Colonic variceal bleeding is a rare cause of lower gastrointestinal (GI) bleeding, which carries a high mortality rate. Due to limited data, the optimal management of colonic variceal bleeding is not known. Coil-assisted retrograde transvenous obliteration (CARTO) has been shown to be very effective in managing non-esophageal variceal bleeding, but only a few cases demonstrate its effectiveness in treating colonic variceal bleeding. Here we present a case of colonic variceal bleeding treated with CARTO in order to expand on the limited body of evidence showing its efficacy in effectively treating this rare cause of life-threatening GI bleeding.

Ectopic varices account for 5% of variceal bleedings and occur outside the gastro-esophageal region. This review evaluates the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) for ectopic variceal management. A comprehensive search through PubMed, Scopus, Web of Science, and Embase was conducted until January 16, 2023, using relevant keywords. Case reports and case series with fewer than 10 patients on TIPS for ectopic variceal management were included. The quality assessment followed the Joanna Briggs Institute checklist for case reports. This systematic review evaluated 43 studies involving 50 patients with ectopic varices undergoing TIPS. Patients had a mean age of 54.3 years, half were female, and two were pregnant. Alcoholic liver disease (48%) and hepatitis C infection (26%) were common causes of portal hypertension. Ascites and splenomegaly were reported in 32% and 28% of the patients, respectively. Rectal, oral, and stomal variceal bleeding accounted for 62%, 16%, and 22% of the patients, respectively. Ectopic varices were mainly located in the duodenum (28%) and rectum (26%) regions. Complications affected 42% of the patients, re-bleeding in eleven and hepatic encephalopathy in seven. The follow-up lasted 12 months on average, and finally, 5 received a liver transplant. Mortality post-TIPS was 18%. Despite complications and a notable mortality rate, favorable outcomes were observed in almost half of the patients with ectopic variceal bleeding managed with TIPS. Further research is warranted to refine strategies and improve patient outcomes.

UNASSIGNED: Arteriovenous fistulas (AVFs) of the craniocervical junction (CCJ) and intradural AVFs are often associated with aneurysms and varics, and it is sometimes difficult to identify the ruptured point on radiological images. We report a case in which vessel wall magnetic resonance image (VW-MRI) was useful for identifying the ruptured point at the CCJ AVF.
UNASSIGNED: A 70-year-old man presented with a sudden onset of headache. He had Glasgow Coma Scale E4V5M6, world federation of neurosurgical societies (WFNS) Grade I. Fisher group 3 subarachnoid hemorrhage and hydrocephalus were found on head computed tomography. Cerebral angiography showed a spinal AVF at the C1 level of the cervical spine. Magnetic resonance image-enhanced motion sensitized driven equilibrium (MSDE-method showed an enhancing effect in part of the AVF draining vein, but the vascular architecture of this lesion was indeterminate. We performed continuous ventricular drainage for acute hydrocephalus and antihypertensive treatment. Cerebral angiography was performed 30days after the onset of the disease, and was revealed an aneurysmal structure in a portion of the AVF draining vein, which VW-MRI initially enhanced. On the 38th day after onset, he underwent direct surgery to occlude the AV fistula and dissect the aneurysmal structure. Histopathology showed that the aneurysmal structure was varices with lymphocytic infiltration, and hemosiderin deposition was observed near the varices.
UNASSIGNED: Recently, VW-MRI has been reported to show an association between the enhancement of varices in dural AVF and rupture cases. VW-MRI, especially the enhanced MSDE method, may be useful in estimating the ruptured point in arteriovenous shunt disease.

BACKGROUND: Atezolizumab/bevacizumab combination therapy became the first-line therapy for advanced hepatocellular carcinoma (HCC). Gastroesophageal varices should be monitored and managed before treatment. The progression of portal hypertension during bevacizumab-containing therapy is unclear.
METHODS: A case of new development of esophageal varices, ascites, and hepatic hydrothorax during atezolizumab/bevacizumab therapy at National Taiwan University Hospital was reported, and relevant literature was reviewed.
RESULTS: We presented an 83-year-old male with resolved hepatitis B without cirrhosis. He had BCLC stage C HCC and received tri-weekly atezolizumab/bevacizumab therapy for 34 cycles with sustained partial response. Progressive ascites, esophageal varices, and hepatic hydrothorax developed, though his portal vein was patent and the tumor was under control. Five similar cases of HCC (BCLC B/C: n = 3/2) had been reported previously. Among them, three had cirrhosis with pre-existing small esophageal varices before treatment. After the administration of 1-15 cycles of atezolizumab/bevacizumab therapy, one patient had a progression of varices, and the other four developed variceal bleeding. The association between atezolizumab/bevacizumab and portal hypertension was possible, which might relate to the VEGF pathway and immune-related adverse events with progressive hepatic fibrosis.
CONCLUSIONS: Atezolizumab/bevacizumab treatment might exacerbate portal hypertension. Careful monitoring and management should be considered during treatment.

