DOCSLIB.ORG

Review Article Review Article

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Review Article Review Article Ectopic varices in portal hypertension D. Sharma, S. P. Misra1 Department of Surgery, NSCB Government Medical College, Jabalpur, Madhya Pradesh, India; 1Department of Gastroenterology, MLN Medical College, Allahabad, Uttar Pradesh, India For correspondence: D Sharma, Department of Surgery, NSCB Government Medical College, P-10, Medical College Campus, Jabalpur, Madhya Pradesh – 482003, India. E-mail: [email protected] ABSTRACT Varices most commonly occur and bleed in the gastro-esophageal region but ectopic varices can arise at extra-gastro-esophageal locations in the gastrointestinal tract like duodenum, jejunum, ileum, colon, rectum, biliary tree and at the site of a surgical ostomy. These varices pose diagnostic as well as therapeutic challenges during endoscopic procedures. Ectopic varices can also occur outside the gastrointestinal tract, giving rise to diagnostic difficulties on imaging and unusual hemorrhage. Although ectopic varices bleed less commonly than gastro-esophageal varices, they are difficult to diagnose and problematic to treat. The absence of stigmata of recent esophageal or gastric variceal bleeding and certain clues in the patient’s history and clinical presentation should raise the clinician’s suspicion of an extra-gastro-esophageal site of variceal bleeding. Patients with extrahepatic causes of portal hypertension, Review Article Review Article Review Article Review Article Review Article cirrhotic patients with a prior history of gastrointestinal surgery and patients who present with profound bleeding but without hematemesis should in particular be evaluated further if an obvious site of gastro­ esophageal variceal bleeding is not observed at UGI endoscopy. Accurate preoperative diagnosis is often difficult in patients bleeding from ectopic varices from extra-gastro-esophageal sites, rebleeding is certain even in those patients who respond to medical treatment, and the optimal surgical decision making protocol has not yet been evolved due to the low prevalence of these ectopic varices. Nevertheless, an appreciation and awareness of these unusual causes of gastro-intestinal bleeding, allied with prompt and appropriate diagnosis can lead to successful endoscopic, radiological or surgical management of ectopic variceal bleeding. Key words: Cirrhosis, ectopic varices, gastrointestinal bleeding, portal hypertension How to cite this article: Sharma D, Misra SP. Ectopic varices in portal hypertension. Indian J Surg 2005;67:246-52. Portal hypertension and the development of DUODENAL VARICES varices in areas of portosystemic venous anas­ tomoses can lead to dramatic and life-threat- Duodenal varices occur in about 0.4% in all patients ening hemorrhage. Varices most commonly with portal hypertension and account for one third of occur and bleed in the gastro-esophageal re- bleeding episodes from ectopic varices. [1,2] Early de­ gion, but ectopic varices can arise at extra-gas- tection is important, as duodenal varices are a poten­ tro-esophageal locations in the gastrointesti- tial source of massive hemorrhage. At upper gastroin­ nal tract like the duodenum, jejunum, ileum, testinal endoscopy, an uninitiated observer may mis­ colon, rectum, and biliary tree. They can also interpret bleeding from duodenal varices as that from occur at the site of a surgical ostomy. Although duodenal ulcer. These should be considered in all pa­ ectopic varices bleed less commonly than es- tients with duodenal tumoral lesions and suspected ophageal varices, they can be far more diffi- portal hypertension. In this context, duodenal biopsy cult to diagnose and treat. can be dangerous and should be avoided. A diminu­ tion in the volume of the duodenal varices with in- Paper Received: August, 2003. Paper Accepted: October, 2005. spiratory movements may help in the differential di- Source of Support: Nil. agnosis during endoscopy.[3] FreeIndian full J Surgtext available| October from 2005 http://www.indianjsurg.com | Volume 67 | Issue 5 241 Sharma D, et al. The duodenal bulb is the most common site of duode­ munication) in adhesions. Possible physiological ori­ nal varices, the second portion of the duodenum ap­ gins of this entity were studied in Edward’s demon­ pears to be the next most common site but duodenal stration of network of fine communication between varices in the other portions are rare.