CASE REPORT: Successful obliteration of a bleeding duodenal varix using endoscopic ligation

The occurrence of duodenal varices is rare and experience in the control of haemorrhage from duodenal varices is limited. A 69-year-old man with hepatocellular carcinoma presenting with upper gastrointestinal bleeding is reported. Emergency upper gastrointestinal endoscopy indicated one varix 1.5 cm in diameter with white nipple sign at the anterior wall of the duodenal bulb. Endosonography confirmed the diagnosis of duodenal varix. The patient was treated with endoscopic ligation and follow-up endoscopy showed complete eradication of duodenal varix 3 weeks later.     

Fatal Ruptured Duodenal Varix: A Case Report and Review of Literature

The incidence of bleeding duodenal varices is exceedingly rare. We report a case of a 35-year-old chronic alcoholic who died of severe fatal upper gastrointestinal bleeding from a ruptured duodenal varix located in the second portion of duodenum. This diagnosis was suspected at endoscopy and was confirmed at autopsy. A review of literature shows 20 case reports of bleeding duodenal varices with two fatalities. While the duodenal bulb is the most common site of varices, the second portion of duodenum appears to be the next most common site. From all of the possible causes of duodenal varix, chronic liver diseases, mainly cirrhosis, remains the predominant etiological factor accounting for 30.7% of reported cases.     

Pancreatic arteriovenous malformation with duodenal ulcer

Summary We report the color Doppler ultrasonography features of arteriovenous malformation (AVM) of the pancreas, a very rare disease. The patient was a 52-year-old man with congenital AVM of the pancreas and a duodenal ulcer that had been resistant to medication. Endoscopic color Doppler ultrasonography (color Doppler EUS) revealed many abnormal color signals showing pulsatile wave form at the portion of the duodenal wall involving the duodenal ulcer. Extracorporeal color Doppler ultrasonography revealed a mosaic-like color signal, caused by turbulent flow, in the portal trunk. Angiography demonstrated a vascular network with extensive proliferation at the pancreatic head and early portal filling. It is possible that the pancreatic AVM had caused the duodenal ulcer. Color Doppler EUS can be a useful modality for detection of vessel abnormalities of the gastrointestinal tract.     

Successful Endoscopic Injection Sclerotherapy of a Bleeding Duodenal Varix

Bleeding from duodenal varices is an unusual event. We report the case of a 50-yr-old man with portal hypertension due to alcoholic cirrhosis who presented with upper gastrointestinal bleeding and encephalopathy. Emergent endoscopy revealed an actively bleeding duodenal varix. The bleeding was treated successfully with injection sclerotherapy. Only four cases of injection sclerotherapy of bleeding duodenal varices have been reported previously. We review and compare reported cases of sclerotherapy of duodenal varices and also review the other therapeutic options. Endoscopic injection sclerotherapy of bleeding duodenal varices appears to be a useful first-line therapy.     

A case of endoscopic injection sclerotherapy for a bleeding duodenal varix

A case of bleeding duodenal varix which was treated successfully with endoscopic injection sclerotherapy (EIS) is reported. The patient developed a hemorrhage from a varix in the descending portion of the duodenum two months after EIS for esophageal varices, and hemostasis was achieved using EIS with an intravericeal injection of 1% polidocanol. The duodenal varix decreased in size after EIS. Two months after EIS, a splenectomy was performed. During a 14-month follow up period after the EIS for the duodenal varix, there was no recurrent bleeding.     

A CASE OF DUODENAL LIPOMA REMOVED BY ENDOSCOPIC POLYPECTOMY

A rare case of duodenal lipoma removed by endoscopic polypectomy is presented herein. A 64‐year‐old female was found to have a polypoid lesion in the duodenum on gastrointestinal endoscopic examination. Endoscopy revealed a submucosal tumor located on the second portion. Endoscopic ultrasonography (EUS) demonstrated a homogenous, hyperechoic mass continuous with the submucosal layer, suggesting a lipoma. Because of the likelihood of the tumor ultimately causing obstruction or bleeding, endoscopic polypectomy was performed. There were no complications after treatment.     

