A Case of Idiopathic Severe Acute Pancreatitis following Cesarean Section Delivery / 대한소화기학회지

Acute pancreatitis rarely occurs in the postpartum period. Furthermore, there are very few reports of it after cesarean section delivery. A 35-year-old woman presented with dyspnea and abdominal distension on the third day after cesarean section delivery. Under a suspicion of acute pancreatitis, she was initially managed with conservative treatment. However, she developed intra-abdominal fluid collections and gastric bleeding, which were managed with percutaneous drainage, endoscopic hemostasis, and angiographic embolization. She was discharged with good clinical recovery. Postpartum pancreatitis, especially after cesarean section, is rare; however, its management is not different from that for usual pancreatitis.

Vascular Plug Assisted Retrograde Transvenous Obliteration (PARTO) for Gastric Varix Bleeding Patients in the Emergent Clinical Setting

PURPOSE: To evaluate the technical feasibility and safety of vascular plug assisted retrograde transvenous obliteration (PARTO) for bleeding gastric varix performed in the emergent clinical setting and describe the mid-term clinical results. MATERIALS AND METHODS: From April 2012 to January 2015, emergent PARTO was tried in total 9 patients presented with active gastric varix bleeding. After initial insufficient or failure of endoscopic approach, they underwent PARTO in the emergent clinical setting. Gelatin sponge embolization of both gastrorenal (GR) shunt and gastric varix was performed after retrograde transvenous placement of a vascular plug in GR shunt. Coil assisted RTO (CARTO) was performed in one patient who had challenging GR shunt anatomy for vascular plug placement. Additional embolic materials, such as microcoils and NBCA glue-lipiodol mixture, were required in three patients to enhance complete occlusion of GR shunt or obliteration of competitive collateral vessels. Clinical success was defined as no variceal rebleeding and disappearance of gastric varix. RESULTS: All technical and clinical success-i.e., complete GR shunt occlusion and offending gastric varix embolization with immediate bleeding control-was achieved in all 9 patients. There was no procedure-related complication. All cases showed successful clinical outcome during mean follow up of 17 months (12-32 months), evidenced by imaging studies, endoscopy and clinical data. In 4 patients, mild worsening of esophageal varices or transient ascites was noted as portal hypertensive related change. CONCLUSION: Emergent PARTO is technically feasible and safe, with acceptable mid-term clinical results, in treating active gastric varix bleeding.

A Case of Gastric Variceal Bleeding Controlled by Percutaneous Tranhepatic Glue Embolization / 계명의대학술지

Gastric variceal bleeding has relatively low incidence rate compared to esophageal variceal bleeding. However, gastric variceal bleeding tends to lead to a massive bleeding and rebleeding which in turn leads to high mortality rate. In cases where endoscopic approach is limited, Ballon-occluded retrograde transvenous obliteration (BRTO) could be considered as a next modality of seizing acute bleeding. Venous catheterization should be preceded to perform venous embolization, however, in cases of hypovolemic shock status, alternative approaches are required. We are reporting a case of 60-year old female with hypovolemic status due to a massive hematemesis, who went through a percutaneous transhepatic glue embolization to control gastric variceal bleeding.

Cavernous Transformation of the Portal Vein with Gastric Varix / 대한내과학회지

No abstract available.

Factors determining the clinical outcome of acute variceal bleed in cirrhotic patients.

Variceal bleed is a severe complication of portal hypertension. We studied the predictors of failure to control variceal bleed and re-bleed in patients with cirrhosis. We reviewed the case records of 382 consecutive patients admitted with variceal bleed from January 2001 to December 2005. Diagnosis of cirrhosis was made on clinical, laboratory, and radiological parameters. Acute variceal bleeding, failure to control bleed, and re-bleeding were defined according to Baveno III consensus report. Failure to control bleed was observed in 39 (10.2%) patients while in hospital re-bleed occurred in 49 (12.8%) patients. Thirty-four patients died. Diabetes was present in 148 (39%) patients. On multivariate logistic regression analysis, predictors of failure to control bleed were presence of diabetes mellitus and active bleeding at the time of endoscopy; predictors of in-hospital re-bleed were diabetes mellitus and serum bilirubin >3 mg/dL. Diabetes mellitus, active bleeding at endoscopy and bilirubin >3 mg/dL are bad prognostic factors for initial control of variceal bleed, and recurrent bleed in patients with cirrhosis.

