RESUMEN

BACKGROUND: Interventional endoscopic ultrasound is clinically used for the treatment of isolated gastric varices (IGVs) owing to its precise visualization. CASE SUMMARY: A 39-year-old man was diagnosed with a large IGV during a routine physical examination. Endoscopic ultrasonography showed gastric varices entwined with an artery, which greatly increased the difficulty of treatment. We successfully treated the patient with endoscopic ultrasonography-guided coil embolization combined with cyanoacrylate injection. CONCLUSION: Endoscopic ultrasonography-guided coil embolization combined with cyanoacrylate injection was safe and effective for the treatment of an IGV entwined with an artery.

RESUMEN

The mortality rate of gastric varices bleeding can reach 20% within 6 weeks. Isolated gastric varices (IGVs) refer to gastric varices without esophageal varices and typically arise as a common complication of left portal hypertension. Although IGVs commonly form in the setting of splenic vein occlusion, the combination of antiphospholipid syndrome and protein S deficiency leading to splenic vein occlusion is rare. We herein present a case of a 28-year-old woman with intermittent epigastric pain and melena. She was diagnosed with antiphospholipid syndrome based on the triad of pregnancy morbidity, unexplained venous occlusion, and positive lupus anticoagulant. Laparoscopic splenectomy and pericardial devascularization were performed for the treatment of IGVs. During the 6-month postoperative follow-up, repeated endoscopy and contrast-enhanced computed tomography revealed disappearance of the IGVs. This is the first description of splenic vein occlusion associated with both antiphospholipid syndrome and protein S deficiency. We also provide a review of the etiology, clinical manifestations, diagnosis, and treatment methods of IGVs.

Asunto(s)

Síndrome Antifosfolípido , Várices Esofágicas y Gástricas , Deficiencia de Proteína S , Enfermedades Vasculares , Femenino , Humanos , Adulto , Várices Esofágicas y Gástricas/complicaciones , Várices Esofágicas y Gástricas/diagnóstico , Síndrome Antifosfolípido/complicaciones , Síndrome Antifosfolípido/diagnóstico , Deficiencia de Proteína S/complicaciones , Hemorragia Gastrointestinal/etiología , Enfermedades Vasculares/complicaciones

RESUMEN

BACKGROUND: Sinusoidal obstruction syndrome has been reported after oxaliplatin-based chemotherapy, but liver fibrosis and non-cirrhotic portal hypertension (NCPH) are rarely reported. CASE SUMMARY: Here, we describe the case of a 64-year-old woman who developed isolated gastric variceal bleeding 16 mo after completing eight cycles of oxaliplatin combined with capecitabine chemotherapy after colon cancer resection. Surprisingly, splenomegaly and thrombocytopenia were not accompanied by variceal bleeding, which has been reported to have predictive value for gastric variceal formation. However, a liver biopsy showed fibrosis in the portal area, suggesting NCPH. The patient underwent endoscopic treatment and experienced no further symptoms. CONCLUSION: It is necessary to guard against long-term complications after oxaliplatin-based chemotherapy. Sometimes splenic size and platelet level may not always accurately predict the occurrence of portal hypertension.

Asunto(s)

Várices Esofágicas y Gástricas , Hipertensión Portal , Capecitabina , Várices Esofágicas y Gástricas/complicaciones , Femenino , Hemorragia Gastrointestinal/inducido químicamente , Hemorragia Gastrointestinal/diagnóstico , Humanos , Hipertensión Portal/inducido químicamente , Hipertensión Portal/diagnóstico , Cirrosis Hepática/complicaciones , Cirrosis Hepática/diagnóstico , Persona de Mediana Edad , Oxaliplatino/efectos adversos

