Rupture Of Varices Research Articles

RECURRENT STOMAL VARICEAL BLEEDING IN CIRRHOSIS: MANAGEMENT WITH TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT AND EMBOLIZATION

Gastrointestinal (GI) bleeding is a common complication of cirrhosis and portal hypertension. Most cases are secondary to gastro-esophageal variceal rupture, managed endoscopically1. Stomal bleeding is rare and there’s no standard therapy2. We present a case of a cirrhotic patient with recurrent stomal hemorrhage successfully treated with transjugular intrahepatic portosystemic shunt (TIPS) and stomal varices embolization.

S2633 Omental Varices Causing Umbilical Bleeding: A Rare Presentation in Cirrhotic Patients With Portal Hypertension

Introduction: Ectopic varices account for less than 5% of all varix-related bleeding episodes. Umbilical bleeding is a well-recognized but unusual complication of portal hypertension, and most of the time is caused by bleeding from umbilical varices (UV). On the other hand, rupture of omental varices (OV) leading to spontaneous umbilical bleeding is rare and has been reported once in the previous literature. Case Description/Methods: A 54-year-old male with a history of liver cirrhosis, MELD score of 21, Child-Pugh Class B, who was found lying in a pool of blood in his bedroom, was transported to the hospital with profuse spontaneous bleeding from his umbilical hernia site. He gave a history of similar, but mild bleeding episodes occurring intermittently over the last week, with no trauma associated. Initially, the patient was hypotensive, tachycardic, and had a protuberant abdomen with a large ventral hernia, covered by a dressing. Removal of the dressing revealed active venous hemorrhage. Laboratories showed hemoglobin 6.9 g/dL, mean corpuscular volume 95.3 fL, platelets 88 × 103/mcL, INR 1.36, total bilirubin 0.7 mg/dL, ammonia level 160 µg/dL, and mild transaminitis. The patient’s hemorrhagic shock was treated with blood transfusions, IV fluids, and vasopressors. Abdomen CT scan showed anterior abdominal wall hernias containing herniated fat with fat stranding. The surgery service evaluated the patient and suspected OV bleeding. Intraoperatively, he was treated with periumbilical excision and ligation of the OV contained within the hernia. The omentum became adhered to the skin of the umbilicus, allowing venous communications to develop between the varices and cutaneous veins of the umbilicus. The section was dissected and a Seprafilm was placed to prevent future adherence, and the bleeding was controlled (Figure 1). Discussion: The most reported cause of spontaneous umbilical bleeding is UV. In our case, the presence of bilateral anterior abdominal hernias containing herniated fat with some fat stranding on the abdominal CT was suspicious for OV, which was confirmed to be the source of bleeding intraoperatively. In such cases, OV as the source of umbilical bleeding should be ruled out. Previous reports have suggested a portosystemic abdominopelvic CT scan preoperatively to define the portal vascular anatomy, identify associated varices, and sites of bleeding before the procedure.Figure 1.: CT Abdomen and pelvis without contrast showing umbilical hernia containing omental fat.

Morbimortality Associated with Liver Cirrhosis in Peru: An Ecological Analysis for the Period of 2004-2016.

Liver cirrhosis (LC) is an irreversible, chronic disease and constitutes the last clinical stage of many different liver diseases. The main cause of death is upper gastrointestinal bleeding caused by esophageal variceal rupture. We aim to depict the trend and estimate the morbimortality. For this, we conducted an ecological study and analyzed data from 2004–2016 using the public information provided by the Peruvian Ministry of Health (Ministerio de Salud del Perú, MINSA). Morbidity and mortality were presented according to 5-year groups. Regions were divided according to age quintiles for each studied year, and standardized morbidity and mortality rates were calculated for each natural geographic region; we found that LC-related morbidity per 100,000 people was 52.3 in 2004 and 117.9 in 2016. LC-related mortality had increased from 13.6 deaths per 100,000 people in 2004–2005 to 16.8 deaths per 100,000 people in 2015–2016. Morbidity showed an upward trend in Peru, especially in the departments of Callao, Ica, and Tumbes, whereas mortality showed an upward trend in the departments of Lambayeque, Ica, and Callao.

