Study of endoscopic aspects and therapeutic options of ectopic gastrointestinal varices

Ectopic varices are best defined as large porto-systemic venous collaterals occurring anywhere in the abdomen except in the cardio-esophageal region. The aim of this work was to study the pattern of presentation and options of management of eighteen cases with ectopic varices in portal hypertensive patients. Eighteen patients with portal hypertension secondary to liver cirrhosis of different etiologies and ectopic gastrointestinal varices were studied. Gastrointestinal endoscopy was done for all patients and the exact location of ectopic varices was reported. Bleeding ectopic varices were managed endoscopically either by injection sclerotherapy or endoloop ligation according to the situation. Surgical treatment was tried only after failure of endoscopic management. Ten patients presented with gastrointestinal bleeding, while in the other eight patients varices were asymptomatic. Ectopic varices were located in the gastric antrum in two patients, in the duodenal bulb in three, in the descending duodenum in four, in the anorectal region in seven, and at the site of a percutaneous enterostomy [stomal varices] in two patients. Non-bleeding ectopic varices were managed conservatively. Management of bleeding ectopic varices included endoscopic injection sclerotherapy in four, endoscopic endoloop ligation in two, and surgical ligation of the bleeding varix after failure of endoscopic treatment in two patients. Local injection of a natural tissue adhesive was successful to control bleeding in the two patients with stomal variceal bleeding. An excellent outcome was observed in all patients without any reported morbidity or mortality. Bleeding did not recur in any of the patients studied during a follow up period of one year. Ectopic varices should be expected in patients with portal hypertension especially at the sites of previous surgery. Treatment is applied to bleeding varices, while non-bleeding ectopic varices would conservatively be followed-up

Cystobiliary fistula in hepatic hydatid disease: diagnostic and therapeutic challenge

In Hydatid disease of the liver cystobiliary fisula [CBF] constitutes an anatomic and a clinicopdthologic entity characterized by the occurrence of a life-threatening cholangitis with increased morbidity and the prolongation of hospital stay. An accurate preoperative diagnosis of this complication is essential for its prompt surgical management. The diagnosis of hydatid disease and the existence of CBF is based primarily on both of the clinical presentation and the characteristic appearance on ultrasonographic [US] and/or computed tomographic [CT] imaging, and confirmed by endoscopic retrograde cholangiography [ERC]. The aim of this work was to study the different diagnostic and therapeutic aspects of cystobiliary fistula in hydatid disease of the liver. From 1996 to 2003, among 63 patients treated for hydatid cysts of the liver, 17 with complicated cysts were included in the current study. They were 11 males and 6 females with a mean age of 34.5 years [ranged from 12 to72 yrs]. According to the clinical presentation, they were divided into 3 groups; group A: nine patients presented with cholangitis, group B: five patients had history of jaundice and group C: three patients presented with jaundice. In 14 patients [groups A and B], the diagnosis of CBF was suspected by abdominal US and/or CT imaging and confirmed by ERC. In the remaining 3 patients [group C], CBF was not documented and they were excluded. Preoperative endoscopic sphencterotomy ES was done in group A with retrieval of hydatid daughter cysts. Among the patients of group A, Seven patients [subgroup Al] were subsequently submitted to surgery entailing endocystectomy in 5 and hepatic resection in two. The remaining 2 patients in group A [subgroup A2] were managed by endoscopic therapy only. Patients of group B [n = 5], were not submitted to preoperative ES and were subsequently managed by hepatic resection in one patient and endocystectomy in four. There was no mortality in the studied group. Postoperative bile leak occurred in four cases; one after hepatic resection and three after endocsytectomy in group B for whom preoperative endoscopic sphincterotmy [ES] was not done. In contrast, none of the patients who were submitted to preoperative ES [subgroup Al] had bile leak. Postoperative wound infection was reported in three patients and minimal subphrenic collection that was aspirated under US guidance was in two. A chest complication in the form of atelecatasis was recorded in one patient. The mean hospital stay was 12.4 days. All patients received albendazole treatment. Surgery still remains the treatment of choice for hydatid cysts of the liver complicated with cystobiliary fistula [CBF]. The results of this work highlight the validity of diagnostic ERC in confirming the diagnosis of CBF in suspected patients with complicated hydatid cysts of the liver. Also, therapeutic ERC has a place in the treatment algorithm of CBF as it was found to be a safe and a reliable therapeutic alternative especially in high risk patients for surgery

Rare gastric tumors: clinical presentations, endoscopic aspects and management challenges