RESUMEN

Objective: To evaluate the efficacy of three endoscopic therapies of isolated gastric varices (IGV) with modified tissue adhesive. Methods: A retrospective analysis was conducted with the clinical data of 73 IGV patients who were treated between January 2008 and December 2019 at Beijing Ditan Hospital. Patient clinical data on age, sex, etiology, biochemistry findings, Child-Pugh classification, the type of spontaneous shunt, preoperative bleeding history, and the presence or absence of liver cancer were collected. The three therapies evaluated were endoscopic intravenous injection of tissue glue combined with lauromacrogol, endoscopic clip-assisted intravenous injection of tissue glue combined with lauromacrogol, and endoscopic clip and LOOP-assisted intravenous injection of tissue glue combined with lauromacrogol. Their respective clinical treatment outcomes, including ectopic embolism rate, survival rate, rebleeding rate, amount of lauromacrogol and tissue glue used, the number of endoscopic clips used, and the number of times of the procedure the patient underwent, were evaluated. Results: In the patient baseline data, Child-Pugh grade, preoperative thrombus formation, and the presence or absence of liver cancer, showed significant difference between the three therapies ( P<0.05). There was no significant difference in the rates of ectopic embolism among the three methods ( P>0.05), but no ectopic embolism occurred after endoscopic clip-assisted intravenous injection of tissue glue combined with lauromacrogol, or after endoscopic clip and LOOP-assisted intravenous injection of tissue glue combined with lauromacrogol. There was no significant difference in the survival rate, the rebleeding rate, amount of lauromacrogol and tissue glue used for the three therapies, but there was significant difference in the number of endoscopic clips used and the number of times the procedure was conducted within one year ( P<0.05). Conclusion: The two endoscopic therapies of intravenous injection of modified tissue glue, one assisted by clip and the other assisted by clip and LOOP, can help reduce the number of procedures IGV patients undergo within one year.

Asunto(s)

Várices Esofágicas y Gástricas , Neoplasias Hepáticas , Adhesivos Tisulares , Várices Esofágicas y Gástricas/tratamiento farmacológico , Várices Esofágicas y Gástricas/cirugía , Humanos , Neoplasias Hepáticas/tratamiento farmacológico , Neoplasias Hepáticas/cirugía , Recurrencia Local de Neoplasia , Polidocanol , Estudios Retrospectivos , Adhesivos Tisulares/uso terapéutico

RESUMEN

Sinistral portal hypertension (SPH), also known as left-sided portal hypertension or segmental portal hypertension, is a rare cause of upper gastrointestinal bleeding. Historically, SPH is a result of obstruction of the splenic vein often secondary to pancreatic pathology. To our knowledge, there are no reported cases of idiopathic SPH in which the findings cannot be attributed to any etiology. It is important to do a detailed workup to rule out common pathologies of SPH before making a diagnosis of idiopathic SPH. Treatment of gastric variceal bleed secondary to idiopathic SPH can be challenging and requires a multidisciplinary approach with surgery and interventional radiology. Our patient's history, examination findings, and imaging revealed no identifiable cause for SPH suggesting idiopathic SPH. We describe a case of isolated gastric variceal hemorrhage due to idiopathic SPH that was successfully treated.

RESUMEN

Isolated gastric varices (IGV) are gastric varices in the absence of esophageal varices. IGV is one of the rare causes of gastrointestinal bleeding and an uncommon complication of pancreatic neuroendocrine tumors (PNET). The gold standard diagnostic tool of varices is esophagogastroduodenoscopy (EGD). IGV tend to bleed with lesser portal pressure compared to esophageal varices. Initial treatment is similar to the gastroesophageal varices. The intervention options include endoscopic, radiological, and surgical approach.

