Mesenteric Angiogram Research Articles

Immediate Capsule Endoscopy or Mesenteric Angiogram in Patients with Acute Overt Obscure Gastrointestinal Bleeding: Interim Results of a Prospective Randomized Trial

The best investigation algorithm for patients with acute obscure gastrointestinal bleeding (OGIB) remains undefined. There are few randomized studies comparing the diagnostic yield of angiogram with CE in patients with active OGIB. Methods: This is a prospective randomized study that compared CE and angiogram in patients with acute OGIB. Consecutive patients presented with melena or hematochezia underwent upper and lower endoscopy within 24 hours of admission. Patients with non-diagnostic upper and lower endoscopy were randomized to undergo either CE or angiogram immediately. Small bowel Pillcam (GIVEN) was performed according to standard practice. A standardized protocol of 3-vessel visceral angiography was used. Patients who developed clinical rebleeding after negative initial investigation, defined as ongoing melena/hematochezia and drop in hemoglobin, were crossed-over to the other imaging modality. Exclusion criteria included moribund patients, patients with renal failure, presence of pacemaker, pregnancy, or those suspected to have intestinal obstruction. All patients were followed for 12-month for rebleeding. Gold standard for bleeding source was based on subsequent pathological findings if available or when this information was unavailable, lesions that most likely represented the source of bleeding. Diagnostic yield of the two modalities were compared. Results: Within an 18-month period, 41 patients with OGIB were randomized to CE or angiogram. Baseline characteristics of the two groups were comparable. The median follow up of two groups was 7.8 and 8.1 months, respectively. Eleven of 20 (55%) in the CE group and 2 of 21 (9.5%) in the angiogram yielded positive findings in their assigned examination (P = 0.003). In addition to small bowel lesions, CE detected gastric and duodenal ulcers that were not detected by initial EGD in 4 patients (20%). Three patients with negative angiographic findings had rebleeding during the same admission (2) or on follow-up (1) were crossed over to CE examinations, which showed definite bleeding source in the small bowel in two and in the proximal colon in the other. No patient in the CE group has rebleeding yet (P = 0.23). There was no adverse event related to both investigations. Surgery was performed in 4 patients (2 from each group) for resection of small bowel lesions (tumors and Meckel's diverticulum) diagnosed by the assigned investigation. One patient died of non-GI cause in the angiogram group. Conclusion: Results of this interim analysis suggest that CE is superior to angiogram as the immediate investigation for patients presented with active OGIB.

Laparoscopic Gastropexy for Congenital Organoaxial Gastric Volvulus in an Adult with Severe Intestinal Malabsorption

A 62 year old male with malabsorption, malnutrition, and multiple comorbidities underwent laparoscopic gastropexy for congenital organoaxial vovulus, an uncommon lesion. The patient was well until 18 months prior, when he developed non-bloody diarrhea (> 20 stools per day), and progressive weight loss of over 120 lbs (>1/3 total body weight). Upper endoscopy and colonoscopy with biopsies were nondiagnostic. His cardiac function deteriorated, with dilated cardiomyopathy, and atrial fibrillation requiring pacemaker/defibrillator placement within 1 year. He underwent 72 hour fecal fat (75% absorption), followed by endoscopic retrograde cholangiopancreatography (“normal”), complicated by acute heart failure with collapse. During subsequent admission, work-up showed normal fecal elastase, and negative genotype for Celiac disease, infection, and PCR for Whipple's disease in blood. Upper GI demonstrated organoaxial gastric volvulus. He was treated empirically for Whipple's, made NPO with full parenteral nutrition, and referred for surgery. Repeat upper endoscopy and biopsies showed increased intraepithelial lymphocytes, and amyloidosis of duodenal vessels (IgM, IgG, IgD, IgA, κ, λ, amyloid A and B negative). At laparoscopy, the liver appeared normal, spleen was slightly enlarged. The stomach was suspended at a normal gastroesophageal junction, but had rotation of the body and fundus with a volvulus that was mostly posterior and a midline pylorus. Liver biopsy, resection of incidental Meckel's diverticulum, gastropexy, and gastrostomy were accomplished laparoscopically without complication. Postoperatively, the patient was started on peptide feeds, but continued to have malabsorption at discharge one week later. He was re-admitted within 4 weeks for Enterobacter gergoviae sepsis, intraabdominal free air/possible peritonitis. Mesenteric angiogram was normal. Over the 6 week admission, complicated by recurrent ventricular tachycardia, TPN was used until optimal weight achieved, then weaned as continuous peptide feeds increased. These were well tolerated with only 2 stools per day, and negative fecal fat, pH, and reducing substances on full GT feeds/low fat diet, upon discharge. The patient remains well 6 months after discharge.

