Splenic arteriovenous fistula formation due to angiodysplasia in a splenic aneurysm of a patient with liver cirrhosis--a report of a case

A 53 year-old Japanese woman with liver cirrhosis manifested massive hematemesis due to ruptured esophageal varices. Celiac angiography demonstrated an aneurysm of the splenic hilus and arteriovenous fistula around the aneurysm. She underwent splenectomy, proximal gastrectomy, distal esophageal devascularization and pyloroplasty. Histological examination of the aneurysm revealed arterial dysplasia with a focal medial gap. Microscopic tissue clefts at the site of a medial gap were considered to be the source of the angiographic arteriovenous fistula.     

失代偿期肝硬化患者食管静脉曲张程度的分析

目的了解肝硬化患者食管静脉曲张程度与门、脾静脉内径及脾脏厚度的关系及其临床价值。方法分析110例肝硬化失代偿期患者的临床资料,包括胃镜检查所见食管静脉曲张程度,腹部B超测门静脉内径、脾静脉内径及脾脏厚度。对患者的食管静脉曲张程度与门静脉内径、脾静脉内径以及脾脏厚度进行等级相关分析。结果食管静脉曲张严重程度与门静脉主干内径呈正相关（γs=0.292,P〈0.01）,与脾静脉内径呈正相关（γs=0.295,P〈0.01）,而且还与脾脏厚度呈正相关（γs=0.336,P〈0.01）。结论测量门静脉、脾静脉内径以及脾脏厚度可判断门脉高压和食管静脉曲张程度,并预测食管静脉曲张破裂出血的风险。     

Values of Doppler sonography predicts high risk variceal bleeding in patients with viral cirrhosis

BACKGROUND/AIMS: Gastrointestinal bleeding such as rupture of esophagogastric varices remains one of the leading causes of death in patients with liver cirrhosis. As a critical issue, assessment of the bleeding risk of esophageal varices is extremely important. In the present study, by determining the relationship between several parameters measured by pulsed Doppler sonography and the bleeding risk of esophageal varices assessed by upper endoscopy, we investigated what is the most valuable parameter as a supplement to the bleeding risk. METHODOLOGY: A total of 158 patients with hepatitis virus-infected liver cirrhosis (56 positive for HBs antigen and 102 positive for HCV antibody) were studied. As controls, 171 normal subjects were used. The flow volumes of the portal trunk and the splenic vein, the Congestion Index, and the S/P ratio were measured by pulsed Doppler sonography. Based on upper endoscopic findings, we classified the patients into two groups based on bleeding risk of esophageal varices: high-risk and low-risk. Logistic regression analysis was employed to identify the most valuable parameter as a supplement to the bleeding risk. RESULTS: The flow volume of the splenic vein, the Congestion Index, and the S/P ratio in cirrhotic patients with esophageal varices were significantly higher than those in normal subjects (P = 0.000). The mean flow volumes of the portal trunk and splenic vein and the mean of the S/P ratio in the high-risk group for bleeding of esophageal varices were significantly higher than those in the low-risk group (P = 0.000-0.005). Based on logistic regression analysis, the flow volume of the splenic vein was found to be the most valuable parameter for bleeding risk (P < 0.001). CONCLUSIONS: The flow volume of splenic vein with pulsed Doppler sonography was the most valuable parameter for the bleeding risk of esophageal varices.     

部分脾动脉栓塞治疗肝硬化合并脾功能亢进及食管静脉曲张疗效分析

为探讨部分脾动脉栓塞治疗脾功能亢进及食管静脉曲张的疗效 ,我们从 1998年 - 2 0 0 1年对 2 0例肝硬化脾功能亢进患者进行部分脾动脉栓塞。结果显示 ,血小板、白细胞、白蛋白、总蛋白较治疗前明显提高 (P <0 0 5 )。脾脏肿大、PV、SV的内径、食管静脉曲张的程度也分别较治疗前明显减小和减轻 (P <0 0 5 )。对肝功能无明显影响 ,转氨酶、胆红素在治疗后 1周、1月、6月后与治疗前无明显变化 (P >0 0 5 )。因此 ,部分脾动脉栓塞对治疗脾功能亢进及食管静脉曲张具有明显的疗效。且对肝功能无明显影响。     

Antral Varices

Varices of the gastric fundus, often associated with esophageal varices, are a common complication of portal hypertension or splenic vein occlusion. However, varices of the gastric antrum have been reported rarely. We describe a 61-yr-old man with antral and esophageal varices caused by portal hypertension due to hepatic cirrhosis.     