Long Term Result of Periesophagogastric Devasculorization in Gastric Fundal Variceal Bleeding

PURPOSE: Gastric variceal bleeding in cirrhotic patient is an emergent, life threatening disease of which the adequate treatment is still in dispute. The periesophagogastric devascularization (PD) would be the alternative operative procedure. The aim of this study is to evaluate the safety and long-term results of PD for the gastric fundal variceal bleeding. METHODS: A retrospective analysis was made of fifty-two patients with gastric variceal bleeding who underwent PD with or without fundectomy from August 1994 to March 2006. We evaluated the clinical characteristics, operative morbidity, mortality and long-term follow up results. RESULTS: The operative morbidity was 34.9% and overall mortality was 17.3%. The Child-Pugh classification at operation, the number of previous varix bleeding episode, the success of preoperative intervention, splenectomy, esophageal transection, and ongoing bleeding at operation had a significant effect on postoperative mortality. Most common cause of postoperative death was hepatic failure. Child-Pugh classification and esophageal transection were significant risk factor for postoperative mortality comparing before and after year 2001. During the mean follow-up period of 33.58+/-27.08 months, there was no recurrent bleeding from gastric varices. The cumulative 5-year survival rate was 64.1%. 0f 14 patients deceased, 6 patients died of hepatocellular carcinoma. Not only there was no death caused by recurrent variceal bleeding, but there was no recurrent gastric variceal bleeding. Hepatic functional reserve and concomitant hepatocellular carcinoma were the most important prognostic factors in the long term survival by multiple regression analysis. CONCLUSION: We concluded that PD reached both low postoperative mortality and recurrent bleeding rate with good long-term survival. So it could be one of the most effective treatment for the gastric fundal variceal bleeding.

Esophago-Gastric Devascularization in Portal Hypertension

PURPOSE: Bleeding from esophago-gastric varices needs urgent treatment. Esophageal varix bleeding usually was controlled by intervention, but rebleeding rate was high. Gastric varix bleeding is unable to be controlled by intervention. Recently, newly developed methods for varix bleeding controll have been used, but surgical intervention is still advocated. We report our experience with esophago-gastric devascularization for bleeding control in portal hypertension and its effectiveness. METHODS: This retrospective study was performed on 32 cases who underwent esophago-gastric devascularization in portal hypertension at Kyuung Hee University Hospital from Nov. 1990 to Feb. 2004. Author analyzed characteristics & patients, causes of portal hypertension, liver function reserve, operation methods, perioperative finding, complications and factors determining postoperative mortality. RESULTS: Sex ratios of male to female was 5.4:1. The ages were ranged from 25 to 70 years old with mean age of 50.5. Postoperative complication rate was 40.6% (13/32) and those were recovered by conservative management. There was one case of recurrent bleeding at 9months postperatively (3%). Mortality rate was 4% in Child-Pugh group A and B, and 57% in group C. The overall mortality rate was 15%. Preoperative hepatic reserve (P<0.05) & preoperative blood pressure (P<0.05) was a significant factors. A mean follow up period is 18.7 months. CONCLUSION: In our study, esophago-gastric devascularization in portal hypertension showed good results with 3% rebleeding rate and 85% overall survival rate. Esophago-gastric devascularization was effective method for esophago-gastric varix bleeding.