Minnesota Tube for Bleeding Rectal Varices

A 51 year old man with Child's C hepatitis C cirrhosis, paroxysmal atrial fibrillation was admitted with decompensated cirrhosis, increasing ascites, and hepatic encephalopathy. As a part of pre-transplant work-up, he underwent colonoscopy which showed polyps in the descending colon as well as non bleeding rectal varices. Polypectomy was performed with no immediate complications. Within 24 hours of discharge, he presented with bright red rectal bleeding which led to hemorrhagic shock and admission to the intensive care unit, requiring massive blood and blood products transfusion. Emergency mesenteric angiogram was non-diagnostic. Despite the correction of his coagulopathy, he continued to bleed requiring emergent laparotomy, left hemicolectomy, and colostomy. Post operatively he had another episode of bleeding and he was taken back to OR for ligation of feeding vessels to rectal varices in addition to intra and extraluminal packing. In the interim, he underwent TIPS procedure for portal hypertension. One day later he returned to OR to have the packings removed, only to find the rectal varices still oozing. It was decided to place Minnesota tube to apply direct pressure using inflated gastric balloon to rectal varices. Due to the presence of rectal stump, which was around 15 cm, 10cm of the tube was cut. The tube was inserted into the rectal stump and gastric balloon was inflated with 200mls of air with immediate cessation of bleeding. The gastric aspiration port was aspirated every 2 hours. The balloon remained inflated for the next 24 hours with no evidence of further bleeding. Discussion: Minnesota tube can be used as rescue treatment for bleeding rectal varices when all other modes of therapy failed to stop bleeding. There has been similar case reports describing the use of Sengstaken-Blakemore tube in patients with rectal bleeding due to angiodysplasia, post partum hemorrhage. However, this is the first case that describes the use of Minnesota tube which has a larger gastric balloon in patient with rectal bleeding due to varices. [figure 1]Figure 1

Gastroduodenal Artery Aneurysm Presenting as Jaundice and Abdominal Pain

Visceral artery aneurysm is a very rare and potentially serious vascular anomaly. The mortality rate from bleeding is 40–60%. Aneurysms of the gastroduodenal artery rank among the rarest splanchnic artery aneurysms, comprising fewer than 2 per cent of all such lesions. We report a case of a 41 year old male with history of pancreatitis admitted with jaundice and vague right upper quadrant pain. Laboratory findings suggested a cholestatic picture and ultrasound of the abdomen revealed a mass of the head of the pancreas causing compression of the common bile duct. Further imaging with a CT scan revealed a 5.6 cm aneurysm of the gastroduodenal artery with surrounding hematoma. Mesenteric angiogram showed aneurysm arising from the proximal gastroduodenal artery and occlusion of the celiac axis with multiple collaterals from superior mesenteric artery to the hepatic and splenic arteries. Coil embolisation could result in hepatic ischemia in the setting of celiac axis occlusion, and was not attempted. Patient underwent ERCP and stenting of the common bile duct with successful decompression of the biliary system. Operative exploration with intraoperative visceral angiogram showed celiac axis compression within the medial arcuate ligament of the diaphragm. The medial arcuate ligament was divided leading to restoration of blood flow to the liver. The inflow and outflow vessels of the aneurysms were ligated without the risk of hepatic ischemia. Patient recovered uneventfully. This case illustrates an uncommon cause of obstructive jaundice caused by bleeding aneurysm of the gastroduodenal artery in the settings of prior pancreatitis and celiac axis occlusion.