RESUMEN

In this review, we summarise the current knowledge on the indications and contraindications of transjugular intrahepatic portosystemic shunt (TIPS) placement for the treatment of the complications of portal hypertension in cirrhosis, specifically variceal haemorrhage and ascites. Moreover, we discuss the role of TIPS for the treatment of portal vein thrombosis (PVT) and the prevention of complications after extrahepatic surgery ('preoperative TIPS') in patients with cirrhosis. The position of TIPS in the treatment hierarchy depends on the clinical setting and on patient characteristics. In acute variceal haemorrhage, preemptive TIPS is indicated in patients at a high risk of failing standard therapy, that is those with a Child-Pugh score of 10-13 points or Child-Pugh B with active bleeding at endoscopy, although the survival benefit in the latter group still remains to be established. Non-preemptive TIPS is a second-line therapy for the prevention of recurrent variceal haemorrhage and for the treatment of ascites. Of note, TIPS may also improve sarcopenia. Contraindications to TIPS placement, independent of clinical setting, include very advanced disease (Child-Pugh >13 points), episodes of recurrent overt hepatic encephalopathy without an identifiable precipitating factor, heart failure, and pulmonary hypertension. In patients with PVT, TIPS placement not only controls complications of portal hypertension, but also promotes portal vein recanalisation. Although the severity of portal hypertension correlates with poor outcomes after extrahepatic surgery, there is no evidence to recommend preoperative TIPS placement.

RESUMEN

Non-selective beta-blockers (NSBBs) are the mainstay of treatment for portal hypertension in the setting of liver cirrhosis. Randomised controlled trials demonstrated their efficacy in preventing initial variceal bleeding and subsequent rebleeding. Recent evidence indicates that NSBBs could prevent liver decompensation in patients with compensated cirrhosis. Despite solid data favouring NSBB use in cirrhosis, some studies have highlighted relevant safety issues in patients with end-stage liver disease, particularly with refractory ascites and infection. This review summarises the evidence supporting current recommendations and restrictions of NSBB use in patients with cirrhosis.

Asunto(s)

Constricción Patológica/diagnóstico por imagen , Hiperesplenismo/diagnóstico por imagen , Vena Porta/diagnóstico por imagen , Esclerosis/diagnóstico por imagen , Vena Esplénica/diagnóstico por imagen , Esplenomegalia/diagnóstico por imagen , Biopsia , Niño , Constricción Patológica/complicaciones , Femenino , Hemólisis , Humanos , Hiperesplenismo/complicaciones , Hipertensión Portal/complicaciones , Hipertensión Portal/diagnóstico por imagen , Imagen por Resonancia Magnética , Vena Porta/patología , Esclerosis/complicaciones , Vena Esplénica/patología , Esplenomegalia/complicaciones , Resultado del Tratamiento , Ultrasonografía

RESUMEN

BACKGROUND: Abdominal tuberculosis (TB) rarely presents with abdominal masses and rarely causes isolated gastric varices. CASE PRESENTATION: We report a case of isolated gastric varices secondary to abdominal TB mimicking lymphoma. A 42-year-old woman without any history of liver disease presented with melena and mild abdominal pain. Upon admission to the hospital, laboratory investigations revealed a hemoglobin level of 76 g/L. Gastroduodenoscopic examination showed isolated gastric fundal varices with red color signs. Abdominal contrast-enhanced computed tomography (CECT) revealed non-enhanced masses of soft-tissue density in the lesser omental and the retropancreatic areas, multiple para-aortic lymph nodes, and multiple small hypodense splenic lesions. Positron emission tomography-CT showed hypermetabolic [F-18]2-fluoro-2-deoxyglucose activity involving multiple regional lymph nodes and the bone marrow, suggestive of lymphoma. Bone marrow biopsy revealed no abnormality. Histopathological examination of a CT-guided biopsy specimen showed granulomatous inflammation with necrosis and microorganisms that stained positive with acid-fast stains. Abdominal CECT showed a decrease in the size of the lesser omental and peripancreatic masses, as well as the para-aortic lymph nodes after 4-month anti-TB therapy. CONCLUSIONS: TB should be considered among the differential diagnoses in patients with abdominal masses, isolated gastric varices, and regional lymphadenopathy. Prompt and definitive diagnosis of abdominal TB requires a coordinated approach involving laboratory tests, radiological examination, and invasive procedures for optimal decision making and management.