[4] Hashizume the parietal surface of the viscera and the posterior et al. studied these varices angiographically and his­ abdominal wall, arising in the embryo due to the jux­ topathologically; and found that the duodenal varix taposition of the developing systemic and visceral ve­ consisted of a single vessel with afferent and efferent nous plexus.[18] Formation of collaterals, de novo, is vessels, forming a portosystemic shunt in the retro­ unlikely if the anatomy is undisturbed. In some cases peritoneum. The varix traversed the duodenum and no cause can be found. Histological examination dem­ was present in the submucosal layer of the posterior onstrates a massive varicose vein and several dilated wall; while the afferent vessel was the superior or in­ veins in the submucosa.[19] ferior pancreaticoduodenal vein originating in the por­ tal vein trunk or superior mesenteric vein, and the ef­ Although rare, bleeding from small bowel varices is ferent vein drained into the inferior vena cava.[2] They associated with a high mortality as accurate preopera­ have also been reported at the site of previous duode­ tive diagnosis is often difficult. Detection of these varic­ nal operations and the resultant adhesions and after es has been a challenging task and several invasive endoscopic sclerotherapy.[5,6] Duodenal varices are diagnostic techniques such as enteroclysis, Tc-99m more common in patients having extrahepatic portal RBC studies, venous phase of mesenteric arteriogra­ vein obstruction and in those with thrombosed porto­ phy, enteroscopy, color flow Doppler ultrasound and systemic shunts.[7,8] magnetic resonance angiography have been used for this purpose.[16,20-23] Intraoperative Sonde enteroscopy Apart from endoscopy, hypotonic duodenography, ul­ is safe and effective, providing complete visualization trasonography, computed tomography, venous phase of the small-bowel mucosa without enterotomy while of superior mesenteric angiography, and percutaneous avoiding the trauma that can be caused by push en­ transhepatic portography have been used to diagnose doscopy. It is the diagnostic assessment of choice.[24] duodenal varices.[4] Medical therapy, including vasopressin infusion via the superior mesenteric artery, is often useful in con­ Medical therapies, including vasopressin and octre­ trolling acute variceal bleeding.[25] Percutaneous tran­ otide may have limited success in controlling active shepatic embolization and transjugular intrahepatic duodenal variceal bleeding.[9] Endoscopic sclerothera­ portosystemic shunt are the therapeutic alterna­ py or endoscopic variceal ligations are the main treat­ tives.[26,27] Surgical treatment consists of lysis of adhe­ ment modalities.[10,11] Embolization and transjugular sions and bowel resection combined with portosys­ intrahepatic portosystemic shunt are the therapeutic temic shunt, under the presumption that the portal alternatives, if endoscopic sclerotherapy or variceal pressure in these patients has been partially decom­ ligation fails to control the bleeding.[12,13] pressed through these spontaneous shunts and may increase significantly after their surgical division.[28] When conservative measures cannot control the hem­ Patients with excellent hepatic reserve survive and orrhage, emergency laparotomy may be indicated. have no further gastrointestinal bleeding.[29] Duodenal varix suture ligation or resection results in a high rate of rebleeding.[14] End-to-side portacaval COLONIC VARICES shunt may be effective.[9] An arteriovenous fistula re­ quires resection of the paramural varix and surgical Colonic variceal bleeding is a rarity and is most com­ occlusion.[14] In view of the difficulty during the duo­ monly due to portal hypertension, with local mesenter­ denal mobilization and the precarious condition of ic vein obstruction constituting a rare cause. The true patient, it is not surprising that the operative mortali­ prevalence of colonic varices is not known, but Feld­ ty is high. man et al. found an incidence of 0.07% in autopsy material.[30] Esophageal varices were present in approx­ JEJUNAL AND ILEAL VARICES imately half of the group with colonic varices.[31] Bleed­ ing has been reported to occur in 2.5% of patients at­ A triad of portal hypertension (generally due to liver tending sclerotherapy sessions for esophageal varic­ cirrhosis), history of abdominal surgery, and hemato­ es.