Solitary Gastric Varix

A case of bleeding from an isolated gastric varix is described in a patient with chronic alcoholic liver disease but without splenomegaly or demonstrable oesophageal varices. The value of splenoportography in the diagnosis of gastric varices is emphasised.     

Clinical management of gastric cancer and concomitant esophagogastric varices

We report the late results of treatment of 13 consecutive patients with gastric cancer and concomitant esophagogastric varices. Of seven good-risk patients classified as Child's class A or B, gastrectomy together with selective shunt operation was performed in two, total gastrectomy with splenectomy in three, and distal partial gastrectomy with paraesophageal devascularization without splenectomy in one. The remaining patient with early gastric cancer underwent distal partial gastrectomy following repeated endoscopic injection sclerotherapy (EIS) for treatment of the esophageal varices. Although the majority of patients who underwent surgical repair of varices (i.e., shunt, splenectomy, or devascularization) died, total gastrectomy with splenectomy was the only procedure that led to control of the esophageal varices. Since partial gastrectomy combined with EIS limits the morbidity and mortality of an extensive resection and at the same time controls esophageal variceal bleeding, it is probably the procedure of choice for patients with a carcinoma in the lower two-thirds of the stomach. Concerning non-surgical cases, two patients were effectively treated using laser endoscopy and EIS, without the occurrence of variceal bleeding. The remaining four patients, given chemotherapy or irradiation for treatment of gastric carcinoma, died within 4 months with variceal bleeding or liver failure. For the poor-risk patients with evidence of severe liver dysfunction, laser treatment and EIS would be the treatment of choice.     

Value of embolisation of collateral veins from gastric varices before balloon-occluded retrograde transvenous obliteration

Objective: The purpose of our investigation was to determine the safety and usefulness of embolisation procedures in balloon occluded retrograde transvenous obliteration (BRTO) as treatment of gastric varices after portal hypertension. Materials and Methods: Between June 2004 and August 2009, 40 patients underwent BRTO for gastric varices that occurred after portal hypertension in our institution. When large collateral vessels of gastric varices had developed as drainage veins other than the gastro‐renal shunt, these collateral vessels were embolised prior to BRTO. Results: Embolisation was performed for 18 collateral vessels in 16 cases before BRTO. Embolised collateral vessels were the left inferior phrenic vein (n = 14), intercostal vein (n = 3), and ascending lumbar vein communicating with the gastro‐renal shunt (n = 1). Mean number of micro‐coils used was 5.7 in left inferior phrenic veins, 4.7 in intercostal veins and 4 in the ascending lumbar vein. In 36 (90%) patients, contrast‐enhanced abdominal CT after BRTO showed that the gastric varices were well obliterated. The rate of occurrence of cases in which the remnant of the enhanced area in the gastric varices was seen even after BRTO was statistically higher in cases requiring embolisation of collateral vessels than in those who did not (4/16 versus 0/24, P = 0.0199 according to Fisher's exact probability test). Recurrence of gastric varices was determined by endoscopy in 1 (2.5%) case necessitating embolisation of collateral vessels. There were no serious complications. Conclusion: Embolisation of collateral vessels before BRTO is a safe and useful procedure. However, especially in cases having collaterals sufficiently large to require embolisation, careful follow‐up for recurrence of gastric varices is necessary.     

Infusion of 50% glucose solution before injection of ethanolamine oleate during balloon-occluded retrograde transvenous obliteration

The feasibility of infusion of 50% glucose solution before balloon-occluded retrograde transvenous obliteration (BRTO) to occlude collateral vessels draining gastric varices other than gastrorenal shunt was evaluated. In five patients with such collateral vessels, 50% glucose solution was infused from the balloon catheter inflated within the gastrorenal shunt. The degree of collateral vessels had decreased when BRTO was carried out so that sclerotic agents sufficiently occupied the gastric varices in all patients. In three patients, embolization of collateral vessels with coils was unnecessary. There were no complications. In conclusion, retrograde infusion of 50% glucose solution assists in effectively carrying out BRTO.     

Pancreatic and gastric metastases of leiomyosarcoma arising in the left leg

Pancreatic or gastric metastases from other primary malignancies are rare, especially from leiomyosarcoma. We report a case of leiomyosarcoma in the left lower leg with metastases to the pancreas and stomach. A 61-year-old man had liver cirrhosis caused by hepatitis C virus infection and was followed up by his primary physician. Two years before presentation at our hospital, he had undergone surgical resection of leiomyosarcoma in the left lower leg and systemic chemotherapy for multiple metastatic tumors in the lung. On admission, endoscopic examination and computed tomography were performed for a routine checkup to exclude esophageal varices and liver tumor. Although the patient had no specific symptoms, multiple gastric and pancreatic metastases were identified by endoscopy and computed tomography, respectively. In general, metastases to the pancreas and stomach are rare. We discuss the clinical and diagnostic findings of pancreatic and gastric metastases by reviewing previously reported cases.     