Results of Histoacryl-Lipiodol Sequential Injection Using Specific Gradient Difference for Bleeding Gastric Varices / 대한소화기내시경학회지

BACKGROUND/AIMS: Histoacryl forms hard substances in an instance after a brief exposure to polar liquid, blood or body temperature. This often causes obstruction of injector and endoscopic channel. Furthermore, splashed Histoacryl during injection can lead to accidental loss of vision. We propose a new convenient method of Histoacryl-lipiodol sequential injection and report the results. METHODS: From May 2001 to August 2004, sequential injector method was performed in treating consecutive thirty gastric varices patients. Histoacryl (S.G. 1.0) 1 mL and lipiodol (S.G. 1.28) 1~1.5 mL are filled in 2.5 mL disposable syringe with 16 gauge needle, which are separated into two compartments by specific gravity difference. The injector attached side of charged syringe is gently placed upward and the piston is pushed after the lesion site puncture. Then, normal saline is promptly infused to wash out and the needle is withdrawn. RESULTS: There were 26 males and 4 females. 4 had active bleeding and 26 had the stigmata of bleeding. Varices types were Lg-c in 10, Lg-cf in 16 and Lg-f in 4 patients and the Child-Pugh classification were A in 17%, B in 53% and C in 30%. The average amount was 1.53 mL. Initial hemostasis rate was 97%, 3 of patients re-bled in 4 weeks and 2 patients later. One patient died after the procedure and a case of procedure related bacteremia has occurred. CONCLUSIONS: Histoacryl-lipiodol sequential injection by specific gravity difference is convenient and safe. Also, it carries less damage to the instruments.

A case of gastric variceal bleeding associated with pancreatic endocrine tumor in the pancreas tail / 대한내과학회지

Isolated obstruction of the splenic vein leads to segmental portal hypertension, which is mainly originated from pancreatic disease, such as chronic pancreatitis, pancreatic pseudocyst, pancreatic cancer. The clinical manifestation are devoid of ascites and encephalopathy, but presented with gastric variceal bleeding. We experienced 27-year-old male patient who complained of hematochezia and melena. After work-up with CT and angiography, we performed operation with the impression of pancreatic tumor associated with splenic vein occlusion. It resulted nonfunctioning pancreatic endocrine tumor. Often called islet cell tumor, pancreatic endocrine tumor has various names according to secreted hormones, such as insulinoma, Zollinger-Ellison syndrome and glucagonoma. It was classified as nonfunctioning tumor if there were any evidence of hormone secretion by radioimmunoassay and immunohistochemistry. Surgical excision and adjuvant medical therapy is the mainstay of therapy. We performed tumor resection and splenectomy for control of gastric variceal bleeding due to splenic vein occlusion.

Perigastric Devascularization with or without Fundectomy for Gastric Variceal Bleeding

PURPOSE: Catastrophic bleeding of the gastric varices has been considered a life threatening emergency. Sclerotherapy cannot easily control the bleeding, and there is a high risk of rebleeding despite successful intervention. Surgery is often necessary to save the life. The purpose of this study was to elucidate the role of surgery and analyze the factors determining operative mortality in gastric variceal bleeding. METHODS: A retrospective study was performed of 30 patients who underwent operation for gastric variceal bleeding with portal hypertension at Ewha Womans University Mok-Dong Hospital from Jul. 1994 to Feb. 2001. Among them, 23 patients received perigastric devascularization with fundectomy and the remainder received perigastric devascularization alone. RESULTS: There was one case of recurrent bleeding from esophageal varix at 8 months postoperative. This was controlled with sclerotherapy. The overall operative mortality rate was 30.0%. Preoperative hepatic functional reserve was a significant factor. The mortality rate was 0% (0/5) in Child-Pugh group A, 27.8% (5/18) in group B, and 57.1% (4/7) in group C (p<0.05). The preoperative success of intervention influenced postoperative outcomes. There was no mortality in the successfully controlled group (0/5). In the failure group, 5 of 7 patients expired (p<0.05). Preoperative transfusion amount was also a significant factor in determining survival. There was 15.8% (3/19) mortality rate in patients trans fused less than 10 units, and a 54.5% (6/11)rate in those receiving more than 10 units (p<0.05). CONCLUSION: This operative approach was effective for saving lives from an otherwise uniformly fatal disease. The rebleeding rate at the follow-up period was low. Proper selection of patients and an early surgical decision could lower the operative mortality.