[32] In patients with portal hypertension the coro­ chezia without hematemesis characterizes small intes­ nary azygous system was the primary portosystemic tinal varices.[16] Bleeding from varices may present with channel in at least half of the cases, but in a quarter of vesical varices and gross hematuria if an intestinal seg­ cases it was the inferior mesenteric-internal iliac sys­ ment is used for an augmentation cystoplasty.[17] tem.[31] Possible etiologies of this condition may be es­ ophageal transection and devascularization and exten­ A history of abdominal surgery appears to predispose sive thrombosis of the portal vein resulting in obliter­ the development of ectopic varices (portosystemic com­ ation of the coronary-azygous anastomotic system. In 242 Indian J Surg | October 2005
Load more

Recommended publications
  • General Signs and Symptoms of Abdominal Diseases
    General signs and symptoms of abdominal diseases Dr. Förhécz Zsolt Semmelweis University 3rd Department of Internal Medicine Faculty of Medicine, 3rd Year 2018/2019 1st Semester • For descriptive purposes, the abdomen is divided by imaginary lines crossing at the umbilicus, forming the right upper, right lower, left upper, and left lower quadrants. • Another system divides the abdomen into nine sections. Terms for three of them are commonly used: epigastric, umbilical, and hypogastric, or suprapubic Common or Concerning Symptoms • Indigestion or anorexia • Nausea, vomiting, or hematemesis • Abdominal pain • Dysphagia and/or odynophagia • Change in bowel function • Constipation or diarrhea • Jaundice “How is your appetite?” • Anorexia, nausea, vomiting in many gastrointestinal disorders; and – also in pregnancy, – diabetic ketoacidosis, – adrenal insufficiency, – hypercalcemia, – uremia, – liver disease, – emotional states, – adverse drug reactions – Induced but without nausea in anorexia/ bulimia. • Anorexia is a loss or lack of appetite. • Some patients may not actually vomit but raise esophageal or gastric contents in the absence of nausea or retching, called regurgitation. – in esophageal narrowing from stricture or cancer; also with incompetent gastroesophageal sphincter • Ask about any vomitus or regurgitated material and inspect it yourself if possible!!!! – What color is it? – What does the vomitus smell like? – How much has there been? – Ask specifically if it contains any blood and try to determine how much? • Fecal odor – in small bowel obstruction – or gastrocolic fistula • Gastric juice is clear or mucoid. Small amounts of yellowish or greenish bile are common and have no special significance. • Brownish or blackish vomitus with a “coffee- grounds” appearance suggests blood altered by gastric acid.
    [Show full text]
  • Developmental Venous Anomaly: MR and Angiographic ­Features
    JBR–BTR, 2014, 97: 17-20. DEVELOPMENTAL VENOUS ANOMALY: MR AND ANGIOGRAPHIC FEATURES M. Faure1, M. Voormolen1, T. Van der Zijden1, P.M. Parizel1 Developmental venous anomaly (DVA) is probably the most common anomaly of the intracranial vasculature. DVAs consist of multiple, radially oriented dilated medullary veins that converge into a transcerebral vein. We describe the imaging findings of this vascular anomaly in different patients and the role of different imaging modalities. Key-words: Cerebral blood vessels, abnormalities – Cerebral blood vessels, MR – Cerebral angiography. Developmental venous anomaly (DVA) was first considered a rare vascular malformation (1, 2). Nowa- days, with the advent of Computed Tomography (CT) and especially Magnetic Resonance Imaging (MRI), DVAs are seen every week to month by radiologists (3, 4). Most DVAs are solitary, asymptomatic lesions and are discovered incidentally. They have a relatively benign nature with a low incidence of hemorrhage. When they do bleed, this is thought to be due to associated vascular mal- formations, like cavernous angiomas. The typical angiographic appearance of a DVA is a caput medusae appear- ance in the venous phase. MRI com- bined with MR angiography (MRA) replaces angiography in most un- A B complicated cases as a non-invasive alternative (3, 5). Case reports Case 1 A 32-year-old woman presented with headache, with no particular location and no neurological deficit. MRI of the brain was made in another hospital that showed a flow void running transcerebral, suggestive for a vascular malformation (Fig. 1A,B). Initially, there was no gadolinium contrast given and an arterial feeder could thus not be excluded with MRI.
