 06/28/2024]
Abstract
PURPOSE To evaluate the efficacy and safety of embolization with or without portal vein stenting for bleeding ectopic jejunal varices in the hepatopetal portal collateral due to extrahepatic portal vein occlusion or stenosis after hepatobiliary and pancreatic surgery. MATERIALS AND METHODS This study included consecutive patients who underwent embolization for bleeding ectopic jejunal varices in the hepatopetal collateral due to extrahepatic portal vein occlusion or stenosis after hepatobiliary and pancreatic surgery between September 2012 and December 2020. The safety, technical and clinical success rates (no re-bleeding within 1 month) and re-bleeding-free survival after the first therapy and overall survival were assessed. RESULTS Fourteen sessions in 11 patients were included. Four patients (7 sessions) underwent variceal embolization only, and the remaining seven patients (7 sessions) underwent portal vein stenting and variceal embolization. Technical success was achieved in all 14 sessions (100%). Clinical success was achieved in 13 of 14 sessions (92.9%). No treatment-related serious complications including liver failure were observed. One-year and 2-year re-bleeding-free survival rate after the first endovascular therapy in all 11 patients was 90.9 and 60.6%, respectively. Two patients who experienced re-bleeding had repeat embolization treatment. There was no significant difference in re-bleeding-free survival after endovascular therapy between the combination with stenting and embolization group and the embolization-only group (p = 0.13). CONCLUSION Embolization with or without portal vein stenting of bleeding ectopic jejunal varices in the hepatopetal portal collateral due to extrahepatic portal vein occlusion or stenosis after hepatobiliary and pancreatic surgery can be considered a safe, effective, and repeatable therapy for long-term hemostasis of uncontrollable bleeding.
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Affiliation(s)
- Satoyuki Ogawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
- Department of Diagnostic Radiology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-Ku, Osaka, 530-0012, Japan
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan.
| | - Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
| | - Ken Kageyama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
| | - Etsuji Sohgawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
| | - Go Ohira
- Department of Hepato-Biliary-Pancreatic Surgery Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Kenjiro Kimura
- Department of Hepato-Biliary-Pancreatic Surgery Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Shogo Tanaka
- Department of Hepato-Biliary-Pancreatic Surgery Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Ryosuke Amano
- Department of Hepato-Biliary-Pancreatic Surgery Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Shigekazu Takemura
- Department of Hepato-Biliary-Pancreatic Surgery Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Takeaki Ishizawa
- Department of Hepato-Biliary-Pancreatic Surgery Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
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4
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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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5
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He K, Pang K, Yan X, Wang Q, Wu D. New sights in ectopic varices in portal hypertension. QJM 2024; 117:397-412. [PMID: 38321102 DOI: 10.1093/qjmed/hcae026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/31/2024] [Indexed: 02/08/2024] Open
Abstract
Ectopic varices and associated bleeding, although rare, pose a significant risk to patients with portal hypertension, carrying a relatively high mortality rate. These varices can occur in various anatomical regions, excluding the gastroesophageal region, which is typically associated with portal vein drainage. The limited data available in the literature, derived mostly from case reports and series, make the diagnosis and treatment of ectopic variceal bleeding particularly challenging. Furthermore, it is crucial to recognize that ectopic varices in different sites can exhibit variations in key decision-making factors such as aetiology and vascular anatomy, severity and bleeding risk and hepatic reserve. These factors significantly influence treatment strategies and underscore the importance of adopting individualized management approaches. Therefore, the objective of this review is to provide a comprehensive overview of the fundamental knowledge surrounding ectopic varices and to propose site-oriented, stepwise diagnosis and treatment algorithms for this complex clinical issue. A multidisciplinary treatment approach is strongly recommended in managing ectopic varices. In addition, to enhance clinical reference, we have included typical case reports of ectopic varices in various sites in our review, while being mindful of potential publication bias.
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Affiliation(s)
- K He
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - K Pang
- Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - X Yan
- Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Q Wang
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - D Wu
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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6
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Egbo O, Dakkak B, Ugonabo OS, Magiera C. Duodenal Varices Presenting as Lower Gastrointestinal Bleeding. Cureus 2024; 16:e63244. [PMID: 39070523 PMCID: PMC11281973 DOI: 10.7759/cureus.63244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2024] [Indexed: 07/30/2024] Open
Abstract
Duodenal varices pose a significant clinical challenge due to their association with severe gastrointestinal bleeding. This condition requires attention because of its acute severity, high morbidity, and mortality rates. The presented case underscores the importance of advancing both knowledge and treatment approaches for duodenal varices. This pursuit is aimed not only at improving immediate clinical outcomes but also at deepening our understanding of complications related to portal hypertension.
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Affiliation(s)
- Olachi Egbo
- Department of Internal Medicine, Aurora Medical Center Oshkosh, Oshkosh, USA
| | - Bassel Dakkak
- Department of Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Onyinye S Ugonabo
- Department of Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
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7
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Ravilla J, Doantrang D. Colonic Varices as an Unsettling Cause of Lower Gastrointestinal Bleeding. Cureus 2024; 16:e60490. [PMID: 38883036 PMCID: PMC11180415 DOI: 10.7759/cureus.60490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2024] [Indexed: 06/18/2024] Open
Abstract
Colonic varicose veins are very rare and are usually discovered incidentally during colonoscopy or when complications occur, such as lower gastrointestinal (GI) bleeding. The primary cause of colonic varices is usually portal hypertension secondary to liver disease or very rarely due to pancreatic disease (e.g., pancreatic adenocarcinoma). Varicose veins secondary to cirrhosis are often seen in the upper GI tract but rarely in the lower GI tract. Here, we report a 54-year-old woman who presented with colonic varices due to decompensated alcoholic cirrhosis. The main intention of this case report was to raise awareness of the possibility of developing colonic varices from liver cirrhosis and to promptly identify and manage its side effects due to the major complication which is lower GI bleeding.
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Affiliation(s)
| | - Du Doantrang
- Internal Medicine, Monmouth Medical Center, Long Branch, USA
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8
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Liu J, Wang P, Wang LM, Guo J, Zhong N. Outcomes of endoscopic sclerotherapy for jejunal varices at the site of choledochojejunostomy (with video): Three case reports. World J Gastroenterol 2024; 30:2059-2067. [PMID: 38681128 PMCID: PMC11045488 DOI: 10.3748/wjg.v30.i14.2059] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/09/2024] [Accepted: 03/26/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Hemorrhage associated with varices at the site of choledochojejunostomy is an unusual, difficult to treat, and often fatal manifestation of portal hypertension. So far, no treatment guidelines have been established. CASE SUMMARY We reported three patients with jejunal varices at the site of choledochojejunostomy managed by endoscopic sclerotherapy with lauromacrogol/α-butyl cyanoacrylate injection at our institution between June 2021 and August 2023. We reviewed all patient records, clinical presentation, endoscopic findings and treatment, outcomes and follow-up. Three patients who underwent pancreaticoduodenectomy with a Whipple anastomosis were examined using conventional upper gastrointestinal endoscopy for suspected hemorrhage from the afferent jejunal loop. Varices with stigmata of recent hemorrhage or active hemorrhage were observed around the choledochojejunostomy site in all three patients. Endoscopic injection of lauromacrogol/α-butyl cyanoacrylate was carried out at jejunal varices for all three patients. The bleeding ceased and patency was observed for 26 and 2 months in two patients. In one patient with multiorgan failure and internal environment disturbance, rebleeding occurred 1 month after endoscopic sclerotherapy, and despite a second endoscopic sclerotherapy, repeated episodes of bleeding and multiorgan failure resulted in eventual death. CONCLUSION We conclude that endoscopic sclerotherapy with lauromacrogol/α-butyl cyanoacrylate injection can be an easy, effective, safe and low-cost treatment option for jejunal varicose bleeding at the site of choledochojejunostomy.
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Affiliation(s)
- Jun Liu
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Peng Wang
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Li-Mei Wang
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Jing Guo
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Ning Zhong
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
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Singh H, Kimchy A, Boustani C, Umoren M, Rangnekar A, Smith C. Hemorrhagic Shock from a Duodenal Ulcer Eroding into an Ectopic Varix. Case Reports Hepatol 2023; 2023:7094924. [PMID: 38187994 PMCID: PMC10771916 DOI: 10.1155/2023/7094924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/15/2023] [Accepted: 12/12/2023] [Indexed: 01/09/2024] Open
Abstract
Ectopic varices are an infrequent yet fatal complication resulting from the progression of liver cirrhosis. Duodenal varices pose a significant challenge to clinicians as they are not easily visualized on endoscopy due to their submucosal location and lack of red color signs. Identification of duodenal varices is important given the risk of massive and life-threatening bleeding that is difficult to control. Patients may present in hemorrhagic shock requiring immediate resuscitation; however, confirmation of the bleeding source as variceal or non-variceal is critical in determining the optimal therapeutic intervention. Here, we report an unusual case of a duodenal ulcer that eroded into an ectopic varix resulting in hemorrhagic shock.