Efficacy of N-Butyl 2-Cyanoacrylate Injection Therapy for Gastric Variceal Bleeding / 대한소화기내시경학회지

BACKGROUND/AIMS: The aim of the study was to evaluate the efficacy of n-butyl 2-cyanoacrylate injection therapy for gastric variceal bleeding and to find out the factors related to clinical outcome. METHODS: Sixty-seven patients treated with n-butyl 2-cyanoacrylate injection therapy for gastric variceal bleeding were retrospectively reviewed. RESULTS: Initial hemostasis was achieved in all 12 patients. Success of therapy was achieved in 88% of the patients. A stepwise logistic regression analysis including age, sex, cause of cirrhosis, Child-Pugh class, variceal form, bleeding site, initial hemoglobin, and presence of hepatocellular carcinoma as variables indicated that only the Child-Pugh class was an independent predictive factor of treatment failure. Rebleeding occurred in 19% of the patients during the 4 weeks after therapy. The cumulative probability of 4-week remaining free of rebleeding was significantly higher in Child-Pugh A and B than in Child-Pugh C. Mortality at 4 weeks was 15%. The Child-Pugh class and the presence of hepatocellular carcinoma were the independent predictive factors of mortality at 4 weeks. CONCLUSIONS: N-butyl 2-cyanoacrylate injection therapy is highly effective in the management of bleeding from gastric varices. Child-Pugh class is an important predictive factor of treatment failure, rebleeding, and survival after the therapy.

A Case of Splenic Infarction after Histoacryl(R) Injection in Gastric Varix Bleeding / 대한소화기내시경학회지

Histoacryl(R) (n-butyl-2-cyanoacrylate) has been used successfully for the treatment of gastric variceal bleeding. The reported complications of Histoacryl(R) injection therapy include bleeding, perforation, stenosis and embolism. Here we describe a case of splenic infarction as an unusual complication of Histoacryl(R) injection. A 51-year-old male patient with liver cirrhosis was admitted due to acute gastric varix bleeding. Sclerotherapy was successfully carried out using Histoacryl(R) mixed with lipiodol (2.6 mL). 4 days later, he complained left upper quadrant pain and developed a fever of 38.2degrees C. Abdominal CT showed wedge-shaped hypodense area in the spleen compatible with infarction. He was treated conservatively. The fever and abdominal pain gradually subsided and he was discharged without significant problems.

The Comparative Study of Ligation and Histoacryl(R) Injection in Gastric Varix Bleeding / 대한소화기내시경학회지

BACKGROUND/AIMS: The variceal bleeding has high rebleeding rate, and mortality rate was higher in gastrix varix. Managements of variceal bleeding were included such as drugs, endoscopic procedures, surgical management and radiological intervention. Recently histoacryl(R) injection method has been introduced. We have compared the effects of the endoscopic ligation and Histoacryl(R) injection therapy (HAI) in patient with gastric variceal bleeding. METHODS: We analyzed the effects of hemostasis, complications, rebleeding rates, and survival rates in gastric varix bleeding of 22 patients with Histoacryl(R) injection therapy and 20 patients with endoscopic ligation therapy, from January 1995 to March 1999. RESULTS: There were no difference in the complication rate between the 2 stretigies (12/14). Most common complication was chest pain in EVL group, but fever was common in HAI group. Also early and post rebleeding rates were not different in both groups. The main cause of death during follow up period was rebleeding in both groups. The survival rates were 65.0% in EVL group and 77.0% in HAI group (p>0.05, duration: 23+/-2, 28+/-4 month), and there was no difference in mortlity rate (p=0.77). CONCLUSIONS: There were no difference in the hemostatic effect, complications, rebleeding rate and survival rate in EVL group and HAI group. However, evaluation of larger numbers of patients and prospective studies were needed to define the effectiveness and complications of these therapies.