Asunto(s)

Várices Esofágicas y Gástricas/microbiología , Linfoma/diagnóstico , Tuberculosis/complicaciones , Tuberculosis/diagnóstico , Abdomen , Adulto , Biopsia , Diagnóstico Diferencial , Endoscopía Gastrointestinal , Várices Esofágicas y Gástricas/diagnóstico por imagen , Femenino , Humanos , Tomografía Computarizada por Rayos X

RESUMEN

Objective@#To observe the endoscopic morphology of gastric varices of patients with portal hypertension type one isolated gastric varices (IGV-1) and to explore the etiology, treatment and prognosis of portal hypertension IGV-1.@*Methods@#From January 2006 to June 2018, at Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine and North Branch of Ruijin Hospital, 54 patients with portal hypertension IGV-1 were retrospectively analyzed. The varices were classified according to the endoscopic morphology and the etiology treatment, therapeutic efficacy and prognosis were also analyzed. Descriptive method was used for statistical analysis.@*Results@#Among the 54 patients with portal hypertension IGV-1, the endoscopic morphology of varices were tuber type in 24 patients (44.4%), grape string type in nine patients (16.7%), strip type in five patients (9.3%), dendritic type in three patients (5.6%) and mixed type in 13 patients(24.1%). Etiological analysis showed that the primary disease of 34 cases (63.0%) were hepatogenic, 11 cases (20.4%) were pancreatic origin, and nine cases (16.7%) were from other diseases. As to treatment, three cases (5.6%) were treated with adhesive, two cases (3.7%) were treated with sclerotherapy, and 49 cases (90.7%) were treated with combination of adhesive and sclerotherapy. Therapeutic efficacy evaluation showed that 46 cases (85.2%) were significantly effective, eight cases were effective, 0 case was ineffective, and all the 54 cases (100.0%) were improved. The prognostic analysis showed that 35 cases (64.8%) had no bleeding in five years and eight cases (14.8%) had no bleeding in 10 years. Nine patients (16.7%) died, including six cases of pancreatic cancer, two cases of liver failure and one case of gastrointestinal bleeding.@*Conclusions@#The endoscopic morphology of IGV-1 portal hypertension in mainly tuber type. The main cause is hepatogenic and the combination of adhesive and sclerotherapy is beneficial to the regression of gastric varices.

RESUMEN

Objective To observe the endoscopic morphology of gastric varices of patients with portal hypertension type one isolated gastric varices (IGV-1) and to explore the etiology,treatment and prognosis of portal hypertension IGV-1.Methods From January 2006 to June 2018,at Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine and North Branch of Ruijin Hospital,54 patients with portal hypertension IGV-1 were retrospectively analyzed.The varices were classified according to the endoscopic morphology and the etiology treatment,therapeutic efficacy and prognosis were also analyzed.Descriptive method was used for statistical analysis.Results Among the 54 patients with portal hypertension IGV-1,the endoscopic morphology of varices were tuber type in 24 patients (44.4％),grape string type in nine patients (16.7％),strip type in five patients (9.3％),dendritic type in three patients (5.6％) and mixed type in 13 patients(24.1％).Etiological analysis showed that the primary disease of 34 cases (63.0％) were hepatogenic,11 cases (20.4％) were pancreatic origin,and nine cases (16.7％) were from other diseases.As to treatment,three cases (5.6％) were treated with adhesive,two cases (3.7％) were treated with sclerotherapy,and 49 cases (90.7％) were treated with combination of adhesive and sclerotherapy.Therapeutic efficacy evaluation showed that 46 cases (85.2％) were significantly effective,eight cases were effective,0 case was ineffective,and all the 54 cases (100.0％) were improved.The prognostic analysis showed that 35 cases (64.8％) had no bleeding in five years and eight cases (14.8％) had no bleeding in 10 years.Nine patients (16.7％) died,including six cases of pancreatic cancer,two cases of liver failure and one case of gastrointestinal bleeding.Conclusions The endoscopic morphology of IGV-1 portal hypertension in mainly tuber type.The main cause is hepatogenic and the combination of adhesive and sclerotherapy is beneficial to the regression of gastric varices.