Local Experience with Transhepatic Portal Catheterization

Transliepatic portal catheterization with embolization is a most effective treatment for the patient with bleeding oesophageal varices. After endoscopy has demonstrated bleeding varices embolization may be performed while the patient is resuscitated. The procedure is explained in detail. In all of 9 patients bleeding was successfully controlled.     

Association of Oesophageal Varices and Splanchnic Vein Thromboses in Patients with JAK2-Positive Myeloproliferative Neoplasms: Presentation of Two Cases and Data from a Retrospective Analysis

Background

Oesophageal varices and gastrointestinal bleeding are common complications of liver cirrhosis. More rarely, oesophageal varices occur in patients with non-cirrhotic portal hypertension that results from thromboses of portal or splanchnic veins.

Case Report

We describe 2 young men who initially presented with varices as a result of portal vein thromboses. In the clinical follow-up, both were tested positive for a JAK2 mutation and consequently diagnosed with myeloproliferative neoplasms (MPNs). In an attempt to characterise the frequency of gastrointestinal complications in patients with JAK2-positive MPNs, we retrospectively analysed all known affected patients from our clinic for the diagnosis of portal vein thromboses and oesophageal varices. Strikingly, 48% of those who had received an oesophagogastroduodenoscopy had detectable oesophageal or gastric varices, and 82% of those suffered from portal or splanchnic vein thromboses.

Conclusion

While the association between JAK2, myeloproliferative disease and thrombotic events is well established, patients with idiopathic oesophageal varices are not regularly tested for JAK2 mutations. However, the occurrence of oesophageal varices may be the first presenting symptom of a MPN with a JAK2 mutation, and affected patients may profit from a close haematological monitoring to assure the early detection of developing MPN.Key words: Oesophageal varices, Variceal bleeding, Splanchnic vein thrombosis, Portal vein thrombosis, JAK2, Myeloproliferative neoplasms     

Metastatic Hepatocellular Carcinoma Mimicking an Early Gastric Cancer: A Case Report

A case of hepatocellular carcinoma metastasizing to the stomachin a 71-year-old man is reported. The gastric metastasis showeda flat elevation compatible with type IIa of early gastric canceron roentgenograms and a white saucer-like, discolored elevationon endoscopic pictures. It had none of the modalities of polypoidsubmucosal tumor usually observed in metastatic tumors of thestomach. Biopsy specimens of the lesion were not sufficientto distinguish metastatic or primary gastric cancer. The patientdied of massive bleeding from varices at the gastric cardia.Autopsy disclosed hepatocellular carcinoma diffusely extendingto the bilateral lobe of the cirrhotic liver. Sections of thegastric mass showed bile deposits in the malignant cells andthe same cell pattern as the hepatic primary tumor. These findingsconfirmed it as the metastatic involvement of the stomach byhepatocellular carcinoma. Although gastric metastases usually form polypoid submucosaltumors with or without central ulceration, it is quite unusualfor gastric involvements of hepatocellular carcinoma to formsuch a modality.     

Local recurrence of pancreatic cancer after primary surgical intervention: How to deal with this devastating scenario?

The dismal prognosis of pancreatic cancer reflects into the increased recurrence rate, even after R0 pancreaticoduodenectomy. Although, conventional radiation-, chemo- or surgical therapy in much selected cases, seem to work out favorably long term, less invasive and non-toxic methods with more immediate results are always preferred, concerning the already aggravated status of this group of patients. We present hereby a comprehensive review of the literature concerning the treatment of recurrent pancreatic cancer based on the case of a patient who 20 months after a pancreaticoduodenectomy developed portal hypertension and symptomatic first degree esophageal, gastric and mesenteric varices, caused by the nearly complete splenic vein obstruction at the portal vein confluence. The varices were revascularized by a percutaneous transhepatic placement of an endovascular stent into the splenic vein, along with a sequent stereotactic body radiation therapy for the local tumor control. Thanks to the accuracy and safety of the present combined treatment, the patient one year later presents control of the disease and its complications. Our paper is the first in the international literature that tries to review all the treatment modalities available (surgical, adjuvant, neoadjuvant and palliative therapy) and their efficacy, concerning the locally recurrent pancreatic cancer; furthermore, we tried to analyze the application of the above mentioned combined therapeutic approach in similar cases, elucidating simultaneously all the questions that arise. The limited existing data in the international literature and the lack of randomized controlled trials make this effort difficult, but the physician should be aware after all of all the available and innovative treatment modalities, before he chooses one. Finally, we would like to emphasize the fact that not only the local control but also the management of the complications are important for a prolonged median survival and a better quality of life after all.     