Abstract 5925: Albumin-bilirubin score as a marker for predicting occurrence of hepatocellular carcinoma in patients with liver cirrhosis

Abstract Background: The newly developed albumin-bilirubin (ALBI) score has been proved to be a simple and useful marker for predicting prognosis in patients with hepatocellular carcinoma (HCC). However, evidence is scarce regarding the use of ALBI score to predict occurrence of HCC in patients with chronic liver disease. In the current study, we examined the usefulness of ALBI score to predict occurrence of HCC in patients with liver cirrhosis. Methods: In this retrospective study, we included only cirrhotic patients without previous history of HCC. A total of 68 cirrhotic patients (median age, 68 years old; 36 males and 32 females; 42 compensated and 26 decompensated cirrhosis) were included. Using a Cox proportional hazard model, we identified the risk factors for HCC occurrence and mortality. The potential factors were age, gender, causes of cirrhosis (hepatitis virus infection vs others), platelet count, serum alpha-fetoprotein (AFP) level, serum endocan level, ALBI score, and successful treatment for cirrhosis (yes vs no). Results: The leading cause of cirrhosis was hepatitis virus infection (9 HBV- and 20 HCV-infected patients), followed by alcohol-related liver disease (23 patients), nonalcoholic steatohepatitis (5 patients), and other causes (2 patients). The median follow-up period was 10 years. During the study period, 16 patients had HCC and 22 patients died (12 liver failure, 3 HCC, 2 variceal rupture, 2 bacterial infection, and 3 other causes). Cumulative survival rates were 92%, 72%, and 59%, at 5, 10, and 15 years, respectively. Regarding risk factors for HCC occurrence, univariate analysis identified a low platelet count and an increased ALBI score as significant factors. However, on multivariate analysis, an increased ALBI score was the only significant factor [hazard ratio, 7.49 (1.65−34.04); p = 0.009]. Regarding risk factors for mortality, univariate analysis identified older age as the only significant factor; male gender and hepatitis virus infection tended to be significant. However, on multivariate analysis, older age, male gender, and hepatitis virus infection were significant factors. Conclusion: The results indicate that an increased ALBI score is a useful factor to predict occurrence of HCC in patients with liver cirrhosis. Citation Format: Nobuyuki Toshikuni, Mutsumi Tsuchishima, Mikihiro Tsutsumi, Joseph George. Albumin-bilirubin score as a marker for predicting occurrence of hepatocellular carcinoma in patients with liver cirrhosis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5925.

Evaluation and management of esophageal varices by through-the-scope endoscopic Doppler probe method.

Objective assessments of esophageal varices (EVs) are inadequate. The recurrence of variceal bleeding after endoscopic variceal ligation (EVL) is associated with residual blood flow underlying EVL or incomplete treatment of a perforating vein by EVL. We aimed to assess our novel through-the-scope endoscopic Doppler probe method (DOP) for the evaluation and management of EVs. This study included 20 patients (54 varices) with a history of esophageal variceal rupture from June 2019 to May 2021 who underwent DOP at a tertiary hospital. Variceal velocities were compared based on the size and endoscopic variceal findings. Additionally, we performed EVL assisted by DOP (EVL + DOP) in nine patients. Doppler imaging of EVs was observed in all 20 patients. The velocity of varices was significantly higher in EVs with a larger size, greater form, blue color, and red color sign positive. Perforating veins connecting to the EVs were identified in six out of nine patients who underwent EVL + DOP. Eight out of nine patients underwent repeat EVL. Repeat EVL was performed until the variceal velocity reached absent. No recurrence of variceal bleeding occurred during the follow-up period (mean 8.7 ± 3.2 months). No adverse events associated with DOP were observed. The evaluation of EVs using DOP is feasible and accurate. EV velocities are related to the variceal size, form, blue color, and red color sign. EVL + DOP may be a more reliable treatment for EVs. Further large-scale, long-term comparative studies are warranted.