Effectiveness of Rex shunt in the treatment of portal hypertension

Background Children with portal venous thrombosis often have severe symptoms secondary to portal hypertension including recurrent upper gastrointestinal (UGI) bleeds and hypersplenism. We report results of the use of the mesenterico–left portal bypass (Rex shunt) in 5 consecutive patients. Methods A retrospective chart review of all patients with portal venous thrombosis who underwent Rex shunt procedure was performed. Children were evaluated preoperatively with magnetic resonance angiogram, Doppler ultrasound, and mesenteric angiogram. Postoperative ultrasounds were performed in follow-up. Results All patients had evidence of portal hypertension and hypersplenism. The average age of the patients was 13.2 ± 4.9 (7-19) years. The patient had an average of 2.6 ± 1.7 UGI bleeds requiring banding and 3.4 ± 4.2 U of blood transfused before undergoing the shunt. The mean operative time was 383 ± 46 minutes, and length of stay was 10.4 ± 7.1 days. In follow-up of 18.8 ± 5.2 months (11-24 months), all but 1 patient had a patent shunt. One narrowed shunt was successfully dilated by percutaneous angioplasty. Thrombocytopenia improved significantly in patients with functioning shunts but did not correlate with a significant decrease in splenic size. Conclusions The Rex shunt reestablishes normal hepatopedal portal flow, and in patients with functioning shunts, no recurrent UGI bleeds or transfusions were required or evidence of encephalopathy were noted.

Isolated, Idiopathic Splenic Vein Thrombosis, Presenting with Massive Lower GI Bleeding.

Isolated, also called idiopathic, splenic vein thrombosis (SVT) is a very rare clinical condition, which usually results in left-sided portal hypertension and isolated fundal varices. This syndrome is a rare cause of mostly upper, gastrointestinal bleeding. There are only a few hundreds of cases reported in the literature. Colonic varices are even much rarer, 0.07% post mortem autopsies, and 0.2% in a prospective large endoscopic trials. Pancreatic disorders, including malignancies are the most common underlying causes for SVT. Congenital aneurysm of the splenic vein is one of the theoretical explanations of the Isolated, Idiopathic SVT.Case report: A 53 year old Caucasian female with history of hypertension, and no history of smoking or alcohol abuse, presented with chronic lower gastrointestinal bleeding. Upper endoscopy and flexible colonoscopy revealed perigastric varices without any source of acute bleeding. A bleeding scan demonstrated marked splenomegaly and source of bleeding from left colon. Mesenteric angiogram during venous phase showed splenic vein thrombosis and extensive perigastric varices. In addition, a single large left colonic varix from the lower pole of the spleen was identified as the source of bleeding. The patient was treated with splenic artery embolization with coils, followed by splenectomy, without any major complication. Coagulation studies 8 weeks after the procedure did not show any hypercoagulable state.Conclusion: The Isolated, Idiopathic SVT, itself is a very rare syndrome. Our center has reported four cases of SVT, secondary to medical conditions, such as; pancreatic malignancy, MRSA sepsis, and multi-organ failure. Upper gastrointestinal bleeding has been more frequently reported than lower bleeding. Interestingly, in our case report, a single colonic varix secondary to SVT was proved to be the cause of chronic lower gastrointestinal bleeding. SVT should be suspected in any patient with a triad of gastric varices, splenomegaly, and normal liver function tests, who presents with gastrointestinal bleeding secondary to left sided or so called “sinistral” portal hypertension. Mesenteric angiography with venous phase is the gold standard for the diagnosis of SVT, as endoscopic studies may not be diagnostic of this syndrome. Splenectomy is the only and definitive procedure of choice in the patients with isolated SVT, followed by post splenectomy vaccination.

A Meta-Analysis of the Yield of Capsule Endoscopy Compared to Other Diagnostic Modalities in Patients with Obscure Gastrointestinal Bleeding