Many challenges will be present on dealing with rare gastric tumors there. The aim of the present work was to study the clinical presentations, endoscopic aspects of some of the uncommon gastric tumors and the different lines of management of such cases. Ten patients, five males and five females, presented with rare gastric tumors were included in the study. Their age ranged between 42 and 73 years. The main presentations were; epigastric pain, vomiting associated with a sizable epigastric and right hypochondrial mass in one patient, upper gastro intestinal tract bleeding in four patients, vague epigastric pain and dyspeptic manifestation not responding to medication in two patients, non specific symptoms [abdominal pain and dyspepsia] which were modified by a known primary malignant disease and the effects of its treatment were the presentation in three patients. Esophago-gastro-duodenoscopy was done for all patients; [the number, site and appearance of the lesions were described], this was repeated twice for the first patient [one year interval] with evidence of GERD grade I and extrinsic antral compression with no definite masses or ulcers, no biopsy was taken. Endoscopic biopsy could not be taken in two patients, inconclusive in two [CT guided core liver biopsy settled the diagnosis in one patient with multiple liver secondaries while surgical resection specimen was the only option in the other three patients] and conclusive in five. Metastatic Gastric Tumors [MGT] were found in three patients, mesenchymal tumors in three, hepatoid adenocarcionoma, gastric carcinoid, and high grade MALT lymphoma one patient each and synchronous tumors in one patient [lower oesophageal adenocarcinoma and antral mesenchymal tumor]. The primary tumor was cutaneous malignant melanoma, breast adenocarcinoma, and pancreatic adenocarcinoma in the three patients with metastatic gastric tumors. Six patients were treated surgically; two by chemotherapy, one by percutaneous biliary drainage followed by chemo-radiotherapy, and one patient received supportive medication. Four patients are still alive during a follow up period of 12 - 32 months, while six patients died within 9 to 28 weeks from the time of diagnosis. The diagnosis of MGTs is often difficult as gastric involvement is usually masked by manifestations of the original tumor. A negative endoscopic biopsy in mesenchymal tumors with intact overlying gastric mucosa is always a diagnostic challenge. Poor response of most gastric tumors to chemo-radiotherapy makes surgery the main line of treatment

Bile duct injury during cholecystectomy diagnostic and surgical aspects

Bile duct injury following cholecystectomy is an uncommon but challenging clinical condition. The aim of this work was to analyze clinical presentations, evaluate different diagnostic procedures and to assess the outcome of surgery. During the period from January 2001 till the end of May 2003, 28 patients with a post cholecystectomy bile duct injury [presented either early 21 patients or late 7 patients] were included in the study. They were 21 females and seven males. Their age ranged between 29 and 66 years. All patients were evaluated clinically and biochemically. To assess the site and extent of injury ultrasonography, direct cholangiography and / or MRCP were done for all patients. Computed tomography was done when needed. In this work, complete bile duct ligation with early onset of progressive jaundice represented the majority of patients who presented early [47.6%]. When the ligation or clipping was distal to the cystic duct insertion a biliary fistula also developed [4.8%]. Injury with subsequent bile leakage [fistula, biloma or diffuse peritonitis] and later stricture formations were the other presentation in this group [47.6%]. Jaundice and cholangitis were the main presentation in patient who presented late. The majority of patients were jaundiced [92.8%] with elevated serum alkaline phosphatase in all of them. Ultrasonography had a 100% success rate to detect; IHBD, localized collection and free intra-peritoneal bile. The success rate to localize the site of the injury was 64.3%, it also evaluated accurately the liver parenchymal pathology. MRCP was the key stone in the diagnosis of the site and the extent of the bile duct injury with a 100% success rate in visualization of the biliary tree below and above the stricture. ERCP failed to opacify the bile ducts proximal to the stricture in 48% of the patients. In this group, low stricture [Bismuth type I and II] was the common finding [84%]. Bilio-enteric anastomosis without preoperative stenting of the bile ducts was done safely for all patients [except one where the procedure could not be completed] with excellent and good results in 82% of our patients

Urgent endoscopic sphincterotomy in acute biliary pancreatitis, an alternative to surgery

Thirty-two patients presenting with acute biliary pancreatitis were included, 20 presented early while 12 presented late after 72 hours from onset. Patients were classified using Atlanta and Ranson scoring into mild [20 patients], and 12 patients]. ERCP and urgent endoscopic sphincterotomy were done within 8 hours from admission, while patients were on supportive treatment and high dose of octreotide infusion. Sizable stones were found in 10, biliary gravel in 10, sludge in 4, inflamed papilla only in 5, fasciola fluke in 2 and an ascaris while those presented early showed complete recovery indicating the success of urgent endoscopic sphincterotomy in halting the progression of pancreatitis