Endoscopic ultrasound-guided fine-needle aspiration for diagnosing a rare extraluminal duodenal gastrointestinal tumor

Duodenal gastrointestinal stromal tumors(GISTs) are extremely rare disease entities, and the extraluminal type is difficult to diagnose. These tumors have been misdiagnosed as pancreatic tumors; hence, pancreaticoduodenectomy has been performed, although partial duodenectomy can be performed if accurately diagnosed. Developing a diagnostic methodology including endoscopic ultrasonography(EUS) and fine-needle aspiration(FNA) has allowed us to diagnose the tumor directly through the duodenum. Here, we present a case of a 50-year-old woman with a 27-mm diameter tumor in the pancreatic uncus on computed tomography scan. EUS showed a well-defined hypoechoic mass in the pancreatic uncus that connected to the duodenal proper muscular layer and was followed by endoscopic ultrasoundguided fine-needle aspiration(EUS-FNA). Histological examination showed spindle-shaped tumor cells positively stained for c-kit. Based on these findings, the tumor was finally diagnosed as a duodenal GIST of the extraluminal type, and the patient underwent successful mass resection with partial resection of the duodenum. This case suggests that EUS and EUS-FNA are effective for diagnosing the extraluminal type of duodenal GISTs, which is difficult to differentiate from pancreatic head tumor, and for performing the correct surgical procedure.     

Duodenal variceal bleeding after balloon-occluded retrograde transverse obliteration: treatment with transjugular intrahepatic portosystemic shunt

We report a case of duodenal varix bleeding as a long term complication of balloon occluded retrograde transvenous obliteration (BRTO), which was successfully treated with a transjugular intrahepatic portosystemic shunt (TIPS). A 57-year-old man was admitted to the emergency room suffering from melena. He had undergone BRTO to treat gastric varix bleeding 5 mo before admission. Endoscopy and a computed tomography (CT) scan showed complete obliteration of the gastric varix, but the nodular varices in the second portion of the duodenum expanded after BRTO, and spurting blood was seen. TIPS was performed for treatment of duodenal variceal bleeding, because attempts at endoscopic varix ligation were unsuccessful. The postoperative course was uneventful and the patient was discharged without complications. A follow up CT scan obtained 21 mo after TIPS revealed a patent TIPS tract and complete obliteration of duodenal varices, but multinodular hepatocellular carcinoma had developed. He died of hepatic failure 28 mo after TIPS.     

Endoscopic ultrasound (EUS)-guided angiotherapy of refractory gastrointestinal bleeding

BACKGROUND: There are well-established methods for treating gastrointestinal (GI) bleeding, although some lesions prove refractory to conventional techniques. Little consideration has been directed toward the use of endoscopic ultrasound (EUS) in the management of refractory bleeding. AIMS: To discuss patient selection, technique, and clinical outcomes for EUS-guided angiotherapy for severe refractory bleeding after conventional therapies. METHODS: The EUS database was reviewed to identify all patients who underwent EUS-directed angiotherapy. RESULTS: Five patients, four with severe bleeding from hemosuccus pancreaticus, Dieulafoy lesion, duodenal ulcer, or gastrointestinal stromal tumor (GIST) and one with occult GI bleeding, had an average of three prior episodes (range 2-4) of severe bleeding and had received 18 (range 14-25) units of packed red blood cells (PRBC). All had failed in at least two conventional attempts to control the bleeding. Under EUS guidance, 99% alcohol was injected (4-7 mL) in two patients, one each with a pancreatic pseudoaneurysm and a duodenal Dieulafoy lesion. In three other patients, cyanoacrylate (3-5 mL) was injected into a duodenal ulcer, and in two patients with a GIST. No patient rebled and no complications were reported. CONCLUSIONS: EUS-guided angiotherapy appears safe and effective in managing selected patients with clinically severe or occult GI bleeding from lesions potentially refractory to standard endoscopic and/or angiographic techniques. Further studies are needed to confirm the safety and efficacy and to refine the selection criteria in an effort to improve patient care.     