Due to its superior ability to examine the entire small bowel mucosa, capsule endoscopy (CE) has broadened the diagnostic evaluation of patients with obscure gastrointestinal bleeding (OGIB). Published studies have revealed a numerically superior performance of CE in determining a source of OGIB compared with other modalities, but due to small sample sizes, the overall magnitude of benefit is unknown. Additionally, the types of lesions more likely to be found by CE versus alternate modalities are also unknown. The aim of this study was to evaluate the yield of small bowel findings with CE in patients with OGIB compared to other modalities using meta-analysis. We performed a recursive literature search of prospective studies comparing the yield of CE to other modalities in patients with OGIB. Data on yield and types of lesions identified among various modalities were extracted, pooled, and analyzed. Incremental yield (IY) (yield of CE-yield of comparative modality) and 95% confidence intervals (95% CI) of CE over comparative modalities were calculated. A total of 14 studies (n = 396) compared the yield of CE with push enteroscopy for OGIB. The yield for CE and push enteroscopy was 63% and 28%, respectively (IY = 35%, p < 0.00001, 95% CI = 26-43%) and for clinically significant findings (n = 376) was 56% and 26%, respectively (IY = 30%, p < 0.00001, 95% CI = 21-38%). Three studies (n = 88) compared the yield of CE to small bowel barium radiography. The yield for CE and small bowel barium radiography for any finding was 67% and 8%, respectively (IY = 59%, p < 0.00001, 95% CI = 48-70%) and for clinically significant findings was 42% and 6%, respectively (IY = 36%, p < 0.00001, 95% CI = 25-48%). Number needed to test (NNT) to yield one additional clinically significant finding with CE over either modality was 3 (95% CI = 2-4). One study each compared the yield of significant findings on CE to intraoperative enteroscopy (n = 42, IY = 0%, p= 1.0, 95% CI =-16% to 16%), computed tomography enteroclysis (n = 8, IY = 38%, p= 0.08, 95% CI =-4% to 79%), mesenteric angiogram (n = 17, IY =-6%, p= 0.73, 95% CI =-39% to 28%), and small bowel magnetic resonance imaging (n = 14, IY = 36%, p= 0.007, 95% CI = 10-62%). Ten of the 14 trials comparing CE with push enteroscopy classified the types of lesions found on examination. CE had a 36% yield for vascular lesions versus 20% for push enteroscopy, with an IY of 16% (p < 0.00001, 95% CI = 9-23%). Inflammatory lesions were also found more often in CE (11%) than in push enteroscopy (2%), with an IY of 9% (p= 0.0001, 95% CI = 5-13%). There was no significant difference in the yield of tumors or "other" findings between CE and push enteroscopy. CE is superior to push enteroscopy and small bowel barium radiography for diagnosing clinically significant small bowel pathology in patients with OGIB. In study populations, the IY of CE over push enteroscopy and small bowel barium radiography for clinically significant findings is >or=30% with an NNT of 3, primarily due to visualization of additional vascular and inflammatory lesions by CE.

A 57 Year Old with Recurrent Hepatic Encephalopahthy

59 year old Caucasian male presents with 3–4 days of encephalopathy. He has a past medical history of celiac sprue, hypertension, asthma, and GERD with history of recurrent encephalopathy for the past 3 years with consistently elevated ammonia levels despite lactulose therapy. He was complaint with a gluten free diet. He has had a complete neurological workup including MRI/CT of brain that showed mild degenerative changes and an EEG that showed generalized slowing of waves not consistent with his symptoms. Hepatic workup for elevated serum ammonia included liver biopsy and an ERCP that was unremarkable. A mesenteric angiogram with transhepatic portagraphy displayed a portal vein to inferior vena caval shunt as a cause of his elevated ammonia levels. Hepatic Encephalopathy is neuro-psychiatric syndrome caused by liver disease. It occurs most often in patients with cirrhosis but is also seen in acute hepatic failure.[1] Liver failure and portasystemic shunting of blood are two important factors underlying hepatic encephalopathy.[1] Portasystemic shunts are of two major types spontaneous and surgical.[1] Surgical porto-caval shunts have been widely used in the treatment of Cirrhosis and recurrent variceal bleeding, however little is known about the congenital formation of these anomalies. Congenital intrahepatic portal-systemic venous shunt is defined as a communication between the portal and the systemic-venous circulation, measuring more than 1 mm in diameter and at least partially located inside the liver.[3] It is a very rare condition with uncertain etiopathogenesis.[3] There are 5 different types. Type I (intrahepatic type) designates cases in which shunts are located between the portal and systemic veins. Type II designates a type of intra/extrahepatic shunt that originates from the umbilical part of the portal vein and serpentines in the liver, then leaves the liver. Type III (extrahepatic type) occurs most frequently. Type IV (extrahepatic) is accompanied by shunts similar to those in type III, but hepatic pathology presents as idiopathic portal hypertension. Type V (extrahepatic) represents the congenital absence of the portal vein, where the superior mesenteric vein joins the intrahepatic inferior vena cava or the left renal vein.[2] Only 47 cases have been reported in the entire French and English literature.[3]

