Melena-associated regional portal hypertension caused by splenic arteriovenous fistula

Regional portal hypertension is a rare cause of upper gastrointestinal bleeding. We reported an extremely rare case in which regional portal hypertension was associated with both the splenic arteriovenous fistula and chronic pancreatitis. In June 2010, our patient, a 41-year-old man, was admitted to a local hospital due to a sudden melena and dizziness without haematemesis and jaundice. The splenic arteriovenous fistula in this patient was successfully occluded through transcatheter arterial embolization. At the 12-mo follow-up, our patient was in good condition.     

Percutaneous transarterial embolization of extrahepatic arteroportal fistula

INTRODUCTION Extrahepatic arteroportal fistula is a rare disorderof hepatic vasculature characterized by anomalous communication between arteries and portal vein system most commonly caused by abdominal trauma, and iatrogenic damage induced by procedures …     

Inferior mesenteric arteriovenous fistula: Case report and world-literature review

Arteriovenous fistulas between the inferior mesenteric artery and vein are rare, with only 26 primary and secondary cases described in the literature. Secondary fistulas occur following operations of the left hemicolon and manifest as abdominal pain, abdominal mass, gastrointestinal bleeding, colonic ischemia and portal hypertension. Symptom intensities are flow-dependent, and can range from minimal symptoms to severe heart failure due to left to right shunt. Diagnosis is usually established by radiological or intraoperative examination. Treatment options include embolization and/or surgical resection. Therapeutic decisions should be adapted to the unique characteristics of the fistula on an individual basis. A new case of a primary arteriovenous fistula is described and discussed along with a complete review of the literature. The patient in this report presented with signs and symptoms of colonic ischemia without portal hypertension. The optimal treatment for this patient required a combination of embolization and surgical operation. The characteristics of these rare inferior mesenteric arteriovenous fistulas are examined and some considerations concerning diagnostic and therapeutic strategies that should be followed are presented.     

Splenic arteriovenous fistula and sudden onset of portal hypertension as complications of a ruptured splenic artery aneurysm： Successful treatment with transcatheter arterial embolization. A case study and review of the literature

Splenic arteriovenous fistula (SAVF) accounts for an unusual but well-documented treatable cause of portal hypertension. A case of a 50-year-old multiparous female who developed suddenly portal hypertension due to SAVF formation is presented. The patient suffered from repeated episodes of haematemesis and melaena during the past twelve days and thus was emergently admitted to hospital for management. Clinical and laboratory investigations established the diagnosis of portal hypertension in the absence of liver parenchymal disease. Endoscopy revealed multiple esophageal bleeding varices. Abdominal computed tomography (CT) and transfemoral celiac arteriography documented the presence of a tortuous and aneurysmatic splenic artery and premature filling of an enlarged splenic vein, findings highly suggestive of an SAVF. The aforementioned vascular abnormality was successfully treated with percutaneous transcatheter embolization. Neither recurrence nor other complications were observed.     

A large congenital and solitary intrahepatic arterioportal fistula in an old woman

Arterioportal fistula （APF） is a rare cause of portal hypertension and may lead to death. APF can be congenital, post-traumatic, iatrogenic （transhepatic intervention or biopsy） or related to ruptured hepatic artery aneurysms. Congenital APF is a rare condition even in children. In this case report, we describe a 73-year-old woman diagnosed as APF by ultrasonography, computed tomography, and hepatic artery selective arteriography. The fistula was embolized twice but failed, and she still suffered from alimentary tract hemorrhage. Then, selective arteriography of the hepatic artery was performed again and venae coronaria ventriculi and short gastric vein were embolized. During the 2-year follow-up, the patient remained asymptomatic. We therefore argue that embolization of venae coronaria ventriculi and short gastric vein may be an effective treatment modality for intrahepatic APF with severe upper gastrointestinal bleeding.     

