Massive hemorrhage after percutaneous liver biopsy in a pediatric patient with graft-versus-host disease; a successful angiographic embolization

Most cases of bleeding that develop after percutaneous liver biopsies can be managed with follow-up and supportive treatment. In life-threatening situations, however, open surgery or minimally invasive methods are required. This case report describes the clinical course of an 11-year-old patient with a diagnosis of Wiskott-Aldrich syndrome who experienced a major hemorrhage following a percutaneous liver biopsy. Clinical findings, imaging, interventions, and results were evaluated. Allogeneic hematopoietic stem cell transplantation was performed without any problem. The patient's bilirubin level started to increase on the 20th day after transplantation. Profuse watery diarrhea started on the 24th day. Graft-versus-host disease of the gastrointestinal tract and liver was considered as his diarrhea continued to the 29th day. An ultrasound-guided Tru-cut® liver biopsy (Merit medical, South Jordan, UT, USA) was performed with an 18-gauge needle on the 52nd day after transplantation. In the fourth hour after the procedure, the general condition of the patient started to deteriorate. Active bleeding was detected in the patient with computed tomography, and he was hypotensive and tachycardic. The patient was urgently transferred to the angiography unit and a successful angiographic embolization was performed. Angiographic embolization is an intervention with high success rates in cases of bleeding where the patient is hemodynamically stable. However, it can also be successfully applied in selected patients who are hemodynamically unstable.

Management of visceral arterial pseudoaneurysms in patients with acute and chronic pancreatitis: a retrospective study from South Indian tertiary care centre

Background: Visceral artery pseudoaneurysms (VAP) are defined as those affecting celiac, superior or inferior mesenteric arteries and their branches. In this study, role of various therapeutic modalities in the management of VAP caused by acute and chronic pancreatitis were analysed which can influence choice of treatment for a given patient.Methods: The study was conducted in institute of surgical gastroenterology, Madras medical college and Rajiv Gandhi government general hospital Chennai, based on retrospective analysis of 41 patients diagnosed with VAP caused by acute and chronic pancreatitis admitted between the periods of September 2014 and January 2020. The medical records of all patients were retrieved and descriptive statistical analyses was carried out regarding various details including demographics, presentation, management and complications.Results: This study includes 41 patients with mean age of 39.73±10.54 (SD) years and 40 (97.56%) of them were males. Fifteen patients (36.59%) had acute pancreatitis and 26 patients (63.41%) had chronic pancreatitis. Pseudocysts were found in 25 (60.98%) patients. Pseudoaneurysm arose most commonly from splenic artery (n=32; 78.04%). The most common symptom was abdominal pain (n=40) followed by gastrointestinal bleeding (n=28). Sixteen patients (39%) received primary radiological reintervention (n=16). Twenty-five patients (60.98%) underwent primary surgical treatment (n=25). Rebleeding was seen in 3 patients (7.32%). Twenty-three patients (56.1%) developed complications. Mortality rate was 5/41 (12.2%).Conclusions: Pseudoaneurysms are fatal complications of pancreatitis. Angiographic embolization, when available, is the initial treatment of choice in hemodynamically stable patients. Surgery in experienced hands will still remain main modality in treating these patients in centres that lack a full-fledged angiographic facility with acceptable outcomes.

A case of colonoscopy-induced Wunderlich's syndrome in a hemodialysis patient: coincidence or association?

Wunderlich syndrome, or spontaneous renal hemorrhage (SRH), is a rare condition encountered in patients undergoing chronic hemodialysis (HD) usually attributed to acquired cystic kidney disease (ACKD) among other causes. In the literature, colonoscopy is associated with splenic injuries, and renal hemorrhage has not been previously described. Management can range from conservative treatment to angiographic embolization or exploration and nephrectomy. Here we report an unusual case of a 54-year-old woman HD patient who presented with SRH within a few days of colonoscopy. The reason of SRH was rupture of an ACKD cyst. We assumed that colonoscopy was a provoking factor and elaborated hypotheses for its etiopathogenesis. The patient underwent successful left nephrectomy. The importance of this case lies in the fact that colonoscopy is not always an innocent procedure in HD patients, and could be complicated by renal cyst hemorrhage.