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Affiliation(s)
- Harjit Singh
- Department of Internal Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Alexandra Kimchy
- Department of Internal Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Camille Boustani
- Department of Gastroenterology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Mfoniso Umoren
- Department of Gastroenterology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Amol Rangnekar
- Department of Transplant Hepatology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Coleman Smith
- Department of Transplant Hepatology, MedStar Georgetown University Hospital, Washington, DC, USA
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10
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Jogo A, Yamamoto A, Kageyama K, Sasaki F, Oura T, Mitsuyama Y, Terayama E, Matsushita K, Asano K, Sakai Y, Ozaki M, Harada S, Murai K, Nakano M, Sohgawa E, Kita R, Kaminou T, Miki Y. Afferent vein embolization via retrograde approach as a potential treatment strategy for bleeding duodenal varices. Radiol Case Rep 2023; 18:4327-4330. [PMID: 37789920 PMCID: PMC10542599 DOI: 10.1016/j.radcr.2023.08.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/13/2023] [Accepted: 08/21/2023] [Indexed: 10/05/2023] Open
Abstract
The standard treatment for ruptured duodenal varices remains to be established. Emergency balloon-occluded retrograde transvenous obliteration is challenging in patients with bleeding because re-rupture of varices can occur due to increased pressure when using the retrograde approach. Herein, we describe a case in which a catheter was retrogradely advanced to the afferent vein beyond bleeding duodenal varices; however, the varices re-ruptured during coil embolization, and a part of the catheter was deviated into the intestinal tract. The rupture site was embolized by liquid embolic materials from the microcatheter. Embolization via retrograde approach needs to be carefully performed.
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Affiliation(s)
- Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Ken Kageyama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Fumi Sasaki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Tatsushi Oura
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Yasuhito Mitsuyama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Eisaku Terayama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Kazuki Matsushita
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Kazuo Asano
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Yuki Sakai
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Masanori Ozaki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Shohei Harada
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Kazuki Murai
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Mariko Nakano
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Etsuji Sohgawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | | | - Toshio Kaminou
- Advanced Imaging and Minimally Invasive Therapy Center, Himeji, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
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11
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Tranah TH, Nayagam JS, Gregory S, Hughes S, Patch D, Tripathi D, Shawcross DL, Joshi D. Diagnosis and management of ectopic varices in portal hypertension. Lancet Gastroenterol Hepatol 2023; 8:1046-1056. [PMID: 37683687 DOI: 10.1016/s2468-1253(23)00209-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/29/2023] [Accepted: 07/03/2023] [Indexed: 09/10/2023]
Abstract
Ectopic variceal bleeding is a rare cause of gastrointestinal bleeding that can occur in settings of cirrhotic and non-cirrhotic portal hypertension and is characterised by its development at locations remote from the oesophagus and stomach. Ectopic varices can be difficult to identify and access, and, although a relatively uncommon cause of portal hypertensive bleeding, can represent a difficult diagnostic and therapeutic challenge associated with considerable mortality. Low incidence and variance in variceal anatomy preclude large randomised controlled trials, and clinical practice is based on experience from case reports, case series, and specialist centre expertise. Optimisation of survival outcomes relies on understanding a patient's portal venous anatomy and functional hepatic reserve to guide timely and targeted endoscopic and endovascular interventions to facilitate the rapid control of ectopic variceal bleeding.
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Affiliation(s)
- Thomas H Tranah
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Institute of Liver Studies, King's College Hospital, London, UK.
| | - Jeremy S Nayagam
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Institute of Liver Studies, King's College Hospital, London, UK
| | - Stephen Gregory
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Sarah Hughes
- Department of Gastroenterology and Hepatology, St George's Healthcare NHS Trust, London, UK
| | - David Patch
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and University College London, London, UK
| | - Dhiraj Tripathi
- Department of Liver and Hepato-Pancreato-Biliary Unit, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Debbie L Shawcross
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Institute of Liver Studies, King's College Hospital, London, UK
| | - Deepak Joshi
- Institute of Liver Studies, King's College Hospital, London, UK
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O'Neill RS, Wang WJ, Chan P, Ho V, Verdon C, Turner I, Acharya P. An obscure cause of gastrointestinal bleeding: Recurrent duodenal variceal hemorrhage treated with intramuscular octreotide in the absence of portal hypertension. JGH Open 2022; 7:78-80. [PMID: 36660056 PMCID: PMC9840189 DOI: 10.1002/jgh3.12847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 11/12/2022] [Indexed: 12/15/2022]
Abstract
Duodenal varices (DVs) are ectopic gastrointestinal varices (ECVs) associated with portal hypertension (PH). We present the case of an 82-year-old woman who presented with symptomatic anemia secondary to DV hemorrhage diagnosed on oesophagogastroduodenoscopy. This lesion was treated with endoscopic adrenaline injection and clip application. The patient re-presented on multiple occasions with bleeding recurrence localized to the duodenum, which was managed with intramuscular octreotide and oral beta-blockade resulting in sustained remission of bleeding. This case highlights a rare cause of upper gastrointestinal hemorrhage and highlights the value of somatostatin analogues for conservative treatment of DVs.
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Affiliation(s)
- Robert S O'Neill
- Department of GastroenterologyCampbelltown HospitalCampbelltownNew South WalesAustralia,St Vincent's Clinical School, Faculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia
| | - William J Wang
- Department of GastroenterologyCampbelltown HospitalCampbelltownNew South WalesAustralia,Western Sydney UniversityCampbelltownNew South WalesAustralia,Townsville University HospitalDouglasQueenslandAustralia
| | - Patrick Chan
- Department of GastroenterologyCampbelltown HospitalCampbelltownNew South WalesAustralia
| | - Vincent Ho
- Department of GastroenterologyCampbelltown HospitalCampbelltownNew South WalesAustralia,Western Sydney UniversityCampbelltownNew South WalesAustralia
| | - Christine Verdon
- Department of GastroenterologyCampbelltown HospitalCampbelltownNew South WalesAustralia,Western Sydney UniversityCampbelltownNew South WalesAustralia
| | - Ian Turner
- Department of GastroenterologyCampbelltown HospitalCampbelltownNew South WalesAustralia,Western Sydney UniversityCampbelltownNew South WalesAustralia
| | - Priya Acharya
- Department of GastroenterologyCampbelltown HospitalCampbelltownNew South WalesAustralia,Western Sydney UniversityCampbelltownNew South WalesAustralia
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13
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Zhang W, Wang Y, Chu J, Liu Y, LingHu E. Investigation report on endoscopic management of esophagogastric variceal bleeding by Chinese endoscopists. Medicine (Baltimore) 2022; 101:e31263. [PMID: 36281109 PMCID: PMC9592513 DOI: 10.1097/md.0000000000031263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Esophagogastric variceal bleeding (EGVB) is a potentially life-threatening complication of portal hypertension. Endoscopic treatment combined with pharmacotherapy remains the mainstay in the management of acute variceal bleeding. AIM This article intends to highlight the potential differences in the endoscopic management of EGVB in China. METHODS A cross-sectional descriptive study was conducted. Endoscopists from 85 hospitals in 62 cities from 26 provinces were contacted by email. The items in questionnaire involved academic experience, screening, esophagogastric varices (EGV) classification, emergency treatment, and primary and secondary prophylaxis of EGVB by endoscopists with different lengths of experience. RESULTS A total of 85 questionnaires were collected. There was no statistical difference in the selection of items (P < .05 indicated statistical significance). The majority of endoscopists (95.29%) offered EGV screening for patients with liver cirrhosis. The location, diameter, and risk factor classification was selected by 82.35% of endoscopists. Endoscopy + medication was preferred (42.35%) for the primary prophylaxis of moderate-to-severe EGVs. There was no statistical difference in emergency intervention time for active EGVB (P > .05). The response "patients receive emergency endoscopic intervention within 12 hours" was selected by 61.2% of the endoscopists. The preferred emergency treatment for EGVB was combination treatment (40%). Tissue adhesive embolization was selected for the treatment of gastric variceal bleeding by 74.12% of endoscopists; transjugular intrahepatic portosystemic stent shunt/percutaneous transhepatic variceal embolization were selected as remedial measures by 48.23% to 52.94% of endoscopists. In addition, 67.06% of endoscopists elected to perform secondary prophylaxis and treatment within 1 week after hemostasis. Endoscopy and endoscopy + medication were selected by 44.71% and 49.41% of endoscopists, respectively, for secondary prophylaxis. The choice of laboratory indicators did not differ with length of experience. CONCLUSIONS There was no statistical difference in the endoscopic management of EGVB among Chinese endoscopists. The selection of diagnosis/treatment schemes was mainly based on guidelines and physician experience.