    [Show full text]
  • Congestive Cholecystopathy; a Frequent Sonographic Sign of Evolving Esophageal Varices in Cirrhotics
    Congestive Cholecystopathy; A Frequent Sonographic Sign of Evolving Esophageal Varices in Cirrhotics KHALID REHMAN YOUSAF, MIAN SAJID NISAR*, SALMAN ATIQ, AZHAR HUSSAIN*, AMNA RIZVI*, M. ISMAIL KHALID YOUSAF, ZAHID MANSOOR. Departments of Radiology and * Medicine, Omer Hospital, Lahore, Pakistan. Correspondence to Dr. Khalid Rehman Yousaf, Radiologist, New Radiology Department, SIMS/ S.H.L. Cell 923009458404 Email: [email protected] ABSTRACT Background: Gallbladder wall congestion (congestive cholecystopathy) is frequent sonographic feature demonstrated in patients with chronic liver disease. Hypoalbuminemia is still considered as a most probable cause of gallbladder wall thickness in cirrhotics. Objective: To demonstrate and establish congestive cholecystopathy as a consistent sonographic sign of developing portal hypertension and its association with evolving esophageal varices in Child’s class B (compensated) and C (decompensated) cirrhotic patients. Methodology: This cross-sectional study was conducted in Department of Radiology in collaboration with Department of Medicine, Omer Hospital, Lahore, between September 2009 and January 2011. We included 103 randomly sampled cirrhotic patients (67 men, 36 women; age range 38-79 years) who were clinically categorized into Class B and Class C liver disease through modified Child Pugh Classification. Upper gastrointestinal video endoscopy was performed for assessment of esophageal varices in all patients according to Japanese Research Society. Gall bladder targeted transabdominal ultrasound was performed on gray scale as well as color Doppler. Gallbladder wall thickness (4mm as a reference upper normal limit), pattern of wall thickening (striated or non-striated) and flow in wall were evaluated. Results: Out of 103 patients, 57 (55.3%) cases were of Child’s B and 46 (44.7%) of Child’s C class.
    [Show full text]
  • Editorial Has the Time Come for Cyanoacrylate Injection to Become the Standard-Of-Care for Gastric Varices?
    Tropical Gastroenterology 2010;31(3):141–144 Editorial Has the time come for cyanoacrylate injection to become the standard-of-care for gastric varices? Radha K. Dhiman, Narendra Chowdhry, Yogesh K Chawla The prevalence of gastric varices varies between 5% and 33% among patients with portal Department of Hepatology, hypertension with a reported incidence of bleeding of about 25% in 2 years and with a higher Postgraduate Institute of Medical bleeding incidence for fundal varices.1 Risk factors for gastric variceal hemorrhage include the education Research (PGIMER), size of fundal varices [more with large varices (as >10 mm)], Child class (C>B>A), and endoscopic Chandigarh, India presence of variceal red spots (defined as localized reddish mucosal area or spots on the mucosal surface of a varix).2 Gastric varices bleed less commonly as compared to esophageal Correspondence: Dr. Radha K. Dhiman, varices (25% versus 64%, respectively) but they bleed more severely, require more blood E-mail: [email protected] transfusions and are associated with increased mortality.3,4 The approach to optimal treatment for gastric varices remains controversial due to a lack of large, randomized, controlled trials and no clear clinical consensus. The endoscopic treatment modalities depend to a large extent on an accurate categorization of gastric varices. This classification categorizes gastric varices on the basis of their location in the stomach and their relationship with esophageal varices.1,5 Gastroesophageal varices are associated with varices along
    [Show full text]