Prevention of variceal recurrence, bleeding, and death in cirrhosis patients with hypersplenism, especially those with severe thrombocytopenia

BACKGROUND/AIMS: We investigated the impact of different treatments on the prognosis of cirrhosis patients with esophageal varices and thrombocytopenia. METHODOLOGY: This prospective study enrolled 52 cirrhosis patients with esophageal varices and hypersplenism (platelet count < 50,000/mm3). In 26 patients, endoscopic variceal ligation plus partial splenic embolization were performed, while endoscopic variceal ligation alone was done in 26 patients. Endoscopic variceal ligation was repeated until complete eradication of varices was achieved. Partial splenic embolization was performed using the Seldinger method and embolic material was injected until a 60% to 80% reduction of splenic blood flow was achieved. The primary endpoints during the follow-up period included recurrence of varices, variceal bleeding, and death. RESULTS: Comparison of endoscopic variceal ligation plus partial splenic embolization with endoscopic variceal ligation alone by multivariate analysis showed a relative risk ratio of 0.390 (95% CI [0.178-0.854]; p = 0.024) for new varices, 0.191 (95% CI [0.047-0.780]; p = 0.021) for variceal bleeding, and 0.193 (95% CI [0.053-0.699]; p = 0.012) for death. CONCLUSIONS: These results suggest that endoscopic variceal ligation plus partial splenic embolization can prevent variceal recurrence, bleeding, and death in cirrhosis patients with esophageal varices and thrombocytopenia.     

肝硬化门静脉高压患者胃镜与B超表现相关性研究

目的 通过对肝炎肝硬化门静脉高压患者胃镜、B超检测结果行相关性分析，为临床判断肝硬化程度、早期预防并发症提供参考。方法 选择肝炎肝硬化门静脉高压患者192例，根据食管静脉曲张程度分为轻、中、重度3组。比较胃底静脉曲张在各组中发生比例，并测量门静脉主干宽度、脾静脉宽度、脾脏厚度，研究其与食管静脉曲张程度相关性。结果 3组患者胃底静脉曲张发生比例存在显著差异，食管静脉曲张程度越重，伴胃底静脉曲张比例越高；随食管静脉曲张程度不同，门静脉主干内径、脾静脉内径及脾脏厚度之间存在差异，脾脏厚度与脾静脉内径之间存在直线相关关系。结论 门静脉主干内径、脾静脉内径、脾脏厚度可为判断门静脉高压提供参考，综合上述3点并结合胃镜检查结果可较准确判断有无食管静脉曲张及程度。     

Portal Hypertension and Esophageal Varices in Cystic Fibrosis: Unreliability of Echo-Doppler Flowmetry

To investigate the role of echo-Doppler flowmetry in evaluating patients with cystic fibrosis and portal hypertension at risk of esophageal varices, we studied 26 subjects divided in 3 groups: 9 with portal hypertension and esophageal varices, 8 with chronic liver disease without varices, and 9 without chronic liver disease. Spleen size, diameter, blood velocity, and flow rate of portal, splenic, and superior mesenteric veins were recorded. In patients without chronic liver disease Doppler measurements were repeated on 2 different days to assess intraobserver variability. Significant differences among the three groups were found for mean values of spleen size and diameters of portal, splenic, and superior mesenteric veins. Nevertheless, a considerable overlapping of individual data was observed. No differences were observed in mean hemodynamic measurements, except for blood velocity in portal vein and flow rate in splenic vein. The intraobserver variability for repeated Doppler measurements was clinically unacceptable for most of the variables studied. Echo-Doppler assessment of splanchnic flow seems to be an unreliable tool in the management of cystic fibrosis patients with portal hypertension at risk of esophageal varices.     

部分脾栓塞联合心得安预防食管胃底静脉曲张再出血的研究

[目的]评价部分脾动脉栓塞术（PSE）联合心得安预防食管胃底静脉曲张再出血的临床疗效.[方法]55例食管胃底静脉曲张破裂出血患者,随机分为两组,其中心得安组28例,PSE联合心得安组27例,比较两组患者外周血象变化,门静脉、脾静脉管径变化,以及3个月、6个月、1年、2年不同时间段的再出血率、病死率和并发症情况.[结果]术后1个月PSE联合心得安组较心得安组外周血白细胞及血小板显著升高,门静脉及脾静脉管径明显缩小,再出血率降低,差异有统计学意义（P＜0.05）.[结论] PSE联合心得安预防食管胃底静脉曲张再出血较单独使用心得安有更好的疗效.     

Isolated gastric varices: splenic vein obstruction or portal hypertension?