Obscure gastrointestinal bleeding due to duodenal infiltration of a non-functioning pancreatic neuroendocrine tumor diagnosed by capsule endoscopy: A case report

Non-functioning pancreatic neuroendocrine tumors (PNETs) are infrequent slowgrowing, clinically-silent tumors. They are incidentally detected and some of them may present in advanced stages with local involvement of surrounding structures. The diagnostic accuracy of endoscopio ultrasound (EUS) and fine needle aspiration (FNA) biopsy is significantly lower in neuroendocrine tumors (46.7%) compared with adenocarcinoma (81.4%) and other histologies (75%). Therefore, preoperative diagnosis is very difficult. Exceptionally, hey present with gastrointestinal bleeding. We present a case of a non-functioning PNET initially diagnosed as cystic serous tumor of pancreas with EUS and FNA biopsy. Two years later patient presented obscure gastrointestinal bleeding due to duodenal infiltration. Diagnosis was made by capsule endoscopy.     

Endoscopic ultrasound guided interventional procedures

Endoscopic ultrasound (EUS) has emerged as an important diagnostic and therapeutic modality in the field of gastrointestinal endoscopy. EUS provides access to many organs and lesions which are in proximity to the gastrointestinal tract and thus giving an opportunity to target them for therapeutic and diagnostic purposes. This modality also provides a real time opportunity to target the required area while avoiding adjacent vascular and other structures. Therapeutic EUS has found role in management of pancreatic fluid collections, biliary and pancreatic duct drainage in cases of failed endoscopic retrograde cholangiopancreatography, drainage of gallbladder, celiac plexus neurolysis/blockage, drainage of mediastinal and intra-abdominal abscesses and collections and in targeted cancer chemotherapy and radiotherapy. Infact, therapeutic EUS has emerged as the therapy of choice for management of pancreatic pseudocysts and recent innovations like fully covered removable metallic stents have improved results in patients with organised necrosis. Similarly, EUS guided drainage of biliary tract and pancreatic duct helps drainage of these systems in patients with failed cannulation, inaccessible papilla as with duodenal/gastric obstruction or surgically altered anatomy. EUS guided gall bladder drainage is a useful emergent procedure in patients with acute cholecystitis who are not fit for surgery. EUS guided celiac plexus neurolysis and blockage is more effective and less morbid vis-à-vis the percutaneous technique. The field of interventional EUS is rapidly advancing and many more interventions are being continuously added. This review focuses on the current status of evidence vis-à-vis the established indications of therapeutic EUS.     

内镜超声检查术对十二指肠囊肿的诊断价值

目的 研究内镜超声检查术(EUS)对十二指肠囊肿的诊断价值.方法 分析十二指肠囊肿患者的临床表现,普通胃镜、EUS的结果和随访结果,研究总结该病的超声影像学特征.结果 105例十二指肠囊肿患者均无与病灶相关的症状,该病在超声内镜下具有特征性的影像学改变,即黏膜下病灶位于肠壁内,探头触压病灶易变形,内呈无回声状,边界清楚,源于黏膜下层,后方有回声增强效应,周围肠壁层次结构正常.EUS可明确病灶的起源、大小和性质并与其他黏膜下病变相鉴别.术后随访5年病灶无明显变化.结论 十二指肠囊肿属良性疾病,EUS对该病的诊断具有较好的临床价值.     

内镜超声检查术对十二指肠囊肿的诊断价值

目的 研究内镜超声检查术（EUS）对十二指肠囊肿的诊断价值.方法 分析十二指肠囊肿患者的临床表现,普通胃镜、EUS的结果和随访结果,研究总结该病的超声影像学特征.结果 105例十二指肠囊肿患者均无与病灶相关的症状,该病在超声内镜下具有特征性的影像学改变,即黏膜下病灶位于肠壁内,探头触压病灶易变形,内呈无回声状,边界清楚,源于黏膜下层,后方有回声增强效应,周围肠壁层次结构正常.EUS可明确病灶的起源、大小和性质并与其他黏膜下病变相鉴别.术后随访5年病灶无明显变化.结论 十二指肠囊肿属良性疾病,EUS对该病的诊断具有较好的临床价值.     