  • Correlation of Portal Vein Size with Esophageal Varices Severity in Patients with Cirrhosis of Liver with Portal Hypertension
    International Journal of Scientific and Research Publications, Volume 5, Issue 1, January 2015 1 ISSN 2250-3153 Correlation of Portal Vein Size with Esophageal Varices Severity in Patients with Cirrhosis of Liver with Portal Hypertension. Dr. K.V.L. Sudha Rani*, Dr. B. Sudarsi**, Dr. R. Siddeswari***, Dr. S. Manohar, **** * M.D., Asst. Prof. of Medicine ** M.D., Asst Prof. of Medicine *** M.D., Prof. of Medicine ****M.D., Prof. & HOD of Medicine. Abstract- This study was conducted to correlate the portal vein Complications of cirrhosis include portal hypertension, diameter measured by ultrasound to development of oesophageal spontaneous bacterial peritonitis, hepato renal syndrome, hepatic varices in patients with cirrhosis of liver with portal encephalopathy and hematological abnormalities. hypertension. Portal vein is formed by confluence of superior mesenteric 92 patients with cirrhosis admitted in OGH were selected for vein and splenic vein. Portal hypertension is defined as elevation the study USG was conducted in all patients to note portal vein of hepatic venous pressure gradient more than 5 mmHg. Portal size and splenic size. Upper GI endoscopy was done to detect hypertension is caused by. 1) Increased intra hepatic resistance to presence of varices with different grades. passage of blood flow through the liver due to cirrhosis and 2) In this study 65 patients had varices. Out of 65 patients 30 increased splanchnic blood flow secondary to vasodilation with had large varices (Grade III & IV) of 65 patients, 53 patients in splanchnic vascular bed. with varices have portal vein diameter > 13 mm patients, with Congestive splenomegaly is common in patients with portal small varices and those without varices portal vein diameter is < hypertension.
    [Show full text]
  • Chapter 156: Upper Gastrointestinal Bleeding
    8/23/2018 Principles and Practice of Hospital Medicine, 2e > Chapter 156: Upper Gastrointestinal Bleeding Stephen R. Rotman; John R. Saltzman INTRODUCTION Key Clinical Questions What is the timing and treatment of peptic ulcer disease? What are the factors in diagnosis and treatment of aortoenteric fistula? What treatments are available for each etiology of upper GI bleeding? What is the appropriate management and follow-up of variceal bleeding? How do you estimate the severity of bleeding so that you can triage appropriate patients to the ICU, medical floor, or observation unit? Which patients are more likely to rebleed and hence require continued observation in the hospital aer their bleeding has apparently stopped, and for how long? Upper gastrointestinal (GI) bleeding is responsible for over 300,000 hospitalizations per year in the United States. An additional 100,000 to 150,000 patients develop upper GI bleeding during hospitalizations. The annual cost of treating nonvariceal acute upper GI bleeding in the United States exceeds $7 billion. Upper GI bleeding is defined as a bleeding source in the GI tract proximal to the ligament of Treitz. The presentation varies depending on the nature and severity of bleeding and includes hematemesis, melena, hematochezia (in rapid upper GI bleeding), and anemia with heme-positive stools. Bleeding can be associated with changes in vital signs, including tachycardia and hypotension including orthostatic hypotension. Given the range of presentations, pinpointing the nature and severity of GI bleeding may be a challenging task. The natural history of nonvariceal upper GI bleeding is that 80% of patients will stop bleeding spontaneously and no further urgent intervention will be needed.
