Successful endoscopic hemostasis for ruptured duodenal varices after balloon-occluded retrograde transvenous obliteration.

A 75-year-old man with general malaise and appetite loss was transferred to our hospital for assessment and treatment of liver failure. Laboratory findings on admission showed anemia, and gastroduodenoscopy (GDS) revealed linear esophageal varices and tensive duodenal varices (DV) in the second portion of the duodenum. Systemic examinations did not reveal any significant lesion capable of explaining his anemia, except for DV. Balloon-occluded retrograde transvenous obliteration was carried out to prevent DV bleeding. Good pooling of sclerosant was observed using two balloon catheters. However, contrast-enhanced computed tomography after the procedure revealed no thrombosis in DV, and the patient complained of tarry stools before additional therapy. Emergent GDS revealed ruptured DV with fresh blood and erosions on the surface. Emergent endoscopic obliteration using the tissue adhesive N-butyl-2-cyanoacrylate was carried out and complete hemostasis was achieved. Although no rebleeding episodes were observed after emergent obliteration, the patient died of sepsis following spontaneous bacterial peritonitis 53 days after admission. Autopsy revealed that DV dropped out, and the deep vein was replaced by granulation tissue. No signs of thrombi were detected, except varices. This autopsy case revealed the difficulty in DV management.

MELD score, child-pugh score, and decreased albumin as risk factors for gastric variceal bleeding.

BACKGROUND/AIMS: Ruptured esophagogastric varices are commonly associated with bleeding in patients with portal hypertension. However, the prediction of esophageal variceal bleeding is not matched by means of predicting gastric variceal bleeding. The present study aim is to elucidate risk factors for gastric variceal bleeding. METHODOLOGY: Twelve patients with gastric variceal bleeding and 18 patients receiving preventive treatment for gastric varices were included in the study. RESULTS: The Child-Pugh (8.0 +/- 0.9 vs. 5.5 +/- 0.3; p = 0.0025) and Model for end-stage liver disease (MELD) (10.6 +/- 2.7 vs. 4.0 +/- 0.9; p = 0.0095) scores were significantly higher for patients with bleeding than for those receiving preventive treatment. Serum albumin concentration was significantly lower in bleeding than in preventive treatment cases, as determined by univariate (2.9 +/- 0.2 vs. 3.7 +/- 0.1 mg/dL; p < 0.0001) and multivariate analyses of serological data (odds ratio, 0.02, 95% confidence interval, 0.001-0.479; p = 0.0144). CONCLUSIONS: The Child-Pugh and MELD scores were significantly higher for patients with gastric variceal bleeding than for those receiving preventive treatment, and multivariate analysis revealed that serum albumin was significantly lower in patients with gastric variceal bleeding. Control of serum albumin is important in preventing gastric variceal bleeding.

[Case of severely disabled child with refractive respiratory infection due to gastroesophageal reflux successfully controlled by using a button-shaped double lumen transgastric jejunal feeding tube].

A 12-year-old severely disabled woman child had been suffering from the refractive respiratory infection due to gastroesophageal reflux (GER) in years. However two transnasal catheters inserted to control GER, one was for feeding to the jejunum and the other was for decompression of the stomach, they were not effective against respiratory infection. Then, to resolve the problems, a button-shaped double lumen transgastric jejunal catheter was inserted into her jejunum via PEG in two-stage. After the procedure, the refractive respiratory infection due to GER could be successfully controlled. Additionally, by using the button-shaped catheter, any position came to be acceptable in daily life, for example in rehabilitation, sleeping and so on. Her ADL (activity of daily life) was well preserved.

[A case of hepatic encephalopathy successfully treated by antegrade glycerin enema through percutaneous endoscopic cecostomy].

A 76-year-old man with liver cirrhosis, a chronic defecation disorder and a refractory hepatic encephalopathy was hospitalized for the hepatic encephalopathy. The encephalopathy quickly improved upon treatment, but a high level of serum ammonia persisted. We inserted a percutaneous endoscopic cecostomy at the cecum and an antegrade glycerin enema through it to treat the chronic defecation disorder, which was a deteriorative factor of the hepatic encephalopathy. After the aforementioned procedure, the chronic defecation disorder improved and the serum ammonia level dramatically decreased. The patient continued the antegrade glycerin enema at home, and serum ammonia values remained low in comparison to levels measured prior to the administration of treatment. The subject has not experienced a recurrence of hepatic encephalopathy.

[A case of secondary gastric wall abscess due to perforation from advanced colonic cancer successfully treated by endoscopic endoprostesis using endoscopic retrograde biliary drainage tube].

A 44 year-old man was admitted to our hospital because of severe left upper abdominal pain and high fever. Blood examinations revealed high levels of white blood cell count and CRP. An abdominal enhanced CT scan showed a low-density mass with an enhanced margin at the posterior side of the gastric body, and an irregular mass nearby at the transverse colon. We diagnosed a gastric wall abscess due to perforation from advanced colonic cancer and performed endoscopic drainage and endoprostesis by ERBD tube insertion into the abscess through the gastric wall. After the procedure, the clinical symptoms and laboratory data improved quickly, and we could continue further examinations and proceed safety with the treatment plan. To our knowledge, this is the first reported case of a gastric wall abscess due to penetration by gastrointestinal tract cancer which was treated with endoscopic endoprostesis.

Small bowel non-Hodgkin's lymphoma remaining in complete remission by surgical resection and adjuvant rituximab therapy.

A 44-year-old man was referred to our hospital with intermittent abdominal pain. Because distention of fluid- and gas-filled loops of small intestine was proved by X-ray, the patient was diagnosed as having small bowel obstruction. A laparotomy revealed a segmental stenosis in the jejunum, which showed diffuse thickening of the intestinal wall. Some mesenteric lymph nodes were swollen. Pathological examination was defined. We diagnosed diffuse large B-cell lymphoma based on the pathological findings of diffuse transmural infiltration of large lymphoid cells and flow-cytometric analyses. Rituximab was administered as adjuvant therapy at weekly doses of 375 mg/m2. Four cycles were performed every 6 mo and he remained CR. Rituximab may be effective as adjuvant therapy.