The presence of isolated gastric varices without esophageal varices is thought to be highly suggestive of splenic vein obstruction. A review of our radiologic files revealed 14 patients with isolated gastric varices on barium studies performed during the past 10 years. Eight of the 14 patients had adequate clinical and/or radiologic follow-up to suggest the pathophysiology of the varices. Seven had evidence of portal hypertension, and the remaining patient had evidence of splenic vein obstruction. Six patients had signs of upper gastrointestinal (GI) bleeding. Double-contrast upper GI examinations revealed thickened, tortuous fundal folds in 6 patients and a lobulated fundal mass in 2. Thus, most patients with isolated gastric varices have portal hypertension rather than splenic vein obstruction as the underlying cause.     

内镜套扎-部分脾栓塞联合术治疗门脉高压症的临床疗效观察

探讨内镜套扎-部分脾栓塞联合术治疗门脉高压症的临床应用价值。对2 5例合并食道静脉曲张和脾功能亢进的门脉高压患者进行内镜套扎-部分脾栓塞联合术,对其术前术后外周血象、脾脏大小、门静脉、脾静脉内径的变化进行对比研究。联合术后患者食道静脉曲张得到根治,脾功能亢进明显缓解,脾脏缩小(P <0 .0 1)、门静脉、脾静脉内径缩小(P <0 . 0 1)。内镜套扎-部分脾栓塞联合术治疗门脉高压症具有简便、安全、效果显著、创伤小、并发症少等优点,是治疗肝硬化门脉高压症的一种新的途径。     

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.     

Drainage-lavage and closure of a late esophageal perforation with esophagopleural fistula and encysted pleural effusion after endoscopic injection sclerotherapy for varices

We report a case of late perforation of the thoracic esophagus with an esophagopleural fistula after endoscopic sclerotherapy for esophageal varices in a Child-Pugh B9 cirrhotic patient. The existence of a thoracic empyema without diffuse mediastinitis allowed management of the fistula by percutaneous drainage-lavage and antibiotic therapy with subsequent closure of the esophageal wall defect and recovery from sepsis. This observation indicates that minimally invasive management of an esophageal perforation complicated by an esophago-pleural fistula is possible in highly selected patients.     

Bleeding isolated gastric varices: a retrospective analysis.

OBJECTIVE: Isolated gastric varices (IGV) are rare and are believed to be associated with left-sided portal hypertension. We studied patients presenting with bleeding from IGV and compared them with those bleeding from both esophageal and gastric varices. METHODS: A retrospective analysis of 14 patients with bleeding from IGV was carried out. Portovenography findings (pattern of collateralization and natural shunts) in these patients were compared with a matched group of 69 patients with both esophageal and gastric varices. RESULTS: Of 14 patients with IGV, 2 had isolated splenic vein thrombosis and 12 had generalized portal hypertension. Portovenograms in 11 of the latter 12 revealed predominantly 'left-sided' collateralization in 8 patients as compared to 17 of 69 (25%) patients with esophageal and gastric varices (p = 0.004); natural shunts were seen in 6 of 11 cases and 15 of 69 (22%) patients in the two groups, respectively (p = 0.05). Abdominal devascularization operation gave good short- and long-term control of bleeding. CONCLUSIONS: Contrary to belief most patients with isolated gastric varices may have generalized portal hypertension rather than splenic vein obstruction as the cause and hence should be treated by a more extensive procedure than just splenectomy. The IGV could be a result of predominant collateralization to the retroperitoneal area (left-sided collateralization and natural shunts) rather than the usual pattern to the azygos system which results in esophageal varices.     

Portal hemodynamics in patients with gastric varices. A study in 230 patients with esophageal and/or gastric varices using portal vein catheterization

The hemodynamic features of gastric varices are not well documented. The purpose of this study was to investigate the nature of hepatofugal collateral veins, their origins, the direction of blood flow in the major veins and collateral veins, and portal venous pressure. To this end, 230 patients, mostly cirrhotic, who had esophageal or gastric varices, or both, demonstrated by endoscopy were investigated by portal vein catheterization. The findings were correlated with endoscopically assessed degrees of varices. Gastric varices were seen in 57% of the patients with varices due to portal hypertension. In most of the patients with advanced gastric varices, esophageal varices were minimal or absent. When patients with gastric varices were compared with those having predominantly esophageal varices, it was found that advanced gastric varices were more frequently supplied by the short and posterior gastric veins, they were almost always associated with large gastrorenal shunts, and portal venous pressure in patients with large gastric varices was lower. Chronic portal systemic encephalopathy was more common in patients with large gastric varices due to hepatofugal flow of superior mesenteric venous blood in the splenic vein than in patients with predominantly esophageal varices. Thus, the hemodynamics in patients with large gastric varices are distinctly different from those in patients with mainly esophageal varices, and such differences seem to account for the differing incidence of chronic encephalopathy and variceal bleeding.     