内镜超声检查术对十二指肠囊肿的诊断价值

目的 研究内镜超声检查术(EUS)对十二指肠囊肿的诊断价值.方法 分析十二指肠囊肿患者的临床表现,普通胃镜、EUS的结果和随访结果,研究总结该病的超声影像学特征.结果 105例十二指肠囊肿患者均无与病灶相关的症状,该病在超声内镜下具有特征性的影像学改变,即黏膜下病灶位于肠壁内,探头触压病灶易变形,内呈无回声状,边界清楚,源于黏膜下层,后方有回声增强效应,周围肠壁层次结构正常.EUS可明确病灶的起源、大小和性质并与其他黏膜下病变相鉴别.术后随访5年病灶无明显变化.结论 十二指肠囊肿属良性疾病,EUS对该病的诊断具有较好的临床价值.     

Endoscopic ultrasound in clinical practice

Endoscopic ultrasonography (EUS) is an accurate technique for the diagnosis and staging of benign and malignant lesions in the gastrointestinal tract and the mediastinum. EUS overcomes the limitations of other imaging diagnostic methods and gives the possibility to obtain tissue for histologic diagnosis (EUS guided FNA). The most useful indications of EUS are differentiation of submucosal tumors, staging for neoplasia, examination of the pancreato-biliary system and therapeutics. EUS can distinguish extrinsic compressions from intramural lesions and defines their nature (solid, cystic or vascular) and origin. EUS is useful for local staging of esophageal, gastric, duodenal, and rectal cancer using the TNM (tumor, node, metastases) system, as well as for diagnosing and staging of pancreatic lesions. The addition of EUS-guided FNA has improved the ability to detect malignant lymph node invasion. EUS is also highly sensitive for the diagnosis of choledocholithiasis, avoiding unnecessary danger of diagnostic ERCP. New therapeutic indications of EUS include drainage of pancreatic pseudocysts and abscesses and celiac plexus block and neurolysis. EUS has become an indispensable diagnostic method in gastroenterological everyday practice and should be part of most endoscopy units.     

内镜下圈套结扎在治疗上消化道小平滑肌瘤中的应用

目的 探讨应用内镜下皮圈结扎的方法来治疗上消化道的小平滑肌瘤，并评价这种方法的安全性和疗效。方法 通过内镜、内镜超声及内镜超声下穿刺细胞学检查确定了59例上消化道小平滑肌瘤患者，共发现64处平滑肌瘤。在这64处平滑肌瘤中，50处为食管平滑肌瘤，12处为胃平滑肌瘤，2处为十二指肠平滑肌瘤。对所有平滑肌瘤进行皮圈套扎治疗，术后2周开始，每周做胃镜检查观察结扎处的变化，直至创面完全愈合。结果 64处病变中50处食管平滑肌瘤被完全去除，创面的平均愈合时间为3．1周。12处胃平滑肌瘤中9处被完全去除，其余3例由于结扎不彻底，仍有残余瘤组织，平均愈合时间为4.5周。2例十二指病变被完全去除，平均愈合时间4．5周。全部患者无一例发生出血、穿孔。结论 内镜下圈套结扎术是治疗上消化道小平滑肌瘤安全、有效的方法。     

十二指肠球部类癌的内镜切除临床疗效分析

目的探讨十二指肠球部类癌的内镜切除治疗的效果。方法回顾性分析2009年6月至2012年6月经内镜切除治疗且术后病理证实的17例十二指肠球部类癌患者资料,其中男11例、女6例,年龄22～52岁,平均（36．3±8．4）岁。结果17例患者术前均应用超声内镜诊断,其中考虑为异位胰腺4例,类癌13例,最大直径0．4～1．0cm,均与固有肌层分界清晰。内镜治疗均取得成功,采用透明帽辅助切除法,术中与术后无并发症出现。术后病理及免疫组化染色均证实为类癌,因此超声内镜的术前诊断准确率为76．5％。患者平均随访观察（20．5±12．4）个月,无复发和转移病例。结论超声内镜可以有效地判定十二指肠球部病变的浸润深度,评价内镜下切除指征,但无法术前定性诊断。内镜透明帽辅助下切除治疗十二指肠类癌是安全有效的。     