Primary Amyloidosis Presenting as Recurrent Ischemic Colitis

Ischemic colitis has a myriad of causes. Primary amyloidosis is a rare cause of ischemic colitis with only a few case reports in the literature. We present an unusual case of ischemic colitis due to primary amyloidosis. A 69 year old woman, with history of activated protein C resistance and lower extremity deep vein thrombosis on chronic warfarin treatment, presented with 1-day history of bloody diarrhea and crampy abdominal pain. Three weeks before, she was hospitalized with similar symptoms at another medical facility and diagnosed with ischemic colitis by colonoscopy. After a week of bowel rest, total parental nutrition, and intravenous antibiotics, her symptoms had resolved. She remained asymptomatic until the night prior to her current admission. She was afebrile with a blood pressure of 108/66 mm Hg and a pulse of 109 beats per minute. Physical examination was significant for mild tenderness to palpation in the lower abdomen, without peritoneal signs. Laboratory evaluation revealed normal white blood cell count, hemoglobin of 11.9 g/dL, and an International Normalized Ratio of 5. Abdominal computed tomography showed nonspecific thickening of the colonic mucosa from the splenic flexure to the descending colon. Sigmoidoscopy revealed multiple large ulcers with areas of mucosal necrosis in the proximal sigmoid colon. Biopsies showed focal ulceration with necroinflammatory exudate. Mesenteric angiogram was unremarkable. On hospital day 7, she underwent a total colectomy with end ileostomy after ischemic changes were observed from mid transverse colon to rectosigmoid junction on intraoperative colonoscopy. Histology revealed extensive amyloidosis involving the omentum and entire colon with deposition in the muscularis mucosa, submucosa, and subserosa. Perivascular deposition of amyloid with luminal narrowing was also present. Serum electrophoresis and immunofixation revealed an IgG lambda monoclonal band, while a bone marrow biopsy showed 5–10% lambda restricted plasma cells. Our case illustrates that primary amyloidosis presenting as recurrent ischemic colitis may be missed despite thorough history, laboratory evaluation, radiographic studies and endoscopic biopsies.

A Case of Traumatic Mesenteric Bleeding Controlled by only Transcatheter Arterial Embolization

We report a case of mesenteric hematoma following blunt abdominal trauma that was successfully treated with transcatheter arterial embolization (TAE) and did not require surgical repair. A 43-year-old man with blunt abdominal trauma caused in a factory accident was admitted with a stable general condition and laboratory data. On CT examination, a large mesenteric hematoma with extravasation of contrast media was observed. TAE was first attempted to control the bleeding. A superior mesenteric angiogram showed extravasation of contrast medium from a branch of the ileocolic artery and obstruction of the cecal branch. After successful TAE using microcoils, the distal portion of the cecal branch was still preserved via collateral circulation. No abdominal symptoms have occurred during the 7 months following TAE. In mesenteric injury cases with limited intestinal damage, TAE may therefore be a reasonable alternative to emergent laparotomy.

Stenting of superior mesenteric and celiac arteries

A 72-year-old woman with a complex medical history, which included abdominal pain in both lower quadrants for many years, presented to the emergency room with increased complaint of abdominal pain. She was evaluated for this complaint and a 30-pound weight loss. She had been seen the previous day for evaluation in the department of vascular surgery. A duplex ultrasound was performed, which demonstrated high-grade stenosis in the superior mesenteric artery (SMA) and celiac artery. An angiogram was scheduled to evaluate with possible intervention. That evening her abdominal pain increased, and she was instructed to go to the emergency room for evaluation. Because her lactate levels had increased to 2.6 mmol/L and she demonstrated the progressive symptoms of postprandial abdominal pain, it was decided to urgently perform a mesenteric angiogram. Arterial access was obtained in an antegrade manner through a left brachial approach by using micropuncture techniques. A 0.035-inch floppy glide wire was advanced from the brachial into the axillary and subclavian arteries and then to the descending thoracic aorta, and the sheath was up-sized to 6 French. A pigtail catheter was placed over the wire; the wire was removed, and an aortogram was performed. This demonstrated severe three-vessel mesenteric occlusive disease (Fig 1). Lateral aortograms and selective views of the SMA were performed. This demonstrated a lesion in the SMA, which was treated with balloon angioplasty and stented with a 6 24 Genesis Stent (Cordis, Johnson & Johnson Company, Warren, NJ). There was a residual lesion that was dilated with a 7 2 Opta-Pro balloon (Cordis, Johnson & Johnson Company). Next, selective views of the celiac artery were performed. This demonstrated a lesion that was treated with balloon angioplasty and stented with a 7 14 Genesis stent (Cordis, Johnson & Johnson Company). An 8 20 Opta-Pro balloon (Cordis, Johnson & Johnson Company) was used to post-dilate the residual lesion. Post-angiograms were taken of the aorta, demonstrating brisk flow through both vessels (Fig 2). The