A case of agnogenic intrahepatic arterioportal fistula complicated by gastric ulcer bleeding and progressive portal thrombosis

AbstractArterioportal fistulas (APFs) are defined as vascular communications between the systemic arteries and portal circulation. APFs are classified as congenital or acquired, large or small, intrahepatic or extrahepatic, and traumatic or spontaneous. The consistent abnormal connection may result in severe presinusoidal portal hypertension, leading to gastrointestinal bleeding (GIB), ascites, elevated liver function enzymes, heart failure, diarrhea, and even pancreatitis or hematobilia in some unusual cases. Indeed, less than half reported cases have GIB, predominately caused by variceal rupture. Peptic ulcer bleeding has rarely been reported in the setting of APFs. Herein, we describe a case in which intrahepatic APF manifested as gastric ulcer bleeding, progressive portal thrombosis, and massive ascites, with these symptoms successfully relieved by endovascular treatment.

Progress in Endoscopic and Interventional Treatment of Esophagogastric Variceal Bleeding.

Esophagogastric variceal bleeding (EGVB) is one of the main complications of portal hypertension, especially in patients with liver cirrhosis, and has a very high fatality rate. At present, the treatment methods for rupture and bleeding of gastroesophageal varices (GV) include drug therapy, compression hemostasis with three-lumen and two-balloon tube, endoscopic therapy, and interventional and surgical operations. Endoscopy and intervention or their combined application is the mainstream treatment modes in clinical practice, especially their combined application has been increasingly recognized by front-line clinicians. This article intends to discuss the application characteristics of the two treatment methods.

A Histogram Model to Predict the Risk of Bleeding from Oesophageal and Gastric Variceal Rupture in Cirrhosis.

To establish and verify a nomogram for individualized prediction of patients with oesophageal and gastric variceal rupture and haemorrhage in cirrhosis. Descriptive study. Department of Digestive Internal Medicine, Funan County People's Hospital, Anhui, China, from June 2017 to June 2020. Univariate and multivariate logistic regression analyses were used to identify the risk factors for oesophageal and gastric variceal bleeding in cirrhosis. An individualized risk prediction model was established, which was validated by the parallel bootstrap method and an external validation set. It was found that emotional stimuli (OR=4.591, 95% CI: 1.419-14.852), improper diet (OR=3.702, 95% CI: 1.606-8.526), overwork (OR=3.529, 95% CI: 1.331-9.366), lower temperature (OR=3.013, 95% CI:1.242-7.308), and increased abdominal pressure (OR=2.416, 95% CI: 0.900-6.487) were independent risk factors for oesophageal and gastric variceal bleeding in cirrhosis. A risk prediction model was established based on the five risk factors, and the R equation test showed that the C-index of the modelling group and the verification group was 0.815 (95% CI: 0.794-0.836) and 0.812 (95% CI: 0.793-0.831), respectively. The results of the correction curve showed little difference, which indicated that the risk prediction model has good accuracy and differentiation. Cirrhosis, Oesophagus varices and gastric fundus varices, Bleeding, Risk factors, Risk model, Validation.

Effects of primary preventive treatment under endoscope for esophageal and gastric varices on bleeding rate and its relevant factors