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Affiliation(s)
- Wenhui Zhang
- Digestive System Department, Capital Medical University Affiliated Beijing Shijitan Hospital, Beijing, China
- Endoscopy Center, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yanling Wang
- Endoscopy Center, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jindong Chu
- Endoscopy Center, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yingdi Liu
- Department of Gastroenterology, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Enqiang LingHu
- Department of Gastroenterology, First Medical Center of Chinese PLA General Hospital, Beijing, China
- *Correspondence: En-Qiang LingHu, Department of Gastroenterology, First Medical Center of Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100039, China (e-mail: )
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14
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Parikh A, Leon D, Ghasemi Rad M, Wynne D, Amaresh A. Percutaneous Transhepatic Embolization of a Bleeding Colic Vein in a Cirrhotic Patient With Massive Hematochezia: A Case Report and Literature Review. Cureus 2022; 14:e25736. [PMID: 35812565 PMCID: PMC9262639 DOI: 10.7759/cureus.25736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2022] [Indexed: 11/15/2022] Open
Abstract
Ectopic varices are an uncommon cause of gastrointestinal bleeding in patients with portal hypertension. A 43-year-old female with alcoholic cirrhosis developed massive hematochezia and hemorrhagic shock, requiring emergent angiography and image-guided intervention. Angiography revealed active extravasation from a branch of the right colic vein. The patient underwent percutaneous transhepatic embolization of the bleeding colic vein with technical success demonstrated on post-embolization angiography. Treatment of bleeding ectopic varices may require endoscopic, image-guided, or surgical approaches.
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15
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Zhu K, Zhang W, Shao W, Ding J, Ma C. Report of a case of cirrhotic portal hypertension with ectopic varices in the bilateral pulmonary hilar. DEN OPEN 2022; 2:e99. [PMID: 35873504 PMCID: PMC9302055 DOI: 10.1002/deo2.99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/13/2022] [Accepted: 01/22/2022] [Indexed: 11/08/2022]
Abstract
Here, we report the case of patient cirrhosis with esophageal and gastric fundal varices who developed rare ectopic varices in the bilateral pulmonary hilar after repeated endoscopic treatments (tissue adhesive for gastric fundal varices + esophageal variceal ligation + esophageal variceal sclerotherapy) accompanied by serious shortness of breath. After transjugular intrahepatic portosystemic shunt + gastric coronary vein embolization, the shortness of breath was relieved, and the portography review indicated that the ectopic varices in the pulmonary hilar were significantly improved.
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Affiliation(s)
- Ke Zhu
- Department of Gastroenterology No.2 People's Hospital of Fuyang City Fuyang China
| | - Wei Zhang
- Department of Gastroenterology No.2 People's Hospital of Fuyang City Fuyang China
| | - Wei Shao
- Department of Gastroenterology No.2 People's Hospital of Fuyang City Fuyang China
| | - Jing Ding
- Department of Gastroenterology No.2 People's Hospital of Fuyang City Fuyang China
| | - Chao Ma
- Department of Gastroenterology No.2 People's Hospital of Fuyang City Fuyang China
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16
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Chatani S, Seki K, Sonoda A, Murakami Y, Tomozawa Y, Fujimoto T, Andoh A, Watanabe Y. Bleeding anorectal varices treated by a direct puncture approach through the greater sciatic foramen: The utility of a steerable microcatheter for reverse catheterization. Radiol Case Rep 2022; 17:1104-1109. [PMID: 35169409 PMCID: PMC8829532 DOI: 10.1016/j.radcr.2022.01.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 11/26/2022] Open
Abstract
Bleeding is less common from anorectal varices than from esophageal varices, but it is potentially life-threatening. Here, we present a case of a woman in her 70s with critical hemorrhage from anorectal varices. The endoscopic approach could not be performed due to the huge variceal formation and the transhepatic approach was also unsuitable due to the presence of portal vein thrombosis and ascites. A direct puncture to the right superior rectal vein was performed through the greater sciatic foramen under computed tomography fluoroscopic guidance. Using a steerable microcatheter, superior rectal veins were bilaterally embolized with a mixture of n-butyl cyanoacrylate and ethiodized oil, and microcoils. Endoscopy and contrast-enhanced computed tomography performed after the procedure confirmed a marked shrinkage of anorectal varices. When endoscopic or any other approaches are difficult, this technique can be a useful alternative therapeutic option.
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Rahoui M, Rami B, hassen K. Vesical varices: An uncommon cause of gross hematuria in young men. Ann Med Surg (Lond) 2022; 74:103286. [PMID: 35242309 PMCID: PMC8858757 DOI: 10.1016/j.amsu.2022.103286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/16/2022] [Accepted: 01/22/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction and importance: Vesical varices are a rare condition. they are an exceptional cause of hematuria. The most common cause of vesical varices reported in literature is portal hypertension. Usually, varices due to portal hypertension develop in the gastroesophageal region. A multidisciplinary team approach is required, with input from gastroenterologists, interventional radiologists, and urologists. Case presentation We present a case of A 38 -year- old man presented to our office for 2 episodes of total macroscopic gross hematuria. The detailed general physical examination revealed: a patient in a good condition, without pallor or icterus. Laboratory investigations are normal. Cystoscopy under locoregional anesthesia was performed. It revealed a group of dilated sub mucosal veins, in the trigone. After discussing the case with gastroenterologists, we had presumed that the etiology of vesical varices may be the portal hypertension. Clinical discussion Vesical varices are an extremely rare cause of hematuria. The most common cause of vesical varices reported in literature is portal hypertension. The vesical varices may remain asymptomatic for a long period and manifest with hematuria in some cases. In order to organize the management of bleeding vesical varices, a detailed cartography of vesical vascularization have to be performed, including cystoscopy and abdominal contrast tomography (10). No definitive treatment has been established for bleeding vesical varices. In case of gross hematuria, surgical devascularization, laser sclerosis and coagulation are often only of temporary effectiveness. Conclusion Vesical varices are an extremely rare pathology. Its main etiology is Portal hypertension. The hematuria due to vesical varices could be life threatening. It requires energetic treatment. The goal of the treatment is portal decompression.
Vesical varices are an extremely rare pathology. Its main etiology is Portal hypertension. The goal of the treatment is portal decompression. Endoscopic treatment could be tried for moderate hematuria.
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Affiliation(s)
- Moez Rahoui
- Corresponding author. Urology Department, FSI La Marsa Hospital, 29 Rue Tahar Ben Achour, Marsa, 2070, Marsa Safsaf La Marsa, Tunisia.
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Al-Warqi A, Kassamali RH, Khader M, Elmagdoub A, Barah A. Managing Recurrent Rectal Variceal Bleeding Secondary to Portal Hypertension With Liquid Embolics. Cureus 2022; 14:e21614. [PMID: 35233302 PMCID: PMC8881284 DOI: 10.7759/cureus.21614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2022] [Indexed: 11/23/2022] Open
Abstract
Rectal variceal bleeding is one of the rarer manifestations of portal hypertension caused by chronic liver disease. The management of these varices is very challenging. Our patient had portal vein thrombosis and presented with chronic recurrent rectal bleeding requiring transfusion secondary to rectal varices. The patient was treated from trans-splenic access with liquid embolics (sclerotherapy and glue) without balloon occlusion, leading to the successful cessation of his bleeding. Access hemostasis was achieved using a vascular plug in the access tract. There are no clear guidelines for the management of these patients. If rectal varices cannot be managed by colonoscopy, this approach to embolization with liquid embolic is an excellent minimally invasive alternative.