SPLENIC ANGIOGRAPHIC EMBOLIZATION IN IV AND V-GRADE SPLENIC INJURIES. DOES IT WORK? OUR EXPERIENCE ON THE MANAGEMENT OF SPLENIC INJURIES IN THE LAST 14 YEARS

INTRODUCTION Spleen is frequently damaged in abdominal trauma. Patients with splenic injury with hemodynamic instability, peritonism signs or other surgical injuries need emergent surgery. Hemodynamically stable patients are treated conservatively. Splenic embolization is indicated in injuries with blush, pseudoaneurysms or arteriovenous fistulas. It is unclear its indication in IV and V-grade splenic injuries without contrast extravasation. Our hypothesis is that IV and V-grade splenic injuries embolization decreases conservative treatment failure. MATERIAL AND METHODS Retrospective observational study, including all patients with blunt splenic injuries, prospectively included in our registry of polytraumatic patients (>16 years) since 2006. RESULTS One hundred and seventy patients have been included since 2006. In 2006-2013, when splenic injuries with active bleeding, pseudoaneurysms or arteriovenous fistulas were embolized, 94 patients were included. 37,2% required surgery and 62,8% conservative treatment. Splenic embolization was performed in 17% of patients who were treated conservatively. Conservative treatment failure was 16,9%: 10 cases out of those who underwent medical treatment (4 required embolization and 6 needed surgery). From 2014 to the present, when IV and V-grade injuries were included in the indications for embolization, 76 patients have been included. 38,2% required surgery and 61,8% were treated conservatively (40,4% were embolized and the rest were treated medically). One case (3,6%) of those treated medically and another (5,3%) of those embolized failed. Overall failure of conservative treatment was 4,3%. CONCLUSION Embolization of IV and V-grade splenic injuries decreases conservative treatment failure from 16,9% to 4,3%.

Jejunal Dieulafoy’s Lesion: A Systematic Review of Evaluation, Diagnosis, and Management

Jejunal Dieulafoy’s lesion is an exceedingly rare but important cause of gastrointestinal bleeding. It frequently presents as a diagnostic and therapeutic conundrum due to the rare occurrence, intermittent bleeding symptoms often requiring prompt clinical action, variability in the detection and treatment methods, and the risk of rebleeding. We performed a systematic literature search of MEDLINE, Cochrane, Embase, and Scopus databases regarding jejunal Dieulafoy’s lesio from inception till June 2020. A total of 136 cases were retrieved from 76 articles. The mean age was 55 ± 24 years, with 55% of cases reported in males. Patients commonly presented with melena (33%), obscure-overt gastrointestinal bleeding (29%), and hemodynamic compromise (20%). Hypertension (26%), prior gastrointestinal surgery (14%), and valvular heart disease (13%) were the major underlying disorders. Conventional endoscopy often failed but single- and double-balloon enteroscopy identified the lesion in 96% and 98% of patients, respectively. There was no consensus on the treatment. Endoscopic therapy was instituted in 64% of patients. Combination therapy (34%) with two or more endoscopic modalities, was the preferred approach. With regard to endoscopic monotherapy, hemoclipping (19%) and argon plasma coagulation (4%) were frequently employed procedures. Furthermore, direct surgical intervention in 32% and angiographic embolization was performed in 4% of patients. The rebleeding rate was 13.4%, with a mean follow-up duration of 17.6 ± 21.98 months. The overall mortality rate was 4.4%. Jejunal Dieulafoy’s lesion is still difficult to diagnose and manage. Although the standard diagnostic and therapeutic modalities remain to be determined, device-assisted enteroscopy might yield promising outcomes.

Delayed Thoracodorsal Artery Pseudoaneurysm After Thoracoscopic Sympathectomy for Hyperhidrosis in an Adolescent: A Case Report

Background: Conversely to intercostal artery false aneurysm, thoracodorsal artery pseudoaneurysm after thoracoscopy has never been reported previously.Case presentation: We report the case of a 15-year-old male presenting a delayed thoracodorsal artery pseudoaneurysm after bilateral thoracospic sympathectomy. Diagnosis was made by Doppler Ultrasound and confirmed by computed tomography angiography. Angiographic embolization was successfully performed. Conclusion: Thoracodorsal artery pseudoaneurysm should be considered in patients presenting with a parietal thoracic mass following thoracoscopy. This is to the best of our knowledge the first report of thoracodorsal artery pseudoaneurysm after thoracoscopy.