    [Show full text]
  • Banana May Be Forbidden After Endoscopic Variceal Ligation: a Case Report
    Case Report Banana may be forbidden after endoscopic variceal ligation: a case report Yingying Li1,2#, Xiaozhong Guo1#, Zhaohui Bai1,3, Xiaodong Shao1, Ran Wang1, Hongyu Li1, Xingshun Qi1 1Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China; 2Postgraduate College, Jinzhou Medical University, Jinzhou 121001, China; 3Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110840, China #These authors contributed equally to this work. Correspondence to: Dr. Xingshun Qi, MD; Prof. Hongyu Li. General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang 110840, China. Email: [email protected]; [email protected]. Abstract: Acute variceal hemorrhage (AVH) is a devastating complication of liver cirrhosis. Endoscopic variceal ligation (EVL) is a useful endoscopic treatment for AVH with few complications. However, the issue regarding management of early re-bleeding after EVL still needs to be concerned. Furthermore, the dietary principle after EVL is unclear. There is no consensus regarding what food should be eaten after EVL. In this paper, we reported a patient who ate a banana after an EVL and then developed early re-bleeding episodes. Keywords: Endoscopic variceal ligation (EVL); portal hypertension; banana; re-bleeding; dietary Received: 02 November 2018; Accepted: 27 January 2019; Published: 20 February 2019. doi: 10.21037/tgh.2019.01.11 View this article at: http://dx.doi.org/10.21037/tgh.2019.01.11 Introduction Case presentation Acute variceal hemorrhage (AVH) is a lethal consequence On May 24, 2018, a 41-year-old male was admitted to of portal hypertension in liver cirrhosis patients (1,2).
    [Show full text]
  • Overview of Esophageal and Gastric Varices
    pISSN 2287-2728 eISSN 2287-285X https://doi.org/10.3350/cmh.2020.0022 Review Clinical and Molecular Hepatology 2020;26:444-460 Managing liver cirrhotic complications: Overview of esophageal and gastric varices Cosmas Rinaldi Adithya Lesmana1,2, Monica Raharjo1, and Rino A. Gani1 1Division of Hepatobiliary, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta; 2Digestive Disease & GI Oncology Centre, Medistra Hospital, Jakarta, Indonesia Managing liver cirrhosis in clinical practice is still a challenging problem as its progression is associated with serious complications, such as variceal bleeding that may increase mortality. Portal hypertension (PH) is the main key for the development of liver cirrhosis complications. Portal pressure above 10 mmHg, termed as clinically significant portal hypertension, is associated with formation of varices; meanwhile, portal pressure above 12 mmHg is associated with variceal bleeding. Hepatic vein pressure gradient measurement and esophagogastroduodenoscopy remain the gold standard for assessing portal pressure and detecting varices. Recently, non-invasive methods have been studied for evaluation of portal pressure and varices detection in liver cirrhotic patients. Various guidelines have been published for clinicians’ guidance in the management of esophagogastric varices which aims to prevent development of varices, acute variceal bleeding, and variceal rebleeding. This writing provides a comprehensive review on development of PH and varices in liver cirrhosis patients and its management based on current international guidelines and real experience in Indonesia. (Clin Mol Hepatol 2020;26:444-460) Keywords: Liver cirrhosis; Hypertension, Portal; Esophageal and gastric varices INTRODUCTION tes, hepatic encephalopathy, coagulation dysfunction, hepatorenal syndrome, and even cardiac and pulmonary complications.
    [Show full text]
  • Esophageal Varices
    View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Crossref Hindawi Publishing Corporation Case Reports in Critical Care Volume 2016, Article ID 2370109, 4 pages http://dx.doi.org/10.1155/2016/2370109 Case Report A Rare but Reversible Cause of Hematemesis: (Downhill) Esophageal Varices Lam-Phuong Nguyen,1,2,3 Narin Sriratanaviriyakul,1,2,3 and Christian Sandrock1,2,3 1 Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, Davis, Suite #3400, 4150 V Street, Sacramento, CA 95817, USA 2Department of Internal Medicine, University of California, Davis, Sacramento, USA 3VA Northern California Health Care System, Mather, USA Correspondence should be addressed to Lam-Phuong Nguyen; [email protected] Received 12 December 2015; Accepted 1 February 2016 Academic Editor: Kurt Lenz Copyright © 2016 Lam-Phuong Nguyen et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. “Downhill” varices are a rare cause of acute upper gastrointestinal bleeding and are generally due to obstruction of the superior vena cava (SVC). Often these cases of “downhill” varices are missed diagnoses as portal hypertension but fail to improve with medical treatment to reduce portal pressure. We report a similar case where recurrent variceal bleeding was initially diagnosed as portal hypertension but later found to have SVC thrombosis presenting with recurrent hematemesis. A 39-year-old female with history of end-stage renal disease presented with recurrent hematemesis. Esophagogastroduodenoscopy (EGD) revealed multiple varices.