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Long-term outcomes of hemostatic therapy for variceal bleeding and the challenge pending in the post-direct-acting antivirals era. Acta Gastroenterol Belg 2022; 85:7-14. [PMID: 35304988 DOI: 10.51821/85.1.9276] [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] [Indexed: 11/21/2022]
Abstract
Background and study aims This study evaluated the longterm outcomes of mainly endoscopic hemostatic therapy for gastrointestinal variceal bleeding and of the transition of hemostatic therapy. Patients and methods Among 1,163 patients treated for gastrointestinal varices between April 2006 and June 2020, a total of 125 patients who underwent emergency hemostatic therapy were enrolled. Survival rates and secondary evaluation points were analyzed. Additionally, patients were classified into two groups: the previous and latter term. Patients' background, therapeutic method, and treatment results were compared between the groups. Results 94.4% had cirrhosis. The average Child-Pugh score was 8.90. Successful primary hemostasis rate was 98.4%, and 5.6% died within 2 weeks, all with a Child-Pugh score ≥9. The respective 1- and 5-year survival rates for Child-Pugh grade A/B were 81.3% and 55.4%, while those for Child-Pugh grade C were 58.1% and 17.8%. Child-Pugh grade C or hepatocellular carcinoma was significantly associated with poor prognosis. In total, 21.6% experienced variceal re-bleeding; 62.9% of these cases were triggered by continued alcohol consumption. There was no significant difference in survival between patients with and without variceal re-bleeding and in post-treatment survival between the previous and latter terms. In the latter term, the number of cases caused by continued alcohol consumption significantly increased. Conclusions Multidisciplinary treatment and continuation of proper management after hemostatic therapy for variceal bleeding are crucial. Continued alcohol consumption leads to variceal bleeding and re-bleeding; its proper management, including alcohol abstinence, is one of the major challenges left in the post-directacting antivirals era.
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20
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Hatami B, Salarieh N, Ketabi Moghadam P, Mahdavi M, Farahani A. Transverse colon varices. GASTROENTEROLOGY AND HEPATOLOGY FROM BED TO BENCH 2022; 15:184-187. [PMID: 35845301 PMCID: PMC9275743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 02/27/2022] [Indexed: 11/20/2022]
Abstract
Portal hypertension associated with liver cirrhosis usually leads to gastroesophageal varices; however, ectopic varices secondary to liver cirrhosis are not common, especially colonic varices which occur with a low frequency. We are going to discuss the case of a 75-year-old man with liver (HBV) cirrhosis who was admitted to the hospital with rectorrhagia. Colonoscopy revealed evidence of acute bleeding in tortuous colonic varices. The band ligation performed during the colonoscopy had failed to control the bleeding. The patient was referred to Taleghani Hospital in Tehran, and rectorrhagia was subsequently successfully controlled by BRTO technique (balloon-occluded retrograded transvenous obliteration).
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Affiliation(s)
- Behzad Hatami
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Naghmeh Salarieh
- Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Mehran Mahdavi
- Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Azam Farahani
- Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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21
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Guglielmo FF, Wells ML, Bruining DH, Strate LL, Huete Á, Gupta A, Soto JA, Allen BC, Anderson MA, Brook OR, Gee MS, Grand DJ, Gunn ML, Khandelwal A, Park SH, Ramalingam V, Sokhandon F, Yoo DC, Fidler JL. Gastrointestinal Bleeding at CT Angiography and CT Enterography: Imaging Atlas and Glossary of Terms. Radiographics 2021; 41:1632-1656. [PMID: 34597220 DOI: 10.1148/rg.2021210043] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Gastrointestinal (GI) bleeding is a common potentially life-threatening medical condition frequently requiring multidisciplinary collaboration to reach the proper diagnosis and guide management. GI bleeding can be overt (eg, visible hemorrhage such as hematemesis, hematochezia, or melena) or occult (eg, positive fecal occult blood test or iron deficiency anemia). Upper GI bleeding, which originates proximal to the ligament of Treitz, is more common than lower GI bleeding, which arises distal to the ligament of Treitz. Small bowel bleeding accounts for 5-10% of GI bleeding cases commonly manifesting as obscure GI bleeding, where the source remains unknown after complete GI tract endoscopic and imaging evaluation. CT can aid in identifying the location and cause of bleeding and is an important complementary tool to endoscopy, nuclear medicine, and angiography in evaluating patients with GI bleeding. For radiologists, interpreting CT scans in patients with GI bleeding can be challenging owing to the large number of images and the diverse potential causes of bleeding. The purpose of this pictorial review by the Society of Abdominal Radiology GI Bleeding Disease-Focused Panel is to provide a practical resource for radiologists interpreting GI bleeding CT studies that reviews the proper GI bleeding terminology, the most common causes of GI bleeding, key patient history and risk factors, the optimal CT imaging technique, and guidelines for case interpretation and illustrates many common causes of GI bleeding. A CT reporting template is included to help generate radiology reports that can add value to patient care. An invited commentary by Al Hawary is available online. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Flavius F Guglielmo
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Michael L Wells
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - David H Bruining
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Lisa L Strate
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Álvaro Huete
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Avneesh Gupta
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Jorge A Soto
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Brian C Allen
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Mark A Anderson
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Olga R Brook
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Michael S Gee
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - David J Grand
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Martin L Gunn
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Ashish Khandelwal
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Seong Ho Park
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Vijay Ramalingam
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Farnoosh Sokhandon
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Don C Yoo
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Jeff L Fidler
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
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Massive duodenal variceal hemorrhage in a patient with prior Roux-en-Y gastric bypass. Radiol Case Rep 2021; 16:3304-3307. [PMID: 34484536 PMCID: PMC8403701 DOI: 10.1016/j.radcr.2021.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 08/01/2021] [Accepted: 08/01/2021] [Indexed: 12/13/2022] Open
Abstract
Duodenal variceal bleeding is a rare form of variceal bleeding which may be fatal if left untreated. There are no specific guidelines available for their treatment. Medical management, surgical, endoscopic, and interventional radiological procedures have been utilized with varied outcomes. In this case summary we report the successful management of duodenal variceal bleeding in a patient with prior Roux-en-Y gastric bypass . The patient with history of cirrhosis presented with acute gastrointestinal bleeding. Esophagogastroduodenoscopy and colonoscopy could not locate the source of bleeding. Computed tomography of the abdomen demonstrated a large duodenal variceal complex. Interventional radiology (IR) treated the patient with a combination of percutaneous transhepatic embolization and subsequent transjugular intrahepatic portosystemic shunt . No recurrence of gastrointestinal bleeding was noted at follow up. This case demonstrates that percutaneous transhepatic embolization along with transjugular intrahepatic portosystemic shunt may be effective treatment of duodenal variceal bleeding.
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Wei ZJ, Zhu X, Yu HT, Liang ZJ, Gou X, Chen Y. Severe hematuria due to vesical varices in a patient with portal hypertension: A case report. World J Clin Cases 2021; 9:4810-4816. [PMID: 34222452 PMCID: PMC8223820 DOI: 10.12998/wjcc.v9.i18.4810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/02/2021] [Accepted: 04/23/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hematuria is one of the most common clinical symptoms for urologists and is typically observed in urinary system tumors, prostate hyperplasia, and urinary stone disease. Hematuria due to vesical varices is very rare, and only a few cases have been reported since 1989. We report the first case of vesical varices due to portal hypertension with aberrant development and functioning of the genitourinary system along with the complete diagnosis and treatment process.
CASE SUMMARY This patient was a 53-year-old man with a history of aberrant development of the genitourinary system and hepatitis B-associated cirrhosis. He was admitted to the emergency department with severe hematuria and bladder clot tamponade. Many abnormally dilated blood vessels were found surrounding the bladder in the pelvis by color Doppler ultrasound, contrast-enhanced computed tomography, and three-dimensional visualization technology. It was difficult to perform transurethral cystoscopy and hemostasis in this patient, so we performed open surgical bladder exploration for hemostasis and surgical devascularization around the bladder.
CONCLUSION Urologists should improve the understanding of the pathophysiology, clinical manifestations, diagnosis, and treatment of vesical varices. This case may be presented as a reference for the diagnosis and management of severe hematuria due to vesical varices.
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Affiliation(s)
- Zong-Jie Wei
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Xin Zhu
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Hai-Tao Yu
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Zong-Jian Liang
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Xin Gou
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yong Chen
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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Shrestha BM, Shrestha S, Kharel S, K C A, Shrestha S, Pradhan S, Bhandari RS. Jejunal varices with extra hepatic portal vein obstruction: A case report. Int J Surg Case Rep 2021; 83:105964. [PMID: 34004566 PMCID: PMC8141758 DOI: 10.1016/j.ijscr.2021.105964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/07/2021] [Accepted: 05/08/2021] [Indexed: 12/01/2022] Open
Abstract
Introduction and importance Extrahepatic portal vein obstruction (EHPVO) with portal hypertension is rare in children. Intestinal varices as new collaterals accompanying portal hypertension are very rare. Presentation of case We report an unusual case of a 12-year-old boy with EHPVO with gastrointestinal bleeding from ectopic jejunal varices, without any gastroesophageal varices. Discussion Portal hypertension is the most common cause of EHPVO. Among various ectopic varices, intestinal varices are found distal to the duodenum and present with complaints of hematochezia, melena, or intraperitoneal bleeding. The diagnosis of the EHPVO is aided by imaging investigations like Doppler ultrasound, computed tomography, or magnetic resonance imaging. A multidisciplinary team including gastroenterologists, interventional radiologists, surgeons, and intensivists is crucial in the management of ectopic varices. Conclusion Jejunal varices must be considered in the differential diagnosis of gastrointestinal (GI) hemorrhage in patients with a negative source of bleed on upper and lower GI endoscopy.