Nodular regenerative hyperplasia (NRH) is a rare cause of non-cirrhotic portal hypertension that should be considered in patients with no risk factors for chronic liver disease or in any unusual presentation of variceal hemorrhage. We present a case of an 82-year-old Chinese female, with a history of previous metastatic sigmoid carcinoma with oxaliplatin use, who presented with melena. A gastroscopy done revealed one column of grade 3 esophageal varix, two columns of grade 2 esophageal varices, and a type 1 gastroesophageal varix with stigmata of recent hemorrhage. Cyanoacrylate glue therapy was performed without any complications. A follow-up computed tomography (CT) imaging of the abdomen did not reveal any significant features of cirrhosis or venous thrombosis, and the decision was made for a transjugular liver biopsy with hepatic venous pressure gradient (HVPG) measurement. The measured HVPG was 6 mmHg, and the liver biopsy showed features consistent with NRH.

Gastric diverticula (GD) are the least prevalent type of gastrointestinal diverticula and are extremely uncommon anatomical anomalies in general. Although the majority of GD cases are asymptomatic and are identified by chance during normal diagnostic testing, they can manifest with a variety of symptoms. In some instances they can lead to life-threatening problems, necessitating surgical intervention. The majority of gastric diverticula go unnoticed. Upper abdomen pain, nausea, emesis, and dyspepsia are the most prevalent symptoms. Patients with GD can present with dramatic symptoms such as major bleeding or perforation on rare occasions. We report a rare case of a 60-year-old male, who presented with a complaint of haematemesis, and upon doing endoscopy and contrast-enhanced computed tomography of the abdomen was diagnosed with GD. The patient was managed successfully with proton pump inhibitor infusion and somatostatin analogs and was discharged in stable condition. Here, we highlight a rare but potentially life-threatening cause of hematemesis which is often missed by treating clinicians, especially in rural and remote areas, and therefore, requires more awareness and clinical vigilance.

Recently, a combined regimen of atezolizumab and bevacizumab (AB) treatment has been approved as a first-line treatment in patients with advanced hepatocellular carcinoma (HCC), contributing to prolonged survival. However, we often encounter cases where treatment must be discontinued due to the occurrence of adverse events. One of these events, which is often fatal, is gastrointestinal bleeding. To clarify the clinical effects of gastrointestinal bleeding after AB treatment, we evaluated patients with HCC who were treated with AB at our institution. Of the 105 patients, five treated with AB developed gastrointestinal bleeding, necessitating treatment discontinuation. Additionally, we encountered two cases where exacerbation of varicose veins was observed, and AB therapy could be continued by preventive treatment of varices. In conclusion, an appropriate follow-up is required during treatment with AB to prevent possible exacerbation of varicose veins.

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Jejunal varices are a rare cause of gastrointestinal bleeding. In most cases, they are due to portal hypertension related to liver cirrhosis, less frequently to superior mesenteric vein stenosis (SMV). In this article we describe an unusual case of a 61 year-old male patient who arrived at our emergency department with intermittent variceal bleeding due to jejunal varices causing melena and subsequent chronic anaemia. Patient was indeed discovered to have primary idiopathic superior mesenteric vein stenosis. We managed to treat this patient via SMV stenting through percutaneous transhepatic approach. In cases of upper-GI bleed with negative endoscopy for active bleeding, a contrast-enhanced CT scan should be performed to diagnose jejunal varices and their underlying cause, such as SMV stenosis which is best treated with percutaneous phlebography.

Liver cirrhosis is a chronic liver disease in which the liver tissue and the vascular beds are remodeled leading to impaired hepatic function. Portal hypertension and subsequent esophageal varices are a frequent complication of liver cirrhosis and are a cause of mortality in patients with liver cirrhosis. Pregnancy in women with liver cirrhosis is uncommon, the incidence being about 1 in 5 950 pregnancies. Hepatocellular damage and the associated alteration in the metabolism of the sex hormones is thought to be responsible and leads to anovulation. In spite of all these factors, women with cirrhosis can and do become pregnant. Pregnancy is successful in most of the patients with chronic liver disease, but maternal and fetal complication rates are still high for decompensated liver cirrhosis. Portal hypertension associated with pregnancy is a high-risk situation as both pregnancy and portal hypertension share some of the hemodynamic changes. Risks of variceal bleeding and hepatic decompensation increases many fold during pregnancy. Despite the possible complications mentioned above, the maternal-fetal morbidity and mortality rates have been decreased by the current developments in hepatology, prevention of bleeding from varices with drugs and/or endoscopic variceal ligation, improvement in liver transplantation, and an increased experience in these issues. We present a case of a 31-year-old female patient with liver cirrhosis who successfully managed pregnancy and birth without complications after the insertion of transjugular intrahepatic portosystemic shunt (TIPS). Unfortunately, 2 years after delivery, the patient developed lymphoblastic lymphoma and, despite intensive therapy for this disease, the patient died at the age of 40. We did not find any link between liver cirrhosis and lymphoblastic lymphoma.