    [Show full text]
  • Venous Angiomas of the Brain A
    - REVIEW ARTICLE systems," Venous angiomas may be Venous angiomas of quite small, draining a limited region of the brain, or may be very large, the brain a sometimes draining an entire hemi- • sphere. They can be single or multi- ple, and even bilateral.P" The com- review monest sites of occurrence are in the frontal and parietal lobes of the cere- venous anomaly' or DVA, pointing bral hemispheres and in the cerebel- Ian C Duncan out that these abnormalities actual- Ium.':" They can also be found in the ly represented an extreme anatomi- FFRad(D)SA occipital and temporal lobes, basal cal variant of the normal venous ganglia and pons." Unitas Interventional Unit POBox 14031 drainage of the brain. Lytlelton Imaging 0140 Pathology The classical radiographic appear- The theory of the development of ance of these abnormalities accurately venous angiomas is that there is fail- reflects the anatomical picture with Introduction ure of regression of normal embryon- multiple enlarged transmedullary Venous angiomas of the brain, also ic transmedullary venous channels. veins radiating in a wedge or radial termed venous malformations or These persistent transmedullary veins pattern toward the larger collecting developmental venous anomalies run axially through the white matter vein producing the pathognomic (DVA) are commonest of the to drain into a single larger calibre col- 'caput medusae' or 'spoke wheel' intracranial vascular malformations lecting venous trunk. The dilated ter- appearance during the venous phase comprising between 50% and 63% of minal collecting vein then penetrates of a cerebral angiogram (Figs 1,2).14,15 all intracranial vascular malforma- the cortex to drain either superficially A similar appearance is often seen on tions.
    [Show full text]
  • Diagnosis and Management of Ectopic Varices
    Gastrointest Interv 2012; 1:3–10 Contents lists available at SciVerse ScienceDirect Gastrointestinal Intervention journal homepage: www.gi-intervention.org Review Article Diagnosis and management of ectopic varices Nabeel M. Akhter, Ziv J. Haskal* abstract Ectopic varices are large portosystemic collaterals in locations other than the gastroesophageal region. They account for up to 5% of all variceal bleeding; however, hemorrhage can be massive with mortality reaching up to 40%. Given their sporadic nature, literature is limited to case reports, small case series and reviews, without guidelines on management. As the source of bleeding can be obscure, the physician managing such a patient needs to establish diagnosis early. Multislice computed tomography with contrast and reformatted images is a rapid and validated modality in establishing diagnosis. Further management is dictated by location, underlying cause of ectopic varices and available expertise. Therapeutic options may include double balloon enteroscopy, transcatheter embolization or sclerotherapy, with or without portosystemic decompression, i.e., transjugular intrahepatic portosystemic shunts. In this article we review the prevalence, etiopathogenesis, anatomy, presentation, and diagnosis of ectopic varices with emphasis on recent advances in management. Copyright Ó 2012, Society of Gastrointestinal Intervention. Published by Elsevier. All rights reserved. Keywords: Balloon-occluded retrograde transvenous obliteration, Ectopic varices, Portal hypertension, Percutaneous embolization,
    [Show full text]
  • Insights Into the Management of Anorectal Disease in the Coronavirus 2019 Disease Era
    University of Massachusetts Medical School eScholarship@UMMS COVID-19 Publications by UMMS Authors 2021-07-09 