HEMOSUCCUS PANCREATICUS PRESENTING IN A MALE WITH CHRONIC PANCREATITIS AND SUSPECTED PANCREATIC MALIGNANCY

Hemosuccus pancreaticus is a rare cause of GI bleeding. It is associated with chronic pancreatitis, pancreatic pseudocyst and tumors. The usual mechanism is erosion of a blood vessel or pseudoaneurysm in to a pancreatic pseudocyst that communicates with the pancreatic duct. 59 year old male with a history of chronic pancreatitis from alcoholism presented with a 6 month history of worsening periumbilical abdominal pain, nausea, weight loss and anorexia. Physical examination revealed cachexia and peri-umbilical tenderness with no organomegaly, mass or peritonitis. The CBC, chemistry panel, liver functional panel, coagulation profile and pancreatic tumor markers (CA 19–9 & CEA) were normal. A CT and MRI of abdomen showed a heterogeneous mass in the head of pancreas. During an attempt to perform EUS and FNA, he became hypotensive. Blood was seen emanating from the ampullary orifice (Figure 1) with a subsequent drop in hemoglobin (from 11.3 to 6.2 g/dl). After instituting aggressive resuscitation and obtaining an urgent surgical consultation, a selective mesen-teric angiogram was performed that revealed a ruptured pseudoaneurysm off the superior pancreaticoduodenal artery (Figure 2). After embolization of aneurysm, bleeding stopped and patient remained hemodynamically stable. A repeat EUS directed FNA of the mass revealed no malignant cells. The presence of a large pseudocyst communicating with the pancreatic duct was later confirmed with ERCP.FigureFigureHemosuccus pancreaticus should be suspected in patients with chronic pancreatitis who present with unexplained massive GI bleeding, hemodynamic instability and/or increased abdominal pain from a sudden expansion of a pseudocyst. Prompt recognition is crucial for adequate therapeutic interventions, [Figure 1] [Figure 2]

Hepatic artery thrombosis and graft ischemia in the presence of preserved arterial inflow: Not a contradiction but a real possibility