RESUMEN

Idiopathic non-cirrhotic portal hypertension (INCPH) is portal hypertension (PHT) without cirrhosis and other identifiable causes. Esophageal and gastric varices are seen in INCPH which are mostly asymptomatic. We present a rare case of symptomatic isolated gastric varices (IGV) in the setting of INCPH. We report a case of a 60-year-old man who presented with an acute onset of hematemesis and no identifiable history. Upon further evaluation, he was found to have non-bleeding dilated gastric varices on esophagogastroduodenoscopy (EGD) and PHT without cirrhosis. Our patient is unique because he has symptomatic IGV and INCPH.

RESUMEN

Balloon-occluded retrograde transvenous obliteration (BRTO) is widely used to treat isolated gastric varices (IGVs) in Japan. However, BRTO is difficult to perform for IGVs with many small collateral veins, and no secondary treatment has been established. We herein report a rare case of IGVs refractory to BRTO successfully treated by shunt-occluded endoscopic injection sclerotherapy (SO-EIS), which is a combination therapy of major shunt occlusion by a balloon catheter and endoscopic injection sclerotherapy. Since SO-EIS can be performed regardless of the IGVs' anatomical configuration, it may be a promising alternative treatment for IGVs refractory to BRTO.

Asunto(s)

Oclusión con Balón/métodos , Várices Esofágicas y Gástricas/complicaciones , Várices Esofágicas y Gástricas/terapia , Hemorragia Gastrointestinal/etiología , Hemorragia Gastrointestinal/terapia , Derivación Portosistémica Intrahepática Transyugular/métodos , Escleroterapia/métodos , Embolización Terapéutica , Humanos , Japón , Masculino , Persona de Mediana Edad , Enfermedades Raras/diagnóstico , Enfermedades Raras/terapia , Resultado del Tratamiento

RESUMEN

Isolated gastric varices (IGV) can occur in patients with left-sided portal hypertension resulting from splenic vein occlusion caused by thrombosis or stenosis. In left-sided portal hypertension, blood flows retrogradely through the short and posterior gastric veins and the gastroepiploic veins, leading to the formation of an IGV. The most common causes of splenic vein occlusion are pancreatic diseases, such as pancreatic cancer, pancreatitis, or a pseudocyst. However, various other cancers, such as colon, gastric, or renal cancers, have also been known to cause splenic vein occlusion. Our patient presented with a rare case of IGV bleeding induced by splenic lymphoma-associated splenic vein occlusion. Splenectomy, splenic artery embolization, and stenting of the splenic vein are the current treatment choices. Chemotherapy, however, is an alternative effective treatment for splenic vein occlusion caused by chemotherapy-sensitive tumors. Our patient responded well to chemotherapy with a cyclophosphamide, hydroxydaunorubicin, oncovin, and prednisolone regimen, and the splenic vein occlusion resolved after the lymphoma regressed.

Asunto(s)

Várices Esofágicas y Gástricas/etiología , Hemorragia Gastrointestinal/etiología , Hipertensión Portal/etiología , Linfoma de Células B/complicaciones , Neoplasias del Bazo/complicaciones , Vena Esplénica/patología , Enfermedades Vasculares/etiología , Anciano , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Biopsia con Aguja , Constricción Patológica , Ciclofosfamida/administración & dosificación , Daunorrubicina/administración & dosificación , Daunorrubicina/análogos & derivados , Doxorrubicina , Endoscopía Gastrointestinal , Várices Esofágicas y Gástricas/diagnóstico , Femenino , Hemorragia Gastrointestinal/diagnóstico , Humanos , Hipertensión Portal/diagnóstico , Linfoma de Células B/diagnóstico , Linfoma de Células B/tratamiento farmacológico , Prednisolona/administración & dosificación , Neoplasias del Bazo/diagnóstico , Neoplasias del Bazo/tratamiento farmacológico , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Enfermedades Vasculares/diagnóstico , Vincristina/administración & dosificación

