Successful use of a mesocaval shunt to treat refractory ascites in a chronic pancreatitis induced portal vein thrombosis

Emergent nonconventional mesosystemic shunt for diffuse portomesenteric thrombosis: Sparing patients from liver/multivisceral transplantation

Portal vein thrombosis in adults: pathophysiology, pathogenesis and management

Role of transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension in pediatric patients.

Bleeding Stomal Varices: Case Series and Systematic Review of the Literature

Cardiac ascites is a classical finding of right-sided heart failure, mainly caused by tricuspid valve disease and constrictive pericarditis. Refractory cardiac ascites, defined as ascites that is uncontrollable with any medication, including conventional diuretics and selective vasopressin V2 receptor antagonists, is a rare but challenging entity. Although cell-free and concentrated ascites reinfusion therapy (CART) is a therapeutic option for refractory ascites in patients with liver cirrhosis and malignancy, its efficacy in cardiac ascites has never been reported. We herein report a case of CART for refractory cardiac ascites in a patient with complex adult congenital heart disease (ACHD). A 43-year-old Japanese female with a history of ACHD involving single ventricle haemodynamics presented with refractory massive cardiac ascites due to progressive heart failure. Because conventional therapy using diuretics could not control her cardiac ascites, abdominal paracentesis was frequently required, resulting in hypoproteinaemia. Therefore, CART was initiated once per month in addition to conventional therapies, which enabled the prevention of hypoproteinaemia and further hospitalizations except to undergo CART. In addition, it helped improve her quality of life without any complications for 6 years until she died from cardiogenic cerebral infarction at the age of 49 years. This case demonstrated that CART can be safely performed in patients with complex ACHD and refractory cardiac ascites due to advanced heart failure. Thus, CART may improve refractory cardiac ascites as effectively as massive ascites caused by liver cirrhosis and malignancy and lead to an improvement in the patients' quality of life.

Peritoneovenous shunting restores atrial natriuretic factor responsiveness in refractory hepatic ascites

Expandable metal stents in chronic pancreatitis

A 33-year-old male with abdominal distention after meals was admitted to the hospital. He had a history of surgery for hydatid liver cyst. The cyst was located at the liver hilum and there were portal venous thrombosis and cavernous transformation. It had been treated with partial cystectomy, omentoplasty and albendazole. Two years later at the admission to our center, his laboratory tests were in normal ranges. Abdominal imaging methods revealed splenomegaly, portal vein thrombosis, cavernous transformation and the previously operated hydatid liver cyst. Upper gastrointestinal endoscopy demonstrated esophageal and gastric fundal varices. Due to his young age and low risk for surgery, the patient was planned for surgical treatment of both pathologies at the same time. At laparotomy, hydatid liver cyst was obliterated with omentum and there was no sign of active viable hydatid disease. A meso-caval shunt with an 8 mm in-diameter graft was created. In the postoperative period, his symptoms and endoscopic varices were regressed. There were four similar cases reported in the literature. This one was the youngest and the only one treated by a surgical shunt. Hydatid liver cysts that located around the hilum can lead to portal vein thrombosis and cavernous thrombosis. Treatment should consist of both hydatid liver cyst and portal hypertension. To the best of our knowledge, this was the first case of surgically treated portal vein thrombosis that was originated from a hydatid liver cyst.

Objective: To analyze the incidence rate, compare the differences, and assess the risk factors for portal vein thrombosis (PVT) formation after different endoscopic treatment methods in patients with esophagogastric varices in cirrhosis. Methods: The laboratory, imaging, and endoscopic treatment methods data for 289 patients with esophagogastric varices in liver cirrhosis who initially received endoscopic treatment at the Endoscopy Center of You'an Hospital, affiliated with Capital Medical University, from January 2020 to December 2022, were retrospectively included. The incidence rate of PVT within 1 year after systematic standardized endoscopic treatment was statistically analyzed. Univariate and multivariate logistic regression analyses were used to screen the risk factors for PVT formation after endoscopic treatment. The t-test or rank-sum test was used to compare continuous data between the two groups. The χ2 test was used for categorical data. Results: The incidence rate of portal vein thrombosis (PVT) within 1 year was 20.76% (60/289) among 289 patients with esophagogastric varices in cirrhosis who underwent standard endoscopic treatment. The PVT incidence rate was 22.81% (13/57) in patients who used sclerotherapy alone and 15.22% (7/46) in patients who used ligation rings alone, with no statistically significant difference in the PVT incidence among different endoscopic treatment methods (χ2=2.354, P>0.05). Univariate analysis showed statistically significant differences in preoperative platelet count, spleen thickness, spleen long diameter, model for end-stage liver disease score, ascites, and smoking between the PVT group and the non-PVT group (P<0.05). Multivariate logistic regression analysis showed that preoperative platelet count [odds ratio (OR) = 0.988, 95% (confidence interval, CI): 0.979-0.998, P = 0.018], splenic ultrasound thickness (OR = 1.051, 95%CI: 1.003-1.101, P = 0.038), massive ascites (OR = 14.153, 95%CI: 2.517-79.577, P = 0.003), and smoking (OR = 2.537, 95%CI: 1.267-5.076, P = 0.009) were independent risk factors for PVT formation. Conclusion: The incidence rate of PVT is similar to the current known annual incidence rate of PVT following endoscopic treatment in patients with esophagogastric varices in liver cirrhosis, and different endoscopic treatment methods have no significant effect on PVT formation. Preoperative platelet count, spleen thickness, massive ascites, and smoking are risk factors for PVT formation.