Objective: To investigate the effects of primary preventive treatment under endoscope for esophageal and gastric varices on bleeding rate and its relevant factors. Methods: 127 cases with liver cirrhosis accompanied with esophageal and gastric varices without bleeding history were included in the endoscopic and non-endoscopic treatment group, respectively. Informed consent was obtained from both groups. Gastric varices (Lgf) and esophageal varices (Leg) were diagnosed according to LDRf classification criteria, and the corresponding treatment scheme was selected according to the recommended principle of this method.The incidence rate of bleeding from ruptured esophageal varices were observed at 3, 6 months, and 1, and 2 years in the treated and the untreated group, and the patients with different Child-Pugh scores were followed-up for 2 years. Gender, age, etiology, varicose degree, Child-Pugh grade, platelet count, prothrombin activity, portal vein thrombosis, collateral circulation, portal vein width and other factors affecting the bleeding rate were assessed. Measurement data were described as mean ± standard deviation (x¯±s), and qualitative data of categorical variables were expressed as percentage (%), and χ2 test was used. Results: 127 cases were followed up for 2 years. There were 55 cases in the endoscopic treatment group (18 cases underwent band ligation, 2 cases underwent band ligation combined with tissue adhesive embolization, 28 cases underwent sclerotherapy, and 7 cases underwent sclerotherapy combined with tissue adhesive embolization). Recurrent bleeding and hemorrhage was occurred in 5 (9.1%) and 28 cases (38.9%), respectively (P<0.05). In addition, there were 72 cases in the untreated group (P<0.05). Severe varicose veins proportions in treated and untreated group were 91.1% and 85.1%, respectively (P>0.05). There was no statistically significant difference in liver cirrhosis-related medication and β-blocker therapy between the treated and untreated group (P>0.05). There was no statistically significant difference in the bleeding rate between the different treated groups (P>0.05). The bleeding rates at 3, 6 months, 1, and 2 years in endoscopic treated and untreated group were 2.00% vs. 2.59% (P>0.05), 2.30% vs. 5.88% (P>0.05), 3.10% vs. 7.55% (P>0.05) and 4.00% vs. 21.62% (P<0.05), respectively. All patients with Child-Pugh grade A, B and C in the treated and the untreated group were followed-up for 2 years, and the bleeding rates were 1.8% vs. 8.1% (P<0.05), 1.1% vs. 9.4% (P<0.05) and 9.1% vs. 10.1% (P>0.05), respectively. There were statistically significant differences in the rupture and bleeding of esophageal and gastric varices, varices degree, Child-Pugh grade and presence or absence of thrombosis formation in portal vein (P<0.05); however, no statistically significant differences in gender, age, etiology, platelet count, prothrombin activity, collateral circulation and portal vein width (P>0.05). There was no intraoperative bleeding and postoperative related serious complications in the treated group. Conclusion: The risk of initial episodes of bleeding from esophageal and gastric varices is significantly correlated with the varices degree, Child-Pugh grade, and portal vein thrombosis. Primary preventive treatment under endoscope is safe and effective for reducing the long-term variceal bleeding risk from esophageal and gastric varices.

Usefulness of partial splenic embolization for left-sided portal hypertension in a patient with a pancreatic neuroendocrine neoplasm: a case report and review of the literature

Left-side portal hypertension (LSPH) is caused by isolated obstruction of the splenic vein and is associated with esophagogastric varices that extend from the lower esophagus to the greater curvature of the gastric body. Here, we report on a 74-year-old man with a pancreatic neuroendocrine neoplasm (NEN) in the pancreatic tail with multiple liver metastases. We decided that partial splenic embolization (PSE) was the best course of treatment to prevent rupture of the gastric varices, which were classified as markedly enlarged, nodular, or tumor-shaped and showed erosion of the mucosa. After PSE, the patient had no major complications and was discharged. At 3 and 6 months after the procedure, esophagogastroduodenoscopy and enhanced computerized tomography showed that the gastric varices had improved. This case demonstrates the usefulness of PSE for LSPH in patients with unresected pancreatic NEN.

Recurrent umbilical varix rupture with hemoperitoneum: a case report and review of literature

BackgroundNon-traumatic hemoperitoneum was a rare event with the risk of sudden death. Spontaneous rupture of hepatocellular carcinoma is the most intuitive diagnosis when hemoperitoneum occurs in cirrhotic patients who are not regularly followed up. However, other etiologies of hemoperitoneum, such as intra-abdominal varix rupture, should be kept in mind.Case presentationA 44-year-old man with alcoholic liver cirrhosis, Child–Pugh B was sent to our emergency department (ED) because of recurrent abdominal pain and hypovolemic shock. He had similar symptoms one month ago and was diagnosed as hepatocellular carcinoma (HCC) rupture with hemoperitoneum, therefore he underwent trans-arterial embolization (TAE). However, the follow-up magnetic resonance imaging (MRI) showed less possibility of hepatocellular carcinoma. Contrast enhanced abdominal computed tomography (CT) showed possible umbilical vein contrast agent extravasation. Exploratory laparotomy confirmed the diagnosis of rupture umbilical varix with hemoperitoneum.ConclusionAlthough umbilical varix rupture is a rare cause of hemoperitoneum, it should be kept in mind in cirrhotic patients with unexplained hemoperitoneum.