A 25-year-old Caucasian male underwent orthotopic liver transplantation in June 2000 because of Caroli's disease. He was retransplanted in May 2001 due to intractable chronic rejection. Retransplantation was performed with a conventional technique using veno-venous bypass, anastomosis between the hepatic artery of the graft and the common hepatic artery of the recipient, and a Roux-en-Y choledochojejunostomy. An episode of acute rejection was diagnosed in the second postoperative week that responded to high-dose steroids, and the patient was discharged 34 days after retransplantation. No significant abnormality in the graft function was detected until June 2003, when the patient developed fever and leukocytosis associated with biochemical signs of cholestasis followed by jaundice; transaminases remained normal or showed minimal increase. Hepatic ultrasonogram revealed moderate dilatation of the intrahepatic bile ducts with 2 small bilomas, while Doppler US showed normal intraparenchymal arterial resistive index and systolic acceleration time. HAT, hepatic artery thrombosis. Abdominal computed tomography scan confirmed diffuse dilatation of the bile ducts with hypodense areas consistent with biloma (Fig. 1). Selective celiac arteriography showed a complete obstruction of hepatic artery (Fig. 2), while the arteriogram of the superior mesenteric artery demonstrated the presence of compensatory collateral vessels recruited from the jejunal vascular arcade of the Roux limb (Fig. 3). Despite antibiotic treatment, the patient developed recurrent episodes of cholangitis with persistent jaundice and is now listed for retransplantation. Hepatic computed tomography showing diffuse dilatation of the intrahepatic bile ducts with hypodense areas in the left liver and triangular areas in the right consistent with biloma and parenchyma ischemia respectively. Celiac axis angiogram shows complete occlusion of the hepatic artery (white arrow). Superior mesenteric artery angiogram shows arterial collaterals (white arrows) arising from the jejunal vascular arcade of the Roux limb perfusing the liver. Hepatic artery thrombosis (HAT) after orthotopic liver transplantation still represents one of the main causes of failure of liver transplantation, with an incidence ranging from 3 to 9% in adult recipients.1 When it occurs in the early postoperative period, unless promptly recognized and treated, HAT is normally associated with graft loss.2, 3 Late HAT typically has been associated with less severe complications and may even be asymptomatic.4 This fact is normally attributed to the development of arterial collaterals, possibly due to the gradual progression of arterial stenosis prior to HAT.5 Development of arterial collaterals has been reported in pediatric liver transplant recipients6-8 probably due to the more common presence of Roux-en-Y choledochojejunostomy, but has been rarely described in adults.9, 10 However, in these patients, even in those rare cases where arterial flow is still detectable, Doppler ultrasonogram always shows gross abnormalities with low resistive index and very high systolic acceleration time (almost always above 100 milliseconds).10, 11 In the present case, probably due to the considerable size of the vessels that revascularized the liver after hepatic artery occlusion, doppler signal was normal. As previously reported the rearterialization spared the graft function while permanent damage to intrahepatic bile tree was observed.5 In our patient the suspicion of liver ischemia was induced by the features of the intrahepatic bile tree. Hepatic angiogram is recommended in the presence of unexplained cholestasis, even when the normal arterial signal is detected at Doppler ultrasonogram.

Severe fatty change of the graft liver caused by a portosystemic shunt of mesenteric varices

Abstract Portosystemic shunt is a common complication in patients with portal hypertension. Mesenteric varix is one of the collaterals that can cause post-transplant liver day-function. In this case report, a 45-year-old woman underwent living relative donor liver transplantation for alcoholic cirrhosis. Although the early postoperative course was uneventful, she was readmitted for treatment of liver hypofunction. Fatty change in the graft liver was confirmed by histopathology of the biopsy specimen. The venous phase of a superior mesenteric angiogram revealed large-caliber mesenteric varices comprising portosystemic venous shunts. Surgery was performed to ligate the shunts. The intraoperative color Doppler ultrasonography showed hepatofugal portal blood flow, which was corrected to hepatopetal blood flow by clamping the shunt vessels. The portal pressure was moderately elevated from 13.6 cm to 21.8 cm H2O. Two shunt vessels were ligated and divided. Her liver function returned to nearly normal thereafter. We recommend that descending collatearals be divided during liver transplantation.

Gastrointestinal involvement in polyarteritis nodosa (1986–2000):: Presentation and outcomes in 24 patients

PurposeGastrointestinal involvement in polyarteritis nodosa carries a poor prognosis. A 1982 review from our institution reported acute abdominal syndromes in 31% of patients with polyarteritis nodosa, and that all 5 patients with acute surgical abdomens died. We reviewed our more recent experience to determine if outcomes have changed since. Subjects and methodsWe reviewed the records of all patients with polyarteritis nodosa in our vasculitis database between 1986 and 2000. Inclusion criteria were a diagnosis of polyarteritis nodosa, symptoms or signs of gastrointestinal involvement, and either a mesenteric angiogram consistent with polyarteritis nodosa or histopathologic proof of a medium-vessel vasculitis. We calculated a prognostic (5 factor) score for all patients. ResultsWe identified 24 patients with polyarteritis nodosa who had gastrointestinal involvement during their illness. Thirteen (54%) of the patients developed acute surgical abdomens, 3 of whom died (P = 0.02 by comparison with the historical cohort). Mean (± SD) prognostic scores were higher among patients in the acute abdomen group compared with those who did not have acute abdominal syndromes (1.7 ± 0.9 vs. 0.6 ± 0.7, P = 0.002), corresponding with the observed mortality in these groups. ConclusionGastrointestinal involvement occurs commonly in polyarteritis nodosa and carries a poor prognosis. Compared with a historical cohort at our institution, mortality from this complication may have decreased, perhaps because of earlier diagnosis.