Intestinal varices are rarely developed as new collaterals accompanying portal hypertension with EHPVO (Extrahepatic portal vein obstruction). Jejunal varices must be considered in patients with a negative source of bleed on upper and lower GI endoscopy.
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Affiliation(s)
| | - Suraj Shrestha
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
| | - Sanjeev Kharel
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal.
| | - Ajay K C
- Department of GI and General Surgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Sujan Shrestha
- Department of GI and General Surgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Sumita Pradhan
- Department of GI and General Surgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Ramesh Singh Bhandari
- Department of GI and General Surgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
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Yipeng W, Cong L, Sizhe W, Chenkai H, Anjiang W, Xuan Z. Effectiveness and safety of endoscopic treatment for duodenal variceal bleeding: a systematic review. Eur J Gastroenterol Hepatol 2021; 33:461-469. [PMID: 32576766 PMCID: PMC7908861 DOI: 10.1097/meg.0000000000001819] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023]
Abstract
Duodenal varix is a rare condition that involves massive bleeding, diagnostic difficulties, and a high rate of rebleeding and mortality. The purpose of this study was to systematically review endoscopic treatment for duodenal variceal bleeding to evaluate its effectiveness and safety. We searched PubMed, Embase, Web of Science, and the Cochrane Library up to 21 November 2019. Ninety-two studies containing 156 patients were finally included, and individual data from 101 patients (mean age: 52.67 ± 13.82 years, male: 64.4%) were collected and further analyzed. We used an analysis of variance and χ2 or Fisher's exact tests to analyze individual data from 101 patients. The cause of duodenal variceal bleeding was cirrhosis-related intrahepatic portal hypertension (IPH) in 76.2% of patients. The overall rates of initial hemostasis and treatment success of endoscopic treatment for duodenal variceal bleeding were 89.1 and 81.2%, respectively. The median duration of follow-up was 4.5 (1.0, 12.0) months. The overall rates of rebleeding and mortality were 8.9 and 13.9%, respectively. Among a variety of endoscopic treatments available, only the initial hemostasis rate was significantly different between the endoscopic injection sclerotherapy and endoscopic tissue adhesive (ETA) groups (72.7 vs. 94.7%, P = 0.023); differences in treatment success, rebleeding, mortality, and adverse events were not statistically significant among the four groups. Endoscopic intervention is a feasible, well tolerated, and effective modality for the treatment of duodenal variceal bleeding. Among the variety of endoscopic treatments available, ETA with cyanoacrylate may be preferable for duodenal variceal bleeding.
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Affiliation(s)
- Wan Yipeng
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Liu Cong
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Wan Sizhe
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Huang Chenkai
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Wang Anjiang
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Zhu Xuan
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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Yipeng W, Anjiang W, Bimin L, Chenkai H, Size W, Xuan Z. Clinical characteristics and efficacy of endoscopic treatment of gastrointestinal ectopic varices: A single-center study. Saudi J Gastroenterol 2020; 27:35-43. [PMID: 33208560 PMCID: PMC8083249 DOI: 10.4103/sjg.sjg_50_20] [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] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Ectopic varices (EcVs) may cause massive bleeding, which can be difficult to control, with a high rate of mortality. The purpose of this study was to analyze the clinical characteristics of EcVs and the efficacy of endoscopic treatment. METHODS From January 2008 to July 2017, the clinical data of 150 patients with EcVs in our center were retrospectively collected and analyzed. RESULTS One hundred and fifty patients with EcVs (male 74.7%), with a mean age of: 54.1 ± 14.6 years were included. The prevalence of EcVs was 0.92% in gastrointestinal varices. Cirrhosis was the most common cause of EcVs (67.0%). The rates of bleeding were 57.14%, 4.34%, 30.0%, 33.3%, and 100% in the duodenal varices rectal varices, colonic varices, anastomotic varices, and small bowel varices, respectively. An age under 55 years, varices in the duodenum, and erythema were considered risk factors for EcV bleeding. Endoscopic treatments were performed in 15 patients with EcV bleeding. The follow-up period of the patients who underwent endoscopic treatment ranged from 0.5 to 24 months. The overall rate of treatment success was 73.33% for endoscopic treatment of EcV bleeding. The overall rates of rebleeding and mortality during 2 years were as high as 53.3% and 26.7%, respectively. CONCLUSION Age, erythema, and the location of EcVs are considered risk factors for EcV bleeding, and the rate of bleeding is higher in patients with duodenal varices than in those with other EcVs. Endoscopic treatment is safe, effective, and feasible for controlling EcV bleeding.
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Affiliation(s)
- Wan Yipeng
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Hospital in Nanchang, China
| | - Wang Anjiang
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Hospital in Nanchang, China
| | - Li Bimin
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Hospital in Nanchang, China
| | - Huang Chenkai
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Hospital in Nanchang, China
| | - Wan Size
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Hospital in Nanchang, China
| | - Zhu Xuan
- Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Hospital in Nanchang, China,Address for correspondence: Dr. Zhu Xuan, Departments of Gastroenterology and Hepatology, First Affiliated Hospital of Nanchang University, Nanchang, China. E-mail:
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Bleeding from gastrointestinal ectopic varices is not associated with haemorrhage from oesophageal or gastric varices. GASTROENTEROLOGY REVIEW 2020; 15:60-64. [PMID: 32215130 PMCID: PMC7089859 DOI: 10.5114/pg.2020.93632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 05/27/2019] [Indexed: 11/21/2022]
Abstract
Introduction Ectopic varices are those that appear in a different region of the gastroesophageal junction. Bleeding from ectopic varices is rare but is usually massive and deadly. Aim To identify the possible factors that cause bleeding from ectopic varices in patients with portal hypertension. Material and methods A cross-sectional and retrospective study; the data were collected between January 2004 and June 2014. We included patients with portal hypertension and gastrointestinal ectopic varices diagnosed by endoscopy. Results We found 31 patients with gastrointestinal ectopic varices. Of these, 25 had liver cirrhosis, and six showed non-cirrhotic portal hypertension. There were 16 men and 15 women in the study. The median age of the patients was 60 years (range minimum–maximum of 27 to 80 years). Nineteen (61%) patients had rectal varices, 10 (32%) had duodenal varices, 1 (3%) had ileal varices, and 1 (3%) had colonic varices. We found bleeding in 4 (13%) of the 31 patients with ectopic varices; two belonged to the cirrhosis group, and the other two were from the non-cirrhotic portal hypertension group. Three of the 4 patients with bleeding from gastrointestinal ectopic varices had exhibited haemorrhage from oesophageal varices (odds ratio = 4.09, 95% CI: 0.37–44.78, p = 0.249), but none of them showed bleeding from gastric varices. Conclusions Bleeding from gastrointestinal ectopic varices is not necessarily associated with bleeding from oesophageal or gastric varices.
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López Couceiro L, Muñoz Codoceo C, Fernández I. Stomal varices: an unusual cause of bleeding in liver cirrhosis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 112:241-242. [PMID: 32022571 DOI: 10.17235/reed.2020.6470/2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Stomal varices are an unusual cause of bleeding in liver cirrhosis. Diagnosis and treatment should be individualized according to the experience and resources of the hospital. Percutaneous embolization can provide a therapeutic option for patients with severe comorbidities.
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Miwa T, Ibuka T, Ozawa N, Sugiyama T, Kubota M, Imai K, Sakai H, Takai K, Araki H, Shimizu M. Idiopathic Ileocolonic Varices Coexisting with a Colon Polyp Treated Successfully by Endoscopy: A Case Report and Literature Review. Intern Med 2019; 58:3401-3407. [PMID: 31366797 PMCID: PMC6928513 DOI: 10.2169/internalmedicine.3131-19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Colonic varices are usually associated with portal hypertension. Idiopathic colonic varices are extremely rare. A 68-year-old man with a positive fecal occult blood test result underwent colonoscopy. We detected idiopathic ileocolonic varices and a coexisting ascending colon polyp. While reviewing the literature, we found cases of biopsies and polypectomies resulting in significant bleeding. We herein report a case of idiopathic ileocolonic varices coexisting with a colon polyp treated successfully by endoscopy. The coexistence of colonic varices and a colorectal lesion that requires endoscopic treatment may lead to significant bleeding. During management, the development of a treatment strategy and obtaining informed consent are necessary.
