A Rare Cause of Gastric Variceal Bleeding

A 68-year-old woman with stage III colon cancer status after right hemicolectomy and adjuvant FOLFOX (5-fluorouracil/leucovorin/oxaliplatin) chemotherapy was hospitalized for melena and found to have new-onset esophageal and gastric varices on esophagogastroduodenoscopy. Her workup did not reveal an underlying liver disease, but her liver biopsy showed noncirrhotic portal hypertension from obliterative portal venopathy (OPV). The development of OPV is likely from her use of oxaliplatin-based chemotherapy.

Splenic artery aneurysms and extrahepatic portal hypertension during pregnancy

Clinical case demonstrates successful treatment of a pregnant woman, who had multiple giant splenic artery aneurysms with a high risk of spontaneous rupture. Pregnancy proceeded along with hereditary thrombophilia, thrombosis and cavernous transformation of the vena cava, extrahepatic portal hypertension, esophageal and gastric varices II–III. The surgical and obstetric tactics, surgical intervention, appropriate salvage and multidisciplinary pregnancy follow-up ensured a successful Cesarean delivery at 38 weeks, saving the life of the child and mother.

A rare case of gastric varices and splenic artery aneurysm secondary to splenic arteriovenous fistula

A 33-year-old male with no past medical history presented with a few months of fatigue and reduced exercise tolerance and was found to have iron-deficiency anemia. An esophagogastroduodenoscopy revealed a cluster of isolated gastric fundal varices with high-risk stigmata. Serologic workup for cirrhosis was negative, and a FibroScan measured liver stiffness at 4.2 kilopascals. Computed tomography (CT) of his abdomen and pelvis showed non-cirrhotic portal hypertension, as well as the presence of a splenic arteriovenous (AV) fistula and splenic artery aneurysm (SAA). Resection of the fistula, SAA, and spleen completely resolved the gastric varices and anemia.

TIPS for the management of stomal variceal bleeding due to cirrhotic and non-cirrhotic portal hypertension

Background Portal hypertension (PH) is associated with the development of esophageal or gastric varices, which can cause bleedings with high mortality. Varices can also manifest at sites of stomata. These parastomal varices can cause recurrent variceal bleedings (VB) despite local therapies. We present a case series of parastomal VB due to PH that were managed with implantation of transjugular intrahepatic portosystemic shunt (TIPS). Methods We retrospectively included all patients (pt) from 2 tertiary medical centers with parastomal VB between January 2014 and February 2020 who underwent the TIPS procedure. Results Nine pt were included. Seven pt had liver cirrhosis, mostly alcohol-related. Two pt had non-cirrhotic PH due to porto-sinusoidal vascular disease (PSD). Four pt had a colostomy, 1 an ileostomy, and 4 an ileal conduit. Malignancy was the leading cause of stoma surgery. All 9 pt suffered from recurrent parastomal VB despite non-selective beta-blocker and/or local therapy (e.g., compression, coagulation, suture ligation, or surgical stoma revision). All pt received TIPS implantation. In 7 pt, TIPS implantation led to sustainable hemostasis. Two pt suffered a bleeding relapse that was attributable to TIPS dysfunction. TIPS revision with coil embolization of the varices terminated the VB sustainably in both pt. Conclusions In pt presenting with recurrent stomal bleedings, parastomal varices as a rare complication of PH must be taken into consideration as an underlying cause. In our case series, we managed to sustainably cease parastomal VB by TIPS implantation with or without coil embolization of the ectopic varices.