Unusual case of digestive hemorrhage: Celiac axis-portal vein arteriovenous fistula

A case of intractable upper gastrointestinal-hemorrhage was reported in a patient with portal hypertension caused by an arterioportal fistula(APF), namely, celiac axis-portal vein arteriovenous fistula. Portal hypertension caused by extrahepatic-APFs is extremely rare. Trauma, malignancy, and hereditary causes are the common etiology of APFs; but were absent in our patient. Our patient represents an unusualcase of unexplained APF who presented with portal hypertension and was successfully managed through endovascular aortic repair.     

Posttraumatic intrapancreatic aortosplenic fistula causing portal hypertension

Arterioportal fistulas are uncommon. The case of a patient with massive uncontrollable esophageal variceal bleeding is presented. Reversible portal hypertension was caused by a posttraumatic giant intrapancreatic aortosplenic fistula. Percutaneous closure was unsuccessful, and pancreatectomy was performed to control the bleeding. The case is discussed and the literature on this exceptional cause of portal hypertension is reviewed.     

Arterioportal Fistula: A Role for Pre-TIPSS Arteriography and Hepatic Venous Pressure Measurements

A 70-yr-old male presented with massive upper gastrointestinal bleeding secondary to esophageal varices. Because the bleeding was not controlled by sclerotherapy or vasopressin and nitroglycerin, the patient was evaluated for a transjugular intrahepatic portosystemic shunt. Preprocedure arteriography was performed because the etiology of the portal hypertension was uncertain. The arteriogram revealed a hepatic artery to portal vein fistula. Hepatic venous pressure measurements documented an elevated hepatic venous pressure gradient, which diminished dramatically upon embolization of the fistula. Rebleeding from the varices was associated with reestablishment of the fistula via collaterals and elevation of the hepatic venous pressure gradient. The case is presented to establish a role for arteriography prior to transjugular intrahepatic portosystemic shunting, especially in patients with unexplained portal hypertension, and to establish the potential value of hepatic venous pressure measurements in the treatment of arterioportal fistulas.     

Gastrointestinal bleeding caused by extrahepatic arterioportal fistula associated with portal vein thrombosis

An extrahepatic arterioportal fistula (APF) involving the gastroduodenal artery and superior mesenteric vein is rare and mostly results from iatrogenic injuries. The clinical symptoms associated with APFs may include abdominal pain, gastrointestinal bleeding, ascites, nausea, vomiting, diarrhea, or even congestive heart failure. We present the case of a 70-year-old man who presented with chronic abdominal pain and gastrointestinal bleeding secondary to APF and portal vein thrombosis. The endovascular embolization of APF was accomplished successfully, and symptoms of portal hypertension resolved immediately after intervention. Unfortunately, the patient did not respond well to anticoagulation therapy with warfarin. Therefore, the patient underwent implantation of a transjugular intrahepatic portosystemic shunt, and the complications of portal hypertension resolved. In conclusion, the embolization of APF is technically feasible and effective and can be considered the first-choice therapy in selected patients.     

Haematochezia in Crohn's disease caused by late-onset haemobilia following percutaneous liver biopsy

The case of a patient with Crohn's disease and who presented 4 days after a percutaneous liver biopsy with haematochezia suggestive of an exacerbation of his inflammatory bowel disease is described. Subsequent abdominal ultrasonography revealed free fluid in the peritoneal cavity and around the gallbladder. Haemobilia was suspected. Selective hepatic arteriography demonstrated a fistula between the hepatic artery and the portal venous system, with the presence of a hepatic artery pseudoaneurysm. Bleeding was stopped by arterial embolisation using titanium microcoils. Haemobilia is a very rare complication of percutaneous liver biopsy, but it should not be overlooked as a potential late-onset cause of rectal bleeding following this procedure. Selective hepatic arterial embolisation is an effective and safe treatment for this serious complication.     