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Affiliation(s)
- Takao Miwa
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Japan
| | - Takashi Ibuka
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Japan
| | - Noritaka Ozawa
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Japan
| | - Tomohiko Sugiyama
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Japan
| | - Masaya Kubota
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Japan
| | - Kenji Imai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Japan
| | - Hiroyasu Sakai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Japan
| | - Koji Takai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Japan
| | - Hiroshi Araki
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Japan
| | - Masahito Shimizu
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Japan
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Lee JH, Kim TH, Choi JW, Kim SY, Choi JY, Lee CK, Park BK, Chung JB. A case report of bleeding from duodenal varices treated with percutaneous transhepatic obliteration. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2019. [DOI: 10.18528/ijgii190002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Ji Hyun Lee
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Hwan Kim
- Department of Vascular and Interventional Radiology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jong Won Choi
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Sun Young Kim
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jin Young Choi
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Chun Kyon Lee
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Byung Kyu Park
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jae Bok Chung
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
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Gheorghiu AC, Proserpio M, Regusci L, Pagnamenta A. Ectopic varices masquerading as lower gastrointestinal bleeding. BMJ Case Rep 2019; 12:12/1/e227469. [PMID: 30709832 DOI: 10.1136/bcr-2018-227469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A middle-aged woman previously in good health arrived to hospital with severe haemorrhagic shock. An abdominal and pelvic CT scan showed hepatomegaly, fluid in the sigmoid colon, perigastric and right sided pelvic varices without a clear source of bleeding. Urgent esophagogastroduodenoscopy excluded gastric varices and active upper gastrointestinal bleeding and the colonoscopy was inconclusive due to haemodynamic instability and massive bleeding which made it impossible to proceed with a full colonoscopy. An explorative laparotomy identified liver cirrhosis and bleeding from varices of the right fallopian tube which had formed a fistula with the caecum. A right hemicolectomy with a side to side anastomosis and a right sided salpingo-oophorectomy were carried out. The patient was thereafter transferred to the intensive care unit intubated, requiring massive fluid resuscitation and high doses of vasoactive agents. Nine days after hospital admission she was transferred to the surgical ward and followed up by a hepatologist.
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Affiliation(s)
- Alina Cristiana Gheorghiu
- Intensive Care Medicine, Ente Ospedaliero Cantonale, Ospedale Regionale di Mendrisio, Mendrisio, Switzerland
| | - Michele Proserpio
- Intensive Care Medicine, Ente Ospedaliero Cantonale, Ospedale Regionale di Mendrisio, Mendrisio, Switzerland
| | - Luca Regusci
- Department of Surgery, Ente Ospedaliero Cantonale, Ospedale Regionale di Mendrisio, Mendrisio, Switzerland
| | - Alberto Pagnamenta
- Intensive Care Medicine, Ente Ospedaliero Cantonale, Ospedale Regionale di Mendrisio, Mendrisio, Switzerland
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Romano J, Welden CV, Orr J, McGuire B, Shoreibah M. Case Series Regarding Parastomal Variceal Bleeding: Presentation and Management. Ann Hepatol 2019; 18:250-257. [PMID: 31113601 DOI: 10.5604/01.3001.0012.7934] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 01/18/2018] [Indexed: 02/04/2023]
Abstract
Parastomal variceal bleeding (PVB) is a serious complication occurring in up to 27% of patients with an ostomy and concurrent cirrhosis and portal hypertension. The management of PVB is difficult and there are no clear guidelines on this matter. Transjugular intrahepatic portosystemic shunt (TIPS), sclerotherapy, and /or coil embolization are all therapies that have been shown to successfully manage PVB. We present a case series with five different patients who had a PVB at our institution. The aim of this case series is to report our experience on the management of this infrequently reported but serious condition. We also conducted a systemic literature review focusing on the treatment modalities of 163 patients with parastomal variceal bleeds. In our series, patient 1 had embolization and sclerotherapy without control of bleed and expired on the day of intervention due to hemorrhagic shock. Patient 2 had TIPS in conjunction with embolization and sclerotherapy and had no instance of rebleed 441 days after therapy. Patient 3 did not undergo any intervention due to high risk for morbidity and mortality, the bleed self-resolved and there was no further rebleed, this same patient died of sepsis 73 days later. Patient 4 had embolization and sclerotherapy and had no instance of rebleed 290 days after therapy. Patient 5 had TIPS procedure and was discharged five days post procedure without rebleed, patient has since been lost to follow-up.
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Affiliation(s)
- John Romano
- Department of Medicine, University of Alabama at Birmingham, Birmingham AL, USA.
| | - Charles V Welden
- Department of Medicine, University of Alabama at Birmingham, Birmingham AL, USA
| | - Jordan Orr
- Department of Medicine, Division of Gastroenterology and Hepatology, Vanderbilt University, Nashville TN, USA
| | - Brendan McGuire
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham AL, USA
| | - Mohamed Shoreibah
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham AL, USA
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Xie BS, Zhong JW, Wang AJ, Zhang ZD, Zhu X, Guo GH. Duodenal variceal bleeding secondary to idiopathic portal hypertension treated with transjugular intra-hepatic porto-systemic shunt plus embolization: A case report. World J Clin Cases 2018; 6:1217-1222. [PMID: 30613686 PMCID: PMC6306627 DOI: 10.12998/wjcc.v6.i16.1217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/20/2018] [Accepted: 11/23/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Duodenal varices are a lesser-known complication with non-cirrhotic portal hypertension. We report a circuitous route from missed diagnosis of duodenal varices to correction. An extremely rare case of duodenal variceal bleeding secondary to idiopathic portal hypertension (IPH) is expounded in this study, which was controlled by transjugular intra-hepatic porto-systemic shunt (TIPS) plus embolization. CASE SUMMARY A 46-year-old woman with anemia for two years was frequently admitted to the local hospital. Upon examination, anemia was attributed to gastrointestinal tract bleeding, which resulted from duodenal variceal bleeding detected by repeated esophagogastroduodenoscopy. At the end of a complete workup, IPH leading to duodenal varices was diagnosed. Portal venography revealed that the remarked duodenal varices originated from the proximal superior mesenteric vein. TIPS plus embolization with coils and Histoacryl was performed to obliterate the rupture of duodenal varices. The anemia resolved, and the duodenal varices completely vanished by 2 mo after the initial operation. CONCLUSION TIPS plus embolization may be more appropriate to treat the bleeding of large duodenal varices.
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Affiliation(s)
- Bu-Shan Xie
- Department of Gastroenterology, the First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Jia-Wei Zhong
- Department of Gastroenterology, the First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - An-Jiang Wang
- Department of Gastroenterology, the First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Zhen-Dong Zhang
- Department of Pathology, the First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Xuan Zhu
- Department of Gastroenterology, the First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Gui-Hai Guo
- Department of Gastroenterology, the First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
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Kunihara S, Oka S, Tanaka S, Otani I, Igawa A, Nagaoki Y, Aikata H, Chayama K. Predictive Factors of Portal Hypertensive Enteropathy Exacerbation in Patients with Liver Cirrhosis: A Capsule Endoscopy Study. Digestion 2018; 98:33-40. [PMID: 29672296 DOI: 10.1159/000486666] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 01/08/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS The clinical course and exacerbation of portal hypertensive enteropathy (PHE) are yet to be fully clarified. This study aimed to identify factors related to PHE exacerbation in patients with liver cirrhosis (LC). METHODS Fifty patients with LC (33 male; mean age, 67 years), who underwent capsule endoscopy (CE) at the Hiroshima University Hospital between February 2009 and September 2015, were followed up for >6 months. Exacerbation is defined as the appearance of new lesions or worsening of existing lesions. The association between PHE exacerbation and the clinical factors was evaluated. RESULTS PHE exacerbation was identified in 24 out of 50 (48%) of cases: erythema (14 cases); angioectasia (11 cases); erosions (9 cases); villous edema (8 cases); and esophageal varices (EVs; 6 cases). The following factors were significantly associated with PHE exacerbation: portosystemic shunts, EVs and portal hypertensive gastropathy (PHG) exacerbation. After therapy, CE findings among the 24 cases were as follows: villous edema (19 cases); erythema (17 cases); angioectasia (16 cases); erosions (12 cases); and EVs (9 cases), and no observable abnormalities in 2 cases. On multivariate analysis, exacerbation of EVs and PHG were independent predictors of PHE exacerbation. CONCLUSION EVs and PHG exacerbation may predict PHE exacerbation in patients with LC.