An autopsy revealing hepatocellular carcinoma with solitary metastatic gastric cancer

This case concerns a 61-year-old man who had been determined as having rt-hypochondrialgia. The plasma AFP was found to have increased and an abdominal-CT revealed multiple low density areas in the liver. Endoscopic examination of the stomach revealed a Borrmann type III cancer and the specimens taken by punch biopsy demonstrated a tubular adenocarcinoma. Therefore, he had been diagnosed as having a gastric cancer with a metastatic liver cancer, or double cancer. Histologically, liver tumor proved to be a hepatocellular carcinoma (Edmondson: Gr III), and the histological findings of the gastric tumor was found to be identical with that of the liver tumor. The fact that this case has esophageal varices during the course of the disease suggested that metastasis to the stomach has likely occurred through the portal vein system.     

The role of transjugular intrahepatic portosystemic shunt prior to abdominal tumoral surgery in cirrhotic patients with portal hypertension.

INTRODUCTION: Major abdominal surgery can be contraindicated in some cirrhotic patients because of severe portal hypertension. The present study reports our experience of three patients with abdominal tumours prepared for surgery by transjugular intrahepatic portosystemic shunts (TIPS) in order to reduce portal hypertension and the risk of intraoperative bleeding. PATIENTS AND METHODS: Three patients with cirrhosis and portal hypertension diagnosed with a right colon carcinoma, an adenocarcinoma of pancreas and a gastric and sigmoid synchronic tumours in the same patient. Because portal hypertension was the leading cause of surgical contraindication, neoadjuvant TIPS placement was proposed before surgery. RESULTS: TIPS placement was performed without intra-procedure complications. An average reduction of 18 mmHg was achieved in portosystemic gradients. The planned operations were performed with a delay of 14-45 days after TIPS without intraoperative bleeding. Complications occurred in one patient without operative mortality. CONCLUSION: TIPS placement allows a pre-operative portal decompression in cirrhotic patients with portal hypertension and abdominal tumours that require surgical treatment. This procedure reduces the risk of bleeding by reducing the portosystemic gradient and the varices around the tumoral area. This procedure is less invasive than conventional shunt surgery, but it is not free of complications and should be performed by experienced interventional radiologists on selected patients. This is still an experimental indication of TIPS which efficacy must be confirmed in larger series.     

肝动脉插管化疗与栓塞治疗肝癌后消化道出血及防治

肝动脉插管灌注化疗与栓塞治疗中晚期肝癌３１０例（５６０次）中，并发消化道出血１３例，发生率占全组病例的４．１９％。出血原因有：ＩＣ６例；肝功能损害，凝血机制差３例；化疗药对胃粘膜毒性作用和部分栓子误入胃供血动脉２例；食管静脉曲张破裂１例；肝肿瘤破裂１例。本文对消化道出血原因与防治方法进行了探讨，并建议在行肝动脉灌注化疗和栓塞治疗前采取肝功能估计和预防出血的方法，以减少因出血、肝衰及感染造成的死亡。     

Angiography in Gastro-Intestinal Bleeding

A review of our experience with angiography in the patient with gastro-intestinal bleeding suggests that it is of great value in (i) the patient with continued and massive bleeding before laparotomy; (ii) the patient with repeated episodes of bleeding; (iii) the patients with portal hypertension and varices. In our series it has been highly accurate in precisely locating arterial bleeding, and we feel it should be far more widely used in those institutions with the necessary staff and equipment.     

[18F] FDG PET in Gastric Non-Hodgkin's Lymphoma

The possibility of using [¹⁸F] FDG PET for assessment of tumor extension in primary gastric non-Hodgkin's lymphoma (NHL) was studied in 8 patients (6 high-grade and 2 Iow-grade, one of the MALT type) and in a control group of 7 patients (5 patients with NHL without clinical signs of gastric involvement, 1 patient with NHL and benign gastric ulcer and 1 patient with adenocarcinoma of the stomach). All patients with gastric NHL and the two with benign gastric ulcer and adenocarcinoma, respectively, underwent endoscopy including multiple biopsies for histopathological diagnosis. All patients with high-grade and one of the two with low-grade NHL and the patient with adenocarcinoma displayed high gastric uptake of [¹⁸F] FDG corresponding to the pathological findings at endoscopy and/or CT. No pathological tracer uptake was seen in the patient with low-grade gastric NHL of the MALT type. In 6/8 patients with gastric NHL, [¹⁸F] FDG PET demonstrated larger tumor extension in the stomach than was found at endoscopy, and there was high tracer uptake in the stomach in two patients who were evaluated as normal on CT. [¹⁸F] FDG PET correctly excluded gastric NHL in the patient with a benign gastric ulcer and in the patients with NHL without clinical signs of gastric involvement. Although the experience is as yet limited, [¹⁸F] FDG PET affords a novel possibility for evaluation of gastric NHL and would seem valuable as a complement to endoscopy and CT in selected patients, where the technique can yield additional information decisive for the choice of therapy.     