Management of portal inflow to the graft in patients with spontaneous splenorenal shunts (SRS) is a matter of concern especially in case of large varices (more than 1 cm). In case of portal vein (PV) thrombosis (PVT), renoportal anastomosis (RPA) directly diverts the splanchnic and renal venous blood assuring a good portal inflow to the graft. Disconnection of the portacaval shunt by left renal vein ligation (LRVL) is another option but requires a patent PV. The indication of primary RPA rather than LRVL in patients with small native PV, especially in case of large graft, should be questioned in these complex cases of liver transplantation. From 1998 to 2012, 17 patients with RPA and 15 patients with LRVL were transplanted in our center. We compared these 2 techniques for short- and long-term results. The rate of preliver transplantation PVT (76% vs 27%) and graft weight (1538 ± 383 g vs 1293 ± 216 g) was significantly higher in the RPA group. Renoportal anastomosis was performed in 4 cases of small but patent PV. Three-month mortality, morbidity, and massive ascitis were similar. No patient was retransplanted. One year after transplantation, PV diameter was still larger in RPA group. Three-year survival was similar (RPA: 79% vs LRVL: 53%, P = 0.1). In cirrhotic patients transplanted with large splenorenal shunts, RPA and LRVL reach similar survivals. In case of complete PVT and failure of thrombectomy, the RPA offers satisfactory long-term results.

Acute effects of peritoneovenous shunting on plasma atrial natriuretic peptide in cirrhotic patients with massive refractory ascites

Refractory ascites can occur in patients with various conditions. Although several procedures based on the reinfusion of ascitic fluid have been reported after the failure of bed rest, salt and water restriction, diuretics, intravenous administration of albumin, and repeated paracentesis, these procedures are performed for ascitic fluid removal without dialytic effect. In this study, a flow control reinfusion of ascites during hemodialysis (HD) was performed to demonstrate the efficacy of this method in a lupus patient with massive refractory ascites and respiratory and acute renal failure (ARF). The alleviation of ascites and ARF attests to the success of the flow control reinfusion of ascites during HD. This procedure can control the rate of ascites and body fluid removal simultaneously during HD using the roller pump. In conclusion, with a normal coagulation profile, the procedure of flow control reinfusion of ascites during HD is an effective alternative treatment for the alleviation of refractory ascites with renal failure.

Alcohol and cigarettes: Partners in crime in chronic pancreatitis

Chronic pancreatitis is a progressive inflammatory disease of the pancreas. Causes of gastrointestinal (GI) bleeding in chronic pancreatitis are bleeding into the pseudocyst, pseudoaneurysm of peripancreatic vessels, and thrombosis of portal vein and splenic vein. We are presenting a rare case presentation of recurrent GI bleed in chronic pancreatitis since childhood and its management. A seventeen-year-old female patient presented with recurrent attacks of upper abdominal pain, hematemesis, bleeding per rectum, and melena since 1 month of age. She was diagnosed with a case of chronic calcific pancreatitis with pseudoaneurysm of common hepatic artery, and portal vein thrombosis with splenomegaly at the age of 2 years. She underwent angioembolization of the common hepatic artery pseudoaneurysm at the age of 2 years. However, she continued to have recurrent episodes of upper GI bleeding which required multiple hospital admissions and blood transfusions in the past. Contrast-enhanced computed tomography of abdomen was suggestive of chronic calcific pancreatitis with status post coil embolization of common hepatic, gastroduodenal, and proper hepatic arteries. She underwent modified Frey’s procedure in view of recurrent symptoms. Currently, the patient is doing well after 18 months of follow-up, with no further episodes of GI bleed. Angioembolization or surgical ligation of pseudoaneurysm of involved vessels in chronic pancreatitis can control GI bleed. However, in cases where the source of bleeding is not localized by imaging/ endoscopy, drainage of pseudocyst or local resection of pancreatic tissue can reduce inflammation in and around the pancreas and prevent further GI bleed in chronic pancreatitis.

Patients of gastrointestinal carcinoma with the refractory ascites are often chemotherapy-resistant cancer patients, and these patients are good indication of the cell-free and concentrated ascites reinfusion therapy (CART). CART is expected to improve symptoms associated with refractory ascites of patients with gastrointestinal carcinoma. The aim of this study is to evaluate the safety and efficacy of the CART system performed on the gastric cancer patients with massive refractory ascites. In this retrospective observational study, we evaluated 5 CART processes performed 3 patients with the gastric cancer. We evaluated the effectiveness and adverse events during CART procedures. The amounts of collected and concentrated ascites were 2410.0 ± 1762.6 ml (mean ± SD), and concentration ratio was 10.5 ± 4.3 times. The amount of collected protein in ascites was 3.4 ± 1.3 g/dl, and concentration ratio of protein was 4.2 ± 2.0 times. Serum protein level was no significant different between before and two weeks after CART. No patients received an albumin (25% albumin preparation Alb) transfusion within two weeks prior to the first CART. Thus, CART allowed for the reduction doses of Alb to be administered. CART has been reported to cause two adverse reactions as elevation of body temperature and decrease in blood pressure. In our study, decreased blood pressure was not observed in all patients, and body temperature significantly rose after CART, but there were no patients more than 37 degrees. In patients with refractory ascites of the gastric cancer patients in whom complete cure cannot be expected, CART improves their QOL and, in terms of medical economy, allows for the reduction doses of