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Affiliation(s)
- Sayoko Kunihara
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Shiro Oka
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Shinji Tanaka
- Department of Endoscopy and Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Ichiro Otani
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Atsushi Igawa
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuko Nagaoki
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroshi Aikata
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
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Park CJ, Lee BE, Jeon HK, Kim GH, Song GA, Ko SH, Lee SJ, Park DY. Case of Bleeding Ileal Varices after a Colectomy Diagnosed by Capsule Endoscopy. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2018; 71:349-353. [PMID: 29943562 DOI: 10.4166/kjg.2018.71.6.349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We report a case of bleeding ileal varices associated with intra-abdominal adhesions after colectomy which was successfully diagnosed using capsule endoscopy. A 77-year-old woman visited the emergency department for several episodes of melena. She had a medical history of neoadjuvant chemo-radiation therapy and subsequent surgery for rectal cancer 6 years previously. Conventional diagnostic examinations including upper endoscopy, colonoscopy, and abdominal computed tomography could not detect any bleeding focus, however, following capsule endoscopy revealed venous dilatations with some fresh blood in the distal ileum, indicating bleeding ileal varices. The patient underwent exploratory laparotomy and the affected ileum was successfully resected. No further gastrointestinal bleeding occurred during the 6 months follow-up. Small intestinal varices are important differential for obscure gastrointestinal bleeding especially in patients with a history of abdominal surgery in the absence of liver cirrhosis, and capsule endoscopy can be a good option for diagnosing small intestinal varices.
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Affiliation(s)
- Chang Joon Park
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Bong Eun Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Hye Kyung Jeon
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Gwang Ha Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Geun Am Song
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Sang Hwa Ko
- Department of Surgery, Pusan National University School of Medicine, Busan, Korea
| | - So Jeong Lee
- Department of Pathology, Pusan National University School of Medicine, Busan, Korea
| | - Do Youn Park
- Department of Pathology, Pusan National University School of Medicine, Busan, Korea
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Periampullary Variceal Bleeding: An Atypical Complication of Portal Hypertension. Case Rep Gastrointest Med 2018; 2018:4643695. [PMID: 29854492 PMCID: PMC5960554 DOI: 10.1155/2018/4643695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 03/19/2018] [Accepted: 03/28/2018] [Indexed: 11/18/2022] Open
Abstract
Variceal bleeding remains a fatal complication of portal hypertension. Periampullary varices are rare and, due to their location, are difficult to diagnose and treat. Similar to esophagogastric varices, they are the result of high portosystemic pressures secondary to intrahepatic causes such as cirrhosis and extrahepatic causes such as portal or splenic vein thrombosis. We report a case of a periampullary varix resulting in hemobilia during endoscopic retrograde cholangiopancreatography (ERCP).
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Túlio MA, Marques S, Bispo M, Bana T, Chagas C. Endoscopic Management of Acute Bleeding from an Ectopic Duodenal Varix. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2017; 24:98-100. [PMID: 28848790 DOI: 10.1159/000450897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 08/29/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Maria Ana Túlio
- Gastroenterology Department, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Susana Marques
- Gastroenterology Department, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Miguel Bispo
- Gastroenterology Department, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Tiago Bana
- Gastroenterology Department, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Cristina Chagas
- Gastroenterology Department, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
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Bhardwaj R, Bhardwaj G, Bee E, Karagozian R. Bleeding ectopic duodenal varix: use of a new microvascular plug (MVP) device along with transjugular intrahepatic portosystemic shunt (TIPSS). BMJ Case Rep 2017; 2017:bcr-2017-221200. [PMID: 28814595 DOI: 10.1136/bcr-2017-221200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Ectopic varices (ECV) occur along the gastrointestinal (GI) tract outside the common variceal sites and represent 2%-5% of all GI variceal bleeds with mortality rates up to 40%. Management is challenging because of inaccessibility and increased risk of rebleeding. We report what is to our knowledge the first clinical use of a new microvascular plug (MVP) with transjugular intrahepatic portosystemic shunt (TIPSS) for a bleeding duodenal varix (DV). A 68-year-old man presented with melena. Endoscopy demonstrated a grade II varix in the second part of the duodenum with red wale sign. TIPSS was performed and portogram revealed a single DV. Poststent placement venogram revealed a persistent varix and hence a 5-7 mm MVP was deployed. Subsequent imaging showed cessation of blood through the DV. The patient had no further bleeding. TIPSS with embolisation is an effective treatment for ECV. This MVP offers advantages due to its size and compatibility and can be redeployed in case of suboptimal placement.
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Affiliation(s)
- Richa Bhardwaj
- Department of Internal Medicine, University of Connecticut Health Center, Farmington, Connecticut, USA
| | - Gaurav Bhardwaj
- Department of Gastroenterology, Saint Francis Hospital and Medical Center, Hartford, Connecticut, USA
| | - Erik Bee
- Department of Radiology, Saint Francis Hospital and Medical Center, Hartford, Connecticut, USA
| | - Raffi Karagozian
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
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Pulmonary Glue Embolization after Endoscopic Treatment of Bleeding Sigmoid Colon Varices. ACG Case Rep J 2017; 4:e52. [PMID: 28459076 PMCID: PMC5404343 DOI: 10.14309/crj.2017.52] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 01/17/2017] [Indexed: 11/17/2022] Open
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Diagnosis and treatment guidelines for aberrant portal hemodynamics: The Aberrant Portal Hemodynamics Study Group supported by the Ministry of Health, Labor and Welfare of Japan. Hepatol Res 2017; 47:373-386. [PMID: 28058764 DOI: 10.1111/hepr.12862] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 12/29/2016] [Accepted: 01/04/2017] [Indexed: 12/18/2022]
Abstract
Idiopathic portal hypertension (IPH), causing aberrant portal hemodynamics, is a disease with an as yet unidentified cause and no established treatment protocol. The Japanese research group on IPH in Japan was set up in 1975 by the Ministry of Health, Labor and Welfare. Extrahepatic portal obstruction and Budd-Chiari syndrome (BCS) have since been added to the group's research subjects. The aims of the research group are to accurately evaluate the current status of the three diseases in Japan, elucidate their etiology and pathogenesis, and develop new treatments. Due to the long-term efforts of the Japanese research group, aberrant portal hemodynamics has been investigated in a variety of aspects, from epidemiological and pathological studies to molecular biology analyses. As a result, it has been shown that there are abnormal genes in the liver, specific for IPH. In addition, pathological findings of BCS were internationally compared and the difference in findings between Japan and Europe (or North America) has been clarified. Furthermore, it was found that complication rates of hepatocellular carcinoma in BCS were higher in Japan. Based on the research, "Diagnosis and treatment of aberrant portal hemodynamics (2001)", including diagnostic criteria for aberrant portal hemodynamics, was published in 2001. In 2013, it was revised to "Diagnosis and treatment guidelines for aberrant portal hemodynamics (2013)" after the incorporation of diagnosis and treatment in accordance with its current status.
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Shim DJ, Shin JH, Ko GY, Kim Y, Han K, Gwon DI, Ko HK. Portal vein stent placement with or without varix embolization of jejunal variceal bleeding after hepatopancreatobiliary surgery. Acta Radiol 2017; 58:423-429. [PMID: 27307028 DOI: 10.1177/0284185116654329] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Extrahepatic portal hypertension after surgery involving the duodenum or jejunum might result in massive ectopic variceal bleeding. Purpose To report the results of portal vein stent placement with the addition of variceal embolization. Material and Methods Between January 2000 and June 2015, portal vein stent placement was attempted in 477 patients. Of these, 22 patients (age, 63 ± 10 years) with jejunal variceal bleeding caused by portal vein obstruction after surgery were included in this study. Computed tomography (CT) findings before and after treatment and the rates of technical and clinical success, complications, and clinical outcomes were retrospectively evaluated. Results Stent placement was successful in 19 of 22 patients. Additional variceal embolization was performed in five cases. Clinical success, defined as the cessation of bleeding without recurrence within 1 month, was achieved in 18 of 19 patients with technical success. One patient developed recurrent bleeding 4 days after stent placement and was successfully treated with additional variceal embolization. There were no procedure-related complications. A regression of the jejunal varices was noted in 14 of 19 patients on follow-up CT scans. During the follow-up period (258 days; range, 7-1196 days), stent occlusion and recurrent bleeding occurred in six and four patients, respectively, of the 19 patients who achieved technical success. Statistical analyses revealed no significant differences regarding stent patency between benign and malignant strictures. Conclusion Percutaneous, transhepatic, portal vein stent placement with or without jejunal variceal embolization appears to be a safe and effective treatment for jejunal variceal bleeding after surgery.