Emergency Nursing of a Case of Upper Gastrointestinal Bleeding Caused by Rupture of Esophagogastric Varices Caused by Foreign Body in Stomach

Emergency nursing of upper gastrointestinal bleeding caused by esophagogastric vein rupture caused by eating rough food was reported. The key to nursing is the timely identification of upper gastrointestinal bleeding and emergency treatment after bleeding. Psychological care and health education after first aid, and prevention of related complications. The rescue was successful in this case.

A case of repeated rupture of esophageal varices during the treatment of a subarachnoid hemorrhage

A case of repeated rupture of esophageal varices during the treatment of a subarachnoid hemorrhage

ROLE OF 2D SHEAR WAVE ELASTOGRAPHY FOR PREDICTING THE PRESENCE OF OESOPHAGEAL VARICES IN PATIENTS WITH ADVANCED CHRONIC LIVER DISEASE

BACKGROUND: Liver cirrhosis and portal hypertension are common outcomes of chronic liver disease. Portal hypertension leads to development of oesophageal varices (EV). Oesophageal variceal rupture is the most common (1,2,3) dreaded complication of cirrhosis that proves to be fatal. In fact, the severity of liver disease can be correlated by the presence and grade of varices. Currently, oesophagogastroduodenoscopy (OGD) is the gold standard investigation for detection and grading of EV's. However, it is invasive, costly and frequently requires sedation. The aim of this study is to investigate the diagnostic performance of 2D shear wave elastography for predicting the presence of oesophageal varices in patients with advanced chronic liver disease (CLD). METHODS: Study population included 32 cases with CLD and 30 controls without CLD undergoing OGD from August 2019 to August 2021.Prior to undergoing OGD, liver and spleen stiffness elastography were recorded using 2D-SWE. ROC curve was used to nd the cut off values for liver and spleen stiffness for prediction of EV. RESULTS: Using 2D-SWE, the association between liver/ spleen stiffness and presence of EV in CLD cases was found to be statistically signicant (p value-&lt;0.001). The optimal cut off values obtained for prediction of EV was 12 kPa and 12.6kPa for liver and spleen respectively (sensitivity of 81.8% and specicity of 82.5%; PPV-72%, NPV- 89.2%). CONCLUSION: Liver and spleen stiffness values obtained by 2D-SWE were found to be a signicant predictive factor for detection of presence of EV's in patients with CLD.

Percutaneous transhepatic obliteration-related procedures for isolated gastric varices: experience of three cases.

Percutaneous transhepatic obliteration (PTO) can facilitate antegrade embolization of variceal veins. We herein report three patients who underwent percutaneous transhepatic sclerotherapy(PTS) or percutaneous transportal outflow-vessel-occluded sclerotherapy (PTOS) for isolated gastric varices. PTS was performed in Cases 1 and 2, and PTOS was performed in Case 3. Technical success was achieved in all patients without a decline in liver function; however, lack of a therapeutic benefit with rupture of esophageal varices occurred in Case 3. Case 3 had a history of pylorus gastrectomy plus Billroth-I reconstruction for gastric cancer and multiple feeding veins existed. PTO-related procedures are good treatment options for isolated gastric varices, but clinicians should be aware of the risk of treatment failure, especially the cases which have multiple feeding veins.