Screening for mesenteric vascular insufficiency and follow-up of mesenteric artery bypass procedures.

Duplex ultrasonography is the preferred noninvasive screening test for superior mesenteric artery (SMA) and celiac artery (CA) stenosis. Although postprandial increases in SMA peak systolic velocity (PSV) are known to occur, the principal duplex criteria for hemodynamically significant SMA and CA stenosis are based on fasting flow velocities. In the SMA, a PSV > or =275 cm/s predicts a > or =70% angiographic stenosis with a sensitivity of 92% and a specificity of 96%, whereas a CA PSV of > or =200 cm/sec predicts a > or =70% stenosis with a sensitivity of 87% and a specificity of 80%. Patients with appropriate symptoms of chronic visceral ischemia and a duplex scan showing high-grade stenosis of the SMA, especially when combined with CA stenosis, should have a confirmatory mesenteric angiogram. This approach will facilitate prompt intervention in these patients. If the duplex examination indicates widely patent mesenteric arteries, alternative diagnoses should be investigated. Other applications of mesenteric duplex scanning include evaluation of median arcuate ligament syndrome and postoperative surveillance of mesenteric artery revascularizations.

Spectrum of transient hepatic attenuation differences in biphasic helical CT.

A, Helical CT scan obtained in hepatic arterial phase shows large hemangioma in left lobe of liver. Liver parenchyma adjacent to lesion (arrowheads) shows early enhancement B, Helical CT scan obtained in portal venous phase reveals that area of early enhancement has become isodense. Left portal vein is compressed by lesion and is faintly opacified (arrowheads). C, Superior mesenteric angiogram shows only main and right portal veins. Left lobe counterpart is not revealed.

Acute intrahepatic portal vein thrombosis complicating cholangitis in biliary atresia

A 2-year-old boy with Kasai portoenterostomy had systemic features suggestive of cholangitis and acute portal vein obstruction. The rapid rise in portal pressure caused a transient, severe decompensation of hepatic function. A superior mesenteric arterial angiogram confirmed the presence of diffuse intrahepatic portal vein thrombosis. This case provides clinical and radiological evidence supporting an association between ascending cholangitis and acute intrahepatic portal vein thrombosis.

SECOND LOOK PROCEDURE AFTER EMBOLECTOMY FOR ACUTE MESENTERIC ARTERY EMBOLISM -A CASE REPORT-

Acute mesenteric artery embolism is a curable disease if the diagnosis and therapy are instituted before irreversible changes have occurred. We experienced a case of acute mesenteric artery embolism which was treated by second look procedure about 40 hours after embolectomy that permitted us to excise the small intestine in a minimal range. A 71-year-old man was admitted to the hospital because of severe abdominal pain. Superior mesenteric artery angiogram demonstrated embolus completely occluding the SMA. Emergency laparotomy was performed. Large segment of the intestine revealed ischemic change. We performed embolectomy of SMA. About 40 hours after embolectomy, second look procedure was performed. Only small segment of the intestine was necrosed. Bowel resection about 150 cm and anstomosis was carried out. The patient died of cardiac arrest on the 66th day after onset of th diseases. Second look procedure after embolectomy appears useful for evaluation of bowel viability.

胸腹部銃創の１救命例

The patient, a 51-year-old male, suffered from two gunshot injuries in the right chest and abdomen. Computed tomography (CT) revealed right hemothorax, pulmonary trauma, hepatic, pancreatic, duodenal and transverse colic injury and postcaval trauma. An emergency operation was performed to repair these injured parts. During surgery, there was massive bleeding from the injured inferior vena cava. Duration of the surgery was 8.5hr and blood loss was 8, 000ml. Massive bleeding due to leakage of pancreatic juice occurred 23 days after surgery. A superior mesenteric angiogram showed extravasation from the right branch of the middle colic artery. Transcatheter arterial embolization (TAE) was successfully performed by using gelatin sponge. The patient was discharged on the 120th postoperative day. Preoperative CT was helpful in diagnosing trauma from the gunshot injuries. After surgery, TAE was useful for postoperative bleeding. We suspect that the gunshot injuries caused the pseudo aneurysm.