Gastric variceal bleeding caused by an intrahepatic arterioportal fistula that formed after liver biopsy: a case report and review of the literature

An intrahepatic arterioportal fistula is a rare cause of portal hypertension and variceal bleeding. We report on a patient with an intrahepatic arterioportal fistula following liver biopsy who was successfully treated by hepatectomy after unsuccessful arterial embolization. We also review the literature on symptomatic intrahepatic arterioportal fistulas after liver biopsy. A 48-year-old male with bleeding gastric varices and hepatitis B virus-associated liver cirrhosis was transferred to our hospital; this patient previously underwent percutaneous liver biopsies 3 and 6 years ago. Abdominal examination revealed a bruit over the liver, tenderness in the right upper quadrant, and splenomegaly. Ultrasonographic examination, computed tomography, and angiography confirmed an arterioportal fistula between the right hepatic artery and the right portal vein with portal hypertension. After admission, the patient suffered a large hematemesis and developed shock. He was treated with emergency transarterial embolization using microcoils. Since some collateral vessels bypassed the obstructive coils and still fed the fistulous area, embolization was performed again. Despite the second embolization, the collateral vessels could not be completely controlled. Radical treatment involving resection of his right hepatic lobe was performed. For nearly 6 years postoperatively, this patient has had no further episodes of variceal bleeding.     

Primary aortoenteric fistula

Primary aortoenteric fistula is a rare complication of aortic aneurysms. This cause of gastrointestinal bleeding poses significant diagnostic challenges due to its nonspecific presentation. We report a case of an 80-year-old man with right flank pain and rectal bleeding. The patient had been admitted 2 weeks before with the same symptoms. Upper and lower endoscopies were unremarkable, but abdominal computed tomography scan showed evidence of aortoduodenal fistula. An emergency laparotomy with aortic bypass and fistula closure was performed and the patient was able to recover in the following weeks. This case highlights the need for a high index of suspicion to avoid diagnostic delay that frequently has fatal results.     

Ischemic colitis secondary to inferior mesenteric arteriovenous fistula and portal vein stenosis in a liver transplant recipient

Arteriovenous fistula （AVF） involving the inferior mesenteric vessels is rare, and the affected patients usually present with abdominal pain, mass, or features of established portal hypertension. Colonic ischemia is a less common and more serious manifestation of AVE We report a case of ischemic colitis secondary to inferior mesentedc AVF in a patient who underwent a previous liver transplantation, subsequently developed portal vein stenosis, and then presented with acute lower gastrointestinal bleeding. He underwent percutaneous transhepatic placement of a portal vein stent and left colectomy.     

Portal hypertension induced by congenital hepatic arterioportal fistula:Report of four clinical cases and review of the literature

Intrahepatic arterioportal fistula(IAPF)can be caused by many secondary factors.We report four cases of portal hypertension that were eventually determined to be caused by congenital hepatic arterioportal fistula.The clinical manifestations included ascites,variceal hemorrhage and hepatic encephalopathy.Computed tomography scans from all of the patients revealed the early enhancement of the portal branches in the hepatic arterial phase.All patients were diagnosed using digital subtraction angiography(DSA).DSA before embolization revealed an arteriovenous fistula with immediate filling of the portal venous radicles.All four patients were treated with interventional embolization.The four patients remained in good condition throughout follow-up and at the time of publication.IAPF is frequently misdiagnosed due to its rarity;therefore,clinicians should consider IAPF as a potential cause of non-cirrhotic portal hypertension.     

Superior Mesenteric Venous Aneurysm

A patient presented with recurrent upper gastrointestinal bleeding. Celiac and superior mesenteric angiography showed a superior mesenteric venous aneurysm, a normal-sized liver, an enlarged spleen, and esophageal varices. The patient gave no history of hepatitis or alcoholism. It is concluded that the portal hypertension was secondary to aneurysm of the superior mesenteric vein. Aneurysms of the portal venous system can cause chronic portal hypertension due to alteration of blood flow. We believe this to be the second case reported in the English literature of a superior mesenteric venous aneurysm.     

Recurrent massive haemorrhage from an endoscopically inevident isolated rectal varix

Anorectal varices are identified endoscopically in up to 40% of patients with liver cirrhosis [Misra SP, Dwivedi M, Misra V. Prevalence and factors influencing haemorrhoids, anorectal varices, and colopathy in patients with portal hypertension. Endoscopy 1996;28:340-5] but are an infrequent cause of bleeding and their management remains controversial. We present a patient with chronic hepatitis C virus infection who developed recurrent haemorrhage from an isolated, endoscopically inevident rectal varix in the absence of clinical or endoscopic evidence of portal hypertension. The difficulties in diagnosis and management of anorectal varices are highlighted.     