Refractory post-band ligation bleeding misdiagnosed as esophageal varix rupture caused by primary biliary cirrhosis: A case report

A 71-year-old woman had refractory post-band ligation esophageal bleeding although emergency EVL was carried out nine times in total. She was originally considered the esophageal variceal hemorrhage in Primary Biliary Cirrhosis (PBC). Through discussion at a multidisciplinary meeting, we could reach an appropriate diagnosis of PBC and incomplete CREST overlap syndrome. It was difficult to distinguish hemorrhagic telangiectasia from bleeding esophageal varices, and argon plasma coagulation safely reduced the risk of rebleeding and necessity of emergency endoscopy. We learned again a valuable lesson that interprofessional communication is essential to overcome diagnostic error and cognitive bias in patients with refractory treatment. Keywords: cognitive bias; diagnostic error; interprofessional communication; PBC and CREST overlap syndrome; refractory post-band ligation bleeding.

Unusual Gastrointestinal Hemorrhaging Mimicking a Rupture of Solitary Gastric Varices Due to a Gastric Gastrointestinal Stromal Tumor with Exogenous Growth

Gastric gastrointestinal stromal tumors can lead to upper gastrointestinal hemorrhaging, which is usually caused by dimpling or ulceration on the tumor surface. While rare, pedunculated gastric gastrointestinal stromal tumors outside the stomach can present as a huge mass with delayed complaints. We herein report an unusual hemorrhaging mimicking a rupture of solitary gastric varices due to a pedunculated gastric gastrointestinal stromal tumor. In this case, contrast-enhanced computed tomography (CECT) was essential for tumor detection. An endoscopic investigation revealed dilated, aberrant veins and arteries in the submucosa of this tumor, recognized as solitary gastric varices.

Exploring patients’ perceptions and experiences of treatments for the prevention of variceal bleeding: a qualitative study

BackgroundThe most common fatal complication of liver cirrhosis is haemorrhaging caused by variceal rupture. The prevention of the first variceal bleed is, therefore, an important clinical goal. Little is known...

Clinical algorithms for the prevention of variceal bleeding and rebleeding in patients with liver cirrhosis.

Portal hypertension (PH), a common complication of liver cirrhosis, results in development of esophageal varices. When esophageal varices rupture, they cause significant upper gastrointestinal bleeding with mortality rates up to 20% despite state-of-the-art treatment. Thus, prophylactic measures are of utmost importance to improve outcomes of patients with PH. Several high-quality studies have demonstrated that non-selective beta blockers (NSBBs) or endoscopic band ligation (EBL) are effective for primary prophylaxis of variceal bleeding. In secondary prophylaxis, a combination of NSBB + EBL should be routinely used. Once esophageal varices develop and variceal bleeding occurs, standardized treatment algorithms should be followed to minimize bleeding-associated mortality. Special attention should be paid to avoidance of overtransfusion, early initiation of vasoconstrictive therapy, prophylactic antibiotics and early endoscopic therapy. Pre-emptive transjugular intrahepatic portosystemic shunt should be used in all Child C10-C13 patients experiencing variceal bleeding, and potentially in Child B patients with active bleeding at endoscopy. The use of carvedilol, safety of NSBBs in advanced cirrhosis (i.e. with refractory ascites) and assessment of hepatic venous pressure gradient response to NSBB is discussed. In the present review, we give an overview on the rationale behind the latest guidelines and summarize key papers that have led to significant advances in the field.

Balloon-occluded retrograde transvenous obliteration for treatment of gastric varices.

Rupture of gastric varices (GVs) can be fatal. Balloon-occluded retrograde transvenous obliteration (BRTO), as known as retrograde sclerotherapy, has been widely adopted for treatment of GVs because of its effectiveness, ability to cure, and utility in emergency and prophylactic treatment. Simplifying the route of blood flow from GVs to the gastrorenal shunt is important for the successful BRTO. This review outlines BRTO indications and contraindications, describes basic BRTO procedures and modifications, compares BRTO with other GVs treatments, and discusses various combination therapies. Combined BRTO and partial splenic embolization may prevent exacerbation of esophageal varices and shows promise as a treatment option.