Retrograde metastasis of hepatocellular carcinoma with an interesting lesion of the stomach--a case report

A 48-year-old man with hepatocellular carcinoma (HCC) showing tumor emboli in the portal vein and a typical retrograde metastasis via the portal vessels, is reported. Metastatic lesions were localized only in the veins of the lesser omentum, stomach, lower esophagus, pancreas, left hemidiaphragm and left adrenal gland, due to the hemodynamic alteration of the portal blood flow caused by liver cirrhosis and HCC. No metastatic lesion was found in the lung, Kidney, bone or intestine. As gastric metastasis Borrmann I, II, III and submusal tumor types were reported, but the present case revealed hard fold-like lesions, as it were, hard white varices.     

血清CEA和CA199及CA724联合检测对胃癌诊断的临床意义

目的探讨血清CEA、CA199、CA724联合检测在胃癌诊断、病情监测及疗效观察中的价值。方法采用电化学发光技术检测30例正常对照组、40例良性胃病、60例胃癌患者血清CEA、CA199、CA724的含量,并对胃癌患者进行治疗前后3种肿瘤标志物的含量变化监测、随访。结果胃癌患者血清CEA、CA199、CA724的阳性检测率明显高于良性胃病及正常对照组,差异有显著性(P<0.01)。胃癌患者治疗后3种肿瘤标志物含量及阳性率较治疗前有明显下降,差异有显著性(P<0.01)。三者联合检测敏感性、准确性均显著提高(P<0.05)。结论血清CEA、CA199、CA724联合检测有助于提高胃癌诊断的敏感性,同时对疗效观察及术后检测有重要意义。     

Curative resection of advanced gastric cancer responding to preoperative chemotherapy--a case report

A 56-year-old male was admitted for treatment of advanced gastric cancer. The patient was diagnosed as having an unresectable advanced gastric cancer because cancer cells had invaded the pancreas head and there were metastatic lymph nodes. The patient underwent preoperative chemotherapy (FLEP: intra-arterial infusion of CDDP, ETP and intravenous infusion of 5-FU, LV). The primary tumor and metastatic lymph nodes were reduced by three course of chemotherapy. The patient underwent curative resection and survived without recurrence for 14 months after operation. Preoperative chemotherapy using FLEP was performed in 15 patients with unresectable primary advanced gastric cancer. This therapy resulted in significantly higher survival times. In conclusion, FLEP has been shown to be effective for unresectable advanced gastric cancer.     

Primary gastric malignant lymphoma followed by gastric adenocarcinoma: report of 4 cases and review of the literature.

Four cases of primary gastric malignant lymphoma followed years later by adenocarcinoma of the stomach are described. Review of the literature revealed eleven other cases of these two lesions occurring in the same patient. In our four cases gastric adenocarcinoma developed many years after successful treatment of primary gastric lymphoma by partial gastrectomy. In three patients gastrectomy had been followed by radiation treatment to the upper abdomen. The relationship between the two tumors is discussed, including the possible role of treatment of the lymphoma in the development later of gastric adenocarcinoma. It is important to consider the possibility of the later development of a second primary gastric cancer in a patient who develops gastric symptoms, after successful treatment for primary gastric neoplasm.     

胰腺癌致门脉高压上消化道出血的临床分析

目的：总结胰腺癌致门脉高压性上消化道出血的诊治经验。方法：回顾性分析7例胰腺癌致门脉高压性上消化道出血的临床表现、诊断方法、治疗措施和疗效。诊断方法主要为超声、CT、MRI和内镜。结果：7例胰腺癌致门脉高压性上消化道出血中,胰颈癌2例,体尾癌5例。临床表现均有不规则性上腹疼痛、纳差、乏力、消瘦、脾脏肿大及上消化道出血,肝功能检查正常。增强CT和（或）MRI可见脾门周围及胃短静脉、胃网膜静脉扩张、迂曲。胃镜检查示孤立性胃底静脉曲张。上消化道出血以药物、内镜治疗为主,但总体预后差。结论：超声、CT、MRI和内镜检查联合特殊的临床特点,诊断胰腺癌致门脉高压性上消化道出血并不困难。治疗以内科保守治疗为主,不宜选择创伤较大的外科手术。