RESUMEN

BACKGROUND: Gastric varices are found in patients with portal hypertension. Incidence of bleeding from gastric varices is relatively low, but tends to be more severe, and is associated with higher mortality than esophageal variceal bleeding. AIMS AND OBJECTIVES: To compare the prevalence and types of gastric varices in cirrhosis versus extrahepatic portal venous obstruction (EHPVO) and the results of endoscopic N-butyl-2-cyanoacrylate (NBC, glue) injection. METHODS: Eighty six patients presenting with bleeding from gastric varices between August 2010 and August 2011 were retrospectively analyzed. RESULTS: Of 86 patients, 65% (n = 56) were cirrhotics and 35% (n = 30) had EHPVO. Distribution of types of gastric varices showed GOV1 in 14% (n = 8) of cirrhotics vs. 7% (n = 2) of EHPVO, GOV2 in 80% (n = 45) of cirrhotics vs. 53% (n = 16) of EHPVO, IGV1 in 40% (n = 12) of patients with EHPVO vs. 4% (n = 2) cirrhotics. The patients were treated with NBC injections. The mean volume of glue injected was 3.7 ± 2.58 ml over a median of 1 session (range: 1-8). The total volume of glue required was lower in cirrhotics (3.2 ± 2 ml vs. 4.7 ± 3.1 ml, p < 0.05) than in EHPVO patients. Twenty (36%) of cirrhotics required >1 sessions of glue injection as compared to 17 (57%) of EHPVO patients. Over mean follow up of 12 months, rebleeding (9% vs. 10%) and mortality (11% vs. 3%) were similar in patients with cirrhosis and EHPVO. CONCLUSIONS: In patients with bleeding from gastric varices, GOV2 is more common in cirrhotics and IGV1 in patients with EHPVO. Patients with EHPVO required higher total volume of glue and more glue sessions for gastric varix obturation.

RESUMEN

Objective To investigate the clinical features and management of pancreatic disease- associated portal hypertension.Methods A retrospective analysis was carried out in patients with portal hypertension complicating with pancreatic diseases in our hospital from January 1986 to April 2005. Medical records of these patients were reviewed,including data of demographics,etiologies,venous involvement,clinical presentation,laboratory tests,imaging studies,therapeutic modalities and out- comes.Results There were 59 cases of portal hypertension resulted from pancreatic diseases in our hos- pital,accounting for 4% of all portal hypertension in 19 years.The underlying pancreatic diseases were chronic pancreatitis(21 cases,35.6%),pancreatic carcinoma(20 cases,33.9%),acute pancreatitis (8 cases,13.6%),pancreatic pseudocyst(3 cases,5.1%).Of the 40 patients whose venous involve ment was identified,splenic vein obstruction occurred in 27 cases(67.5%),followed by portal vein obstruction(16 cases,40.0%).Mild or moderate splenomegaly was present in 48 cases(81.4%),with leukocytopenia as the most common manifestation of the 31 cases(52.5%)of concomitant hyper- splenism.Forty-five patients(76.3%)developed gastroesophageal varices(including 35 isolated gastric varices),among them,19 had bled(32.2%).Conservative treatment was effective in controlling acute bleeding,but could not prevent re-bleeding.Splenectomy was performed in 18 patients,mainly because of gastrointestinal hemorrhage.No postoperative bleeding occurred in the period of follow-up from 8 months to 9 years.Conclusions Pancreatic diseases may compromise portal vein and its tributaries, leading to generalized or regional portal hypertension.Pharmacological therapy can effectively control acute variceal bleeding,while surgical treatment is the appropriate procedure of choice in case of hemor- rhage recurrence.