Isolated Gastric Varices Due to Spontaneous Splenic Vein Thrombosis

Isolated bleeding gastric varices due to a spontaneous idiopathic thrombosis of the splenic vein was found to be the cause of obscure, painless recurrent bleeding in our patient. The diagnosis of spontaneous splenic vein thrombosis should be considered in the presence of gastrointestinal bleeding with unexplained splenomegaly. Prominent gastric folds may be the only barium contrast or endoscopic finding often lacking esophageal varices. Arteriography is essential in demonstrating an obstructed splenic vein. Splenectomy is the treatment of choice of "left-sided" portal hypertension.     

Portal vein thrombosis following sclerotherapy.

We present the case of a woman with idiopathic portal hypertension who underwent sclerotherapy for bleeding esophageal varices. She had a rebleed 27 months after complete eradication of esophageal varices. Endoscopy showed bleeding gastric varices. Ultrasonography, and later splenoportography, revealed a large thrombus in the right branch of the portal vein causing gross dilation of the portal and splenic vein. A proximal splenorenal shunt was done to decompress the portal system and hence gastric varices. Repeat endoscopy 4 weeks after surgery revealed complete disappearance of the gastric varices, while ultrasonography at 38 weeks showed marked decompression of the portal system with complete disappearance of the thrombus from the right branch of the portal vein. No new thrombus formation was seen.     

Combination treatment of partial splenic embolization, endoscopic embolization and transjugular retrograde obliteration for complicated gastroesophageal varices

The treatment of complicated gastroesophageal varices with a gastrorenal shunt and portal hypertensive gastropathy has not yet been established. We were able to control a case of complicated large gastroesophageal varices with gastrorenal shunt and portal hypertensive gastropathy using a combination treatment of partial splenic embolization, endoscopic embolization and transjugular retrograde obliteration. We first applied partial splenic embolization to reduce the hyperdynamic cycle of portal hypertension and to treat thrombocytopenia. We secondarily applied endoscopic embolization for the esophageal varices. Transjugular retrograde obliteration was performed for the gastric varices 14 days after endoscopic embolization. The wedged hepatic venous pressure had not changed after transjugular retrograde obliteration. After the combination treatment, the gastroesophageal varices were successfully obliterated, but portal hypertensive gastropathy did not worsen. The platelets count, arterial ketone body ratio and ICGR15 were improved. Partial splenic embolization was useful to protect side effects of endoscopic embolization and transjugular retrograde obliteration. We conclude that the combination treatment of partial splenic embolization, endoscopic embolization and transjugular retrograde obliteration is a rational, effective and safe treatment for complicated gastroesophageal varices with gastrorenal shunt and portal hypertensive gastropathy.     

New methods for the management of gastric varices

INTRODUCTION Bleeding from esophageal varices (EVs) or gastric varices (GVs) is a catastrophic complication of chronic liver disease. Bleeding from GVs is generally thought to be more severe than bleeding from EVs[1], but it occursless frequently[2-4]. Though many recent developments have improved the outcome of treatments for GVs, no consensus has been reached on the optimum treatment. In this paper we review the pathomorphology, hemodynamics, risk factors for bleeding, and treatment…     

Control of isolated gastric varices by combination therapy using embolization and endoscopic scleroligation therapy

Balloon-occluded retrograde venous obliteration is a powerful new technique for eliminating gastric varices. However anatomic considerations may preclude its use in some instances. Two cases are reported in which combination embolization followed by endoscopic injection scleroligation therapy eradicated isolated gastric varices where balloon-occluded retrograde venous obliteration was impossible. Two men with alcoholic cirrhosis were admitted with bleeding gastric varices. Inability to access variceal venous drainage precluded balloon-occluded retrograde venous obliteration. In Case 1, transileocolic vein obliteration left gastric embolization, and partial splenic embolization only partially eradicated gastric varices. In Case 2, percutaneous transhepatic obliteration, left gastric embolization, and partial splenic embolization were only partially successful. In both cases, endoscopic injection scleroligation therapy was performed adjunctively. Endoscopic injection scleroligation therapy completely eradicated gastric varices in both patients following partially successful embolization therapy. These cases demonstrate the importance of individualizing treatment of esophageal varices, the value of combination therapy, and the effectiveness of endoscopic injection scleroligation therapy for treating varices.