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Affiliation(s)
- Dong Jae Shim
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Gi-Young Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Yook Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Kichang Han
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Dong-Il Gwon
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Heung-Kyu Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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Park SW, Cho E, Jun CH, Choi SK, Kim HS, Park CH, Rew JS, Cho SB, Kim HJ, Han M, Cho KM. Upper gastrointestinal ectopic variceal bleeding treated with various endoscopic modalities: Case reports and literature review. Medicine (Baltimore) 2017; 96:e5860. [PMID: 28072750 PMCID: PMC5228710 DOI: 10.1097/md.0000000000005860] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
RATIONALE Ectopic variceal bleeding is a rare (2-5%) but fatal gastrointestinal bleed in patients with portal hypertension. Patients with ectopic variceal bleeding manifest melena, hematochezia, or hematemesis, which require urgent managements. Definitive therapeutic modalities of ectopic varices are not yet standardized because of low incidence. Various therapeutic modalities have been applied on the basis of the experiences of experts or availability of facilities, with varying results. PATIENT CONCERNS We have encountered eight cases of gastrointestinal ectopic variceal bleeding in five patients in the last five years. DIAGNOSES All patients were diagnosed with liver cirrhosis presenting melena or hematemesis. INTERVENTIONS All patients were treated with various endoscopic modalities (endoscopic variceal obturation [EVO] with cyanoacrylate in five cases, endoscopic variceal band ligation (EVL) in two cases, hemoclipping in one case). OUTCOMES Satisfactory hemostasis was achieved without radiologic interventions in all cases. EVO and EVL each caused one case of portal biliopathy, and EVL induced ulcer bleeding in one case. LESSONS EVO generally accomplished better results of variceal obturations than EVL or hemoclipping, without serious adverse events. EVO may be an effective modality for control of ectopic variceal bleeding without radiologic intervention or surgery.
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Affiliation(s)
- Sang Woo Park
- Division of Gastroenterology, Department of Internal Medicine
| | - Eunae Cho
- Division of Gastroenterology, Department of Internal Medicine
| | - Chung Hwan Jun
- Division of Gastroenterology, Department of Internal Medicine
| | - Sung Kyu Choi
- Division of Gastroenterology, Department of Internal Medicine
| | - Hyun Soo Kim
- Division of Gastroenterology, Department of Internal Medicine
| | - Chang Hwan Park
- Division of Gastroenterology, Department of Internal Medicine
| | - Jong Sun Rew
- Division of Gastroenterology, Department of Internal Medicine
| | - Sung Bum Cho
- Division of Gastroenterology, Department of Internal Medicine
| | - Hee Joon Kim
- Department of Surgery, Chonnam National University Hospital, Gwangju, South Korea
| | - Mingui Han
- Division of Gastroenterology, Department of Internal Medicine
| | - Kyu Man Cho
- Division of Gastroenterology, Department of Internal Medicine
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Williams MJ, Hayes P. Improving the management of gastrointestinal bleeding in patients with cirrhosis. Expert Rev Gastroenterol Hepatol 2016; 10:505-15. [PMID: 26581713 DOI: 10.1586/17474124.2016.1122523] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Gastrointestinal bleeding remains a major cause of mortality in patients with cirrhosis. The most common source of bleeding is from gastroesophageal varices but non-variceal bleeding from peptic ulcer disease also carries a significant risk in patients with liver disease. The prognosis is related to the severity of the underlying liver disease, and deaths often occur due to liver failure, infection or renal failure. Optimal management should therefore not only achieve haemostasis but address these complications as well. The management of gastrointestinal bleeding in patients with cirrhosis includes a range of medical, endoscopic and radiological interventions. This article updates the recent developments in this area and highlights topics where further research is still required.
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Affiliation(s)
- Michael J Williams
- a Centre for Liver and Digestive Diseases , Royal Infirmary of Edinburgh , Edinburgh , UK
| | - Peter Hayes
- a Centre for Liver and Digestive Diseases , Royal Infirmary of Edinburgh , Edinburgh , UK
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Ertel AE, Chang AL, Kim Y, Shah SA. Management of gastrointestinal bleeding in patients with cirrhosis. Curr Probl Surg 2016; 53:366-95. [PMID: 27585818 DOI: 10.1067/j.cpsurg.2016.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 06/21/2016] [Indexed: 12/14/2022]
Affiliation(s)
- Audrey E Ertel
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Alex L Chang
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Young Kim
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH.
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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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Capsule Endoscopy for Portal Hypertensive Enteropathy. Gastroenterol Res Pract 2015; 2016:8501394. [PMID: 26819613 PMCID: PMC4706926 DOI: 10.1155/2016/8501394] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 07/15/2015] [Indexed: 02/08/2023] Open
Abstract
Portal hypertensive enteropathy (PHE) is a mucosal abnormality of the small bowel that is observed in patients with portal hypertension (PH) and can lead to gastrointestinal bleeding and anemia. The pathogenesis is still not completely understood. The introduction of new endoscopic methods, including capsule endoscopy (CE) or balloon-assisted enteroscopy, has increased the detection of these abnormalities. CE can also serve as a road map for deciding subsequent interventions and evaluating the treatment effect. The prevalence of PHE is reportedly 40-70% in patients with PH. Endoscopic findings can be roughly divided into vascular and nonvascular lesions such as inflammatory-like lesions. Traditionally, PHE-associated factors include large esophageal varices, portal hypertensive gastropathy or colopathy, Child-Turcotte-Pugh class B or C, a history of variceal treatment, and acute gastrointestinal bleeding. More recently, on using scoring systems, a high computed tomography or transient elastography score was reportedly PHE-related factors. However, the prevalence of PHE and its related associated factors remain controversial. The management of PHE has not yet been standardized. It should be individualized according to each patient's situation, the availability of therapy, and each institutional expertise.
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Belsha D, Thomson M. Challenges of banding jejunal varices in an 8-year-old child. World J Gastrointest Endosc 2015; 7:1350-1354. [PMID: 26722617 PMCID: PMC4689798 DOI: 10.4253/wjge.v7.i19.1350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 06/02/2015] [Accepted: 07/17/2015] [Indexed: 02/05/2023] Open
Abstract
Endoscoic variceal ligation (EVL) by the application of bands on small bowel varices is a relatively rare procedure in gastroenterology and hepatology. There are no previously reported paediatric cases of EVL for jejunal varices. We report a case of an eight-year-old male patient with a complex surgical background leading to jejunal varices and short bowel syndrome, presenting with obscure but profound acute gastrointestinal bleeding. Wireless capsule endoscopy and double balloon enteroscopy (DBE) confirmed jejunal varices as the source of bleeding. The commercially available variceal banding devices are not long enough to be used either with DBE or with push enteroscopes. With the use of an operating gastroscope, four bands were placed successfully on the afferent and efferent ends of the leads of the 2 of the varices. Initial hemostasis was achieved with obliteration of the varices after three separate applications. This case illustrates the feasibility of achieving initial hemostasis in the pediatric population.
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Shim DJ, Shin JH. Management of jejunal bleeding by jejunal variceal embolization and portal venous recanalization after pylorus-preserving pancreaticoduodenectomy. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2015. [DOI: 10.18528/gii1150002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Dong Jae Shim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Laborda A, Guirola JA, Medrano J, Simón MÁ, Ioakeim I, de-Gregorio MÁ. TIPS treatment in a patient with severe lower gastrointestinal bleeding with a misdiagnosis of cirrhotic portal hypertension. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2015; 107:766-7. [PMID: 26671592 DOI: 10.17235/reed.2015.3794/2015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abernethy malformation is a rare abnormal embryological development of splanchnic venous system characterised by the presence of a congenital extrahepatic portosystemic shunt. We present a rare case of an adult male patient that was admitted with severe lower gastrointestinal bleeding, requiring multiple blood transfusions. The patient's medical history and the laboratory tests performed led to the misdiagnosis of a congenital Abernethy malformation. We present a rare case, discussing the reasons for the misdiagnosis and we conclude that management of clinical data and imaging are highly important to discard these types of congenital malformations that can mimic a portal hypertension condition.
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Affiliation(s)
| | | | | | - Miguel Ángel Simón
- Servicio de Aparato Digestivo., Hospital Clínico Universitario Lozano Blesa, España
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