A Case of Pulmonary Embolism Induced by Complication of Histoacryl Injection Therapy in Gastric Varix Bleeding / 대한소화기내시경학회지

N-Butyl-2-cyanoacrylate (Histoacryl) has been used successfully to control bleeding from esophagogastric varices since the first report in 1986 by Soehendra. Complications of Histoacryl injection include local sloughing with ulcer formation, rebleeding, sepsis, mediastinitis, esophageal strictures and fever. Systemic embolization, including pulmonary and cerebral embolization, has been reported. We describe here the presentation of an un-usual complication of Histoacryl injection. A 42-year-old woman presented with an attack of massive hematemesis. Endoscopy revealed bleeding evidence of gastric varices. Sclero-therapy was carried out using Histoacryl mixed with Lipiodol (ratio 1 : 1), with complete solidification of the varix. Next morning she complained of dyspnea and tachycardia. The chest x-ray showed multiple metallic densities, consistent with cyanoacrylate mixed with lipoidol, located at central portion. She was diagnosed as having pulmonary embolism by convential precontrast chest CT. She was treated conservatively using oxygen and analge-sics. She recovered soon and was discharged without significant problems.

Endoscopic Sclerotherapy in Bleeding Gastric Varices / 대한소화기내시경학회지

A study carried out to evaluate the bleeding control and prophylactic effect of rebleeding using emergency endoseopic sclerotherapy in patients with hleeding gastric varices. 42 patients with gastric variceal bleeding were admitted to the Yeungnam University Hospital from May, 1983 to August, 1992. Patients were randomly classified into control group, 20 patients treated with conservative management, and sclerotherapy group, 22 patients treated with emergency endoscopic sclerotherapy. The two group were analysed with age, sex, etiology of liver cirrhosis, nature of bleeding episode, hematocrit on admitting day, amount of sclercsants used, rebleeding episodes, complications, and mortality. There were no significant differences in the severity of underlying liver disease and hematocrit on admission between two groups. Blood transfusion were performed in 19 cases of control group and 21 cases in sclerotherapy group(p>0.05). The amounts of transfusion were 7. 7units in control group and 6.1 units in sclerotherapy group(p<0,05). Rebleeding were developed in 65% and 18% of the patiehts with control and sclerotherapy group, respectively(p<0.05). Chest pain and mild fever were observed after endoscopic sclerotherapy. These results suggest that the endoscopic sclerotherapy is effective method in hemostasis of bleeding gastric varices and short-term prevention of rebleeding, but mortality rate was not decreased compared to control group. Development of more effective methods to treat gastric variceal bleeding is required.

The Effects of Esophageal Varix Eradication on Pericardial Gastric Varix by Endoscopic Injection Sclerotherapy with Ethanolamine Oleate / 대한소화기내시경학회지

Bleeding from esophageal or gastric varix is the most critical and life-threatening complication of portal hypertension and the most common cause of deaths in the patients with cirrhosis. In the management of variceal bleeding, the various therapeutic interventions including operation and nonoperative procedure were tried, but neither of management was successfully achieved. Between February 1992 and November 1994, we performed endoscopic injection sclerotherapy(EIS) in 35 cirrhotic patients who had recently bled from esophageal varices and had a past history of esophageal variceal bleeding in Chonbuk National Univesity Hospital. Among 35 patients, 32 were male and 3 were female. The underlying severity of liver disease was graded A, B or C according to modification of Child-Pugh classification. EIS was repeated every 1 week until the esophageal varices had been complete obliterated and removed. To investigate the effects of esophageal varix eradication by EIS on combined peri- cardial varix, endoscopic examinations were performed both before procedure and after complete EIS sessions and this study was performed to examine a changes of combined pericardial varices after EIS procedure for the treatment of esophageal varices bleeding secondary to portal hypertesion. We reviewed medical records and compared changes or sizes of pericardial varices before and after EIS procedure. Mean follow up peiod was 61 days. Total number of 162 EIS for variceal eradication were performed. Mean session for eradication of esophageal varices was 4.6 per person, mean amount of injected sclerosant was 8.3cc(1-18cc), mean duration of EIS was 39 days, and mean follow up was 62 days after complete EIS procedure. In total 162 EIS procedure, complications associated with EIS including substernal discomfort 53.7%(n=87), substernal chest pain 45.7%(n=74), fever 4.9%(n=8), dysphagia 14.2%(n=23) and pleural effusion 3.1%(n=5), were transient and not required specific management. During the follow-up period, complete disapperance of pericardial varix or reduction of size was appeared in l8 cases(51.4%) among total 35 patients. No significant changes of variceal size before and after procedure were l6 cases(45.7%) and only 1 case(2.9%) was more aggravated. So, these results suggest that EIS procedure of esophageal varix on pericardial varix seems either to improve or to maintain the severity of the pericardial gastric varix without aggravation.