A New Candidate as a Hemostatic Agent for Difficult Situations During Variceal Bleeding: Ankaferd Blood Stopper

Variceal bleeding is the most challenging emergent situation among the causes of upper gastrointestinal bleeding. Despite substantial improvement, a need remains for therapeutic armamentarium of such cases, which is easy, effective and without side-effect. Ankaferd blood stopper (ABS) is a standardized herbal extract acting as a hemostatic agent on the bleeding or injured areas. In this observational study, a total of four patients with variceal bleeding were treated with endoscopic ABS application. The lesions were bleeding gastric varices (n:3) and bleeding duodenal varix (n:1). ABS was selected as a bridge to definitive therapies due to unavailability or inappropriateness of bleeding lesions to conventional measures. ABS was instilled or flushed onto the bleeding areas by sclerotherotherapy needle or heater probe catheter. Periprocedural control of the bleeding was achieved in all instances. Thereafter, on an elective basis, two patients with gastric varices underwent cyanoacrylate injection, while third underwent Transjugular intrahepatic portosystemic shunt and embolization. The patient with duodenal varix refused further therapy, after a few hours after admission and was discharged. He again presented the same day with rebleeding, but died before any attempt could be made to control his bleeding. ABS seems to be effective in cases of variceal bleeding as a bridge to therapy. Its major advantages are the ease of use and lack of side-effects.     

COMBINED DUODENAL STENT PLACEMENT AND ENDOSCOPIC ULTRASONOGRAPHY‐GUIDED BILIARY DRAINAGE FOR MALIGNANT DUODENAL OBSTRUCTION WITH BILIARY STRICTURE

Patients with malignant pancreatobiliary neoplasm sometimes manifest duodenal obstruction and biliary stricture synchronously or metachronously. In this paper, we reviewed our experience with and technique for combined endoscopic duodenal stent placement and endoscopic ultrasonography (EUS)‐guided biliary drainage. Between May 2007 and September 2009, this combined technique was performed on seven patients with distal biliary strictures and duodenal obstructions. The clinical success rate of the procedure, complications, patency periods of duodenal stents and patency periods of biliary stents were retrospectively evaluated. Clinical success was achieved in all seven cases for both procedures. Complications related to EUS‐biliary drainage, namely localized peritonitis due to bile leakage, occurred in two cases. Both patients recovered without additional interventions. Occlusion of a duodenal stent was observed in one patient, but additional intervention could not be performed due to sepsis. Occlusion of both a duodenal stent and a biliary stent was also observed in one patient, and this was resolved with the insertion of an additional duodenal stent and a biliary stent exchange. In conclusion, combined duodenal stent placement and EUS‐guided biliary drainage is a therapeutic option in case of failed endoscopic retrograde cannulation of malignant strictures with a malignant duodenal obstruction.     

胰腺假性囊肿内镜超声图像的特征

目的：研究胰腺假性囊肿内镜超声图像的特征，探讨内镜超声在胰腺假性囊肿诊断中的价值。方法：对35例胰腺假性囊肿患者进行超声内镜检查。结果：在35例胰腺假性囊肿中，单发3l例，多发4例，共有囊肿41个；位于胰头13个，胰体3个，胰尾19个，胰体尾6个。囊壁光滑29例，毛糙6例；囊液透声良好19例，有絮状回声16例，囊内有分隔l例，囊壁有钙化l例，伴有胰管扩张7例；胰腺实质回声不均匀21例，胰实质钙化4例，胰腺萎缩2例，胰腺癌2例，胰腺未见异常6例。5例在胃肠道有压迹，其中1例压迫十二指肠降段致梗阻；胃底静脉曲张4例，2例引起消化道出血。结论：内镜超声可以清晰显示囊肿的大小、部位、形态以及与胰腺的关系，且能进行EUS引导下的穿刺检查，对假性囊肿的诊断和鉴别诊断均有重要意义。