Successful hemostasis of intractable rectal variceal bleeding using variceal embolization

Portal hypertension causes portosystemic shunting along the gastrointestinal tract,resulting in gastrointestinalvarices.Rectal varices and their bleeding is a rare complication,but it can be fatal without appropriate treatment.However,because of its rarity,no established treatment strategy is yet available.In the setting of intractable rectal variceal bleeding,a transjugular intravenous portosystemic shunt can be a treatment of choice to enable portal decompression and thus achieve hemostasis.However,in the case of recurrent rectal variceal bleeding despite successful transjugular intravenous portosystemic shunt,alternative measures to control bleeding are required.Here,we report on a patient with liver cirrhosis who experienced recurrent rectal variceal bleeding even after successful transjugular intravenous portosystemic shunt and was successfully treated with variceal embolization.     

Stomal varices: a rare cause of stomal hemorrhage. A report of three cases

Stomal varices secondary to portal hypertension are a rare but potentially fatal cause of hemorrhage. Management, determined by the site of the bleeding, centers on preventing additional bleeds and may include providing local pressure, applying silver nitrate, injection sclerotherapy, suture ligation of the bleeding point, and/or the placement of transjugular intrahepatic portosystemic shunts and refashioning the stoma. Two patients (60- and 69-year-old women) had panproctocolectomy for inflammatory bowel disease and presented at the authors' hospital with bleeding from the ileostomy 1 and 19 years, respectively, following the creation of their stomas. A third patient (a 72-year-old man) bled from an end colostomy following an abdominoperineal resection for Duke's C rectal adenocarcinoma performed 3 years previous. All three patients had recurrent admissions for stomal bleeding and stomal varices secondary to portal hypertension and were initially treated with local measures (pressure, silver nitrate, and suture ligation). Two had undergone revision of their stomas prior to current treatment. One patient responded to local treatment but later died due to liver failure, one stopped bleeding after transjugular portosystemic shunt placement, and one died from metastatic cancer. Clinicians should maintain a high index of suspicion of stomal varices in patients with underlying liver disease who present with recurrent stomal bleeds and provide appropriate treatment to stop active bleeding and reduce portal venous pressure.     

Portal hypertension secondary to intrahepatic arterio-portal shunt in primary amyloidosis: a case report

Portal hypertension is a rare complication in hepatic amyloidosis. We experienced a case of a 40-year-old man with primary amyloidosis and advanced esophageal varices. Angiographic procedures clearly demonstrated portal hypertension secondary to intrahepatic arterio-portal shunting. Hepatic arterial embolization brought about a disappearance of the A-P shunt and portal hypertension, though rebleeding occurred. To our knowledge, this is the first case report in which the pathogenesis of portal hypertension in hepatic amyloidosis was elucidated.     

A case in which danaparoid sodium was effective for portal venous thrombosis developed after endoscopic injection sclerotherapy for esophageal varices

We report a case of hepatitis C type liver cirrhosis with portal venous thrombosis in which danaparoid sodium was very effective. The patient developed portal venous thrombosis, esophageal ulcer, and esophageal stenosis at the same time after sclerotherapy. Since it was confirmed by abdominal computed tomography that there was no portal venous thrombosis before sclerotherapy, development of the thrombosis was considered to be associated with sclerotherapy. The patient was treated with balloon dilation therapy for esophageal stenosis, and with anticoagulation therapy using danaparoid sodium for portal venous thrombosis. The portal venous thrombosis disappeared 4 weeks after the treatment. Despite the condition of esophageal ulcer being caused by sclerotherapy, the patient was safely treated without any adverse effects and complications, and the clinical course has been good. It was indicated that danaparoid sodium was an anticoagulant unlikely to cause adverse effects such as hemorrhage and might be an effective drug for treatment of portal venous thrombosis.