The Effects of Esophageal Varix Eradication on Pericardial Gastric Varix by Endoscopic Injection Sclerotherapy with Ethanolamine Oleate / 대한소화기내시경학회지

Bleeding from esophageal or gastric varix is the most critical and life-threatening complication of portal hypertension and the most common cause of deaths in the patients with cirrhosis. In the management of variceal bleeding, the various therapeutic interventions including operation and nonoperative procedure were tried, but neither of management was successfully achieved. Between February 1992 and November 1994, we performed endoscopic injection sclerotherapy(EIS) in 35 cirrhotic patients who had recently bled from esophageal varices and had a past history of esophageal variceal bleeding in Chonbuk National Univesity Hospital. Among 35 patients, 32 were male and 3 were female. The underlying severity of liver disease was graded A, B or C according to modification of Child-Pugh classification. EIS was repeated every 1 week until the esophageal varices had been complete obliterated and removed. To investigate the effects of esophageal varix eradication by EIS on combined peri- cardial varix, endoscopic examinations were performed both before procedure and after complete EIS sessions and this study was performed to examine a changes of combined pericardial varices after EIS procedure for the treatment of esophageal varices bleeding secondary to portal hypertesion. We reviewed medical records and compared changes or sizes of pericardial varices before and after EIS procedure. Mean follow up peiod was 61 days. Total number of 162 EIS for variceal eradication were performed. Mean session for eradication of esophageal varices was 4.6 per person, mean amount of injected sclerosant was 8.3cc(1-18cc), mean duration of EIS was 39 days, and mean follow up was 62 days after complete EIS procedure. In total 162 EIS procedure, complications associated with EIS including substernal discomfort 53.7%(n=87), substernal chest pain 45.7%(n=74), fever 4.9%(n=8), dysphagia 14.2%(n=23) and pleural effusion 3.1%(n=5), were transient and not required specific management. During the follow-up period, complete disapperance of pericardial varix or reduction of size was appeared in l8 cases(51.4%) among total 35 patients. No significant changes of variceal size before and after procedure were l6 cases(45.7%) and only 1 case(2.9%) was more aggravated. So, these results suggest that EIS procedure of esophageal varix on pericardial varix seems either to improve or to maintain the severity of the pericardial gastric varix without aggravation.

A Case of Portal and Splenic Vein Thrombosis Developed by Complication of Histoacryl Injection Therapy in Gastric Varix / 대한소화기내시경학회지

Liquid tissue adheisve, Histoacryl (n-butyl-2-cyanoacrylate) has been used for the treatment of gastric variceal bleeding. The techniques are as follows: 0.5cc Histoacryl mixed with Lipiodol per each injection are used. 3 to 4 injections are usually required for large variceal convolutes under the fluoroscopic visualization after the injection of Histoacryl. Complications of sclerotherapy with Histoacryl are bleeding, perforation, stenosis and embolism depending on the concentration and amount used, as well as the intensity of the treatment. Here we describe a case report developing portal and splenic vein thrombosis as a side effect after Histoacryl injection therapy for the treatment of gastric varix bleeding, A 59-year-old male patient with liver cirrhosis was admitted due to acute gastric varix bleeding. The control of gastrie variceal bleeding was achieved by several injections of 0.7c mixture of 0.5cc histoacryl and 0,8cc Lipiodol. However, simple X-ray and ultrasonography revealed the elements of Histoacryl-lipiodol mixture in the portal and splenic vein.