Importance of the vessel distribution at splenic hilum for laparoscopic Warshaw procedure

The laparoscopic Warshaw procedure (LWP) is a considered to carry a risk of splenic infarction and perigastric varices formation. We retrospectively analyzed the clinical outcomes and relationship between the distribution of the splenic hilum vessels and splenic infarction in patients who underwent LWP from February 2007 to February 2017. A total of 19 patients underwent LWP, and the median follow-up duration was 78 months. The median operative time and blood loss were 295 min and 200 gr. Six patients with splenic partial infarction and 3 with gastric varices were detected, but they have not needed any treatments. According to the classification by Michels, the distribution of splenic vessels were divided as distributed type and magistral type at the splenic hilum. In our study, 16 patients were distributed type and 3 were magistral type. Three of the 16 patients developed splenic infarction in distributed type. In contrast, all of magistral patients showed splenic infarction. Although LWP is a safe procedure, there is a high risk of splenic infarction if the splenic vessel distribution is a magistral type. Understanding the type before surgery leads to the identification of an appropriate vascular dissection position and reduces postoperative complications.

Additional Benefits Conferred by Endoscopic Sclerotherapy to Liver Cirrhosis Patients Receiving Endoscopic Variceal Ligation

Objective. Gastroesophageal varices are a direct consequence of portal hypertension in cirrhosis. The management of gastroesophageal varices has evolved over the last decade resulting in reduced mortality and morbidity rates. The study was aimed to analyze the short-term and long-term efficacy of different endoscopic methods in the treatment of gastric varices in cirrhotic patients. Methods. From January 2016 to December 2019, 135 patients with liver cirrhosis and gastric varices undergoing different endoscopic treatment protocols were retrospectively analyzed. The patients were divided into three groups according to endoscopic variceal ligation, endoscopic sclerotherapy, and a combination of both, respectively. Main outcomes including the overall response rate, hemostasis, short- and long-term rebleeding (3 months before and after treatment), complication, blood pressure, heart rate, portal venous pressure (PVP), portal vein diameter (PVD), portal vein velocity (PVV), portal vein blood flow (PVF) detected by ultrasound, recurrence rate, and mortality were analyzed after treatments. Results. The overall response rate in the combined group was higher than that in the ligation group and the sclerotherapy group ( P < 0.05 ). The incidence rate of complications in the combined group and the ligation group was lower than that in the sclerotherapy group ( P < 0.05 ). After treatment, the PVP, PVD, and PVF were reduced in the combined group compared with the ligation group and the sclerotherapy group, while the PVV was not ( P < 0.05 ). Lower rates of long-term rebleeding, recurrence, and mortality were noted in the combined group compared to the ligation group and the sclerotherapy group ( P < 0.05 ). Conclusion. Endoscopic variceal ligation combined with endoscopic sclerotherapy is more effective than both alone in treating liver cirrhosis and gastric varices. The combined therapy contributed to reduced short-term and long-term rebleeding rate, decreased long-term recurrence rate, and mortality.

Platelet count and abdominal dynamic CT are useful in predicting and screening for gastroesophageal varices after Fontan surgery

Objective Patients who undergo Fontan surgery for complex cardiac anomalies are prone to developing liver and gastrointestinal complications. In particular, gastroesophageal varices (GEVs) can occur, but their prevalence is unknown. We aimed to elucidate the occurrence of GEVs and the predicting parameters of GEVs in these patients. Materials and methods Twenty-seven patients (median age, 14.8 years; median time since surgery, 12.9 years) who had undergone the Fontan surgery and were examined by abdominal dynamic computed tomography (CT) for the routine follow-up were included in the study. Radiological findings including GEVs and extraintestinal complications were retrospectively evaluated by experienced radiologists in a blinded manner. Relationships between blood-biochemical and demographic parameters and the presence of GEVs were statistically analyzed. Results Dynamic CT revealed gastric varices (n = 3, 11.1%), esophageal varices (n = 1, 3.7%), and gastrorenal shunts (n = 5, 18.5%). All patients with gastric varices had gastrorenal shunts. All gastric varices were endoscopically confirmed as being isolated and enlarged, with indications for preventive interventional therapy. A platelet count lower than 119 × 109 /L was identified as a predictor of GEV (area under the receiver operating curve, 0.946; sensitivity, 100%; and specificity, 87%). Conclusions GEVs are important complications that should not be ignored in patients who have undergone a Fontan procedure. Platelet counts lower than 119 × 109 /L may help to prompt patient screening by using abdominal dynamic CT to identify GEVs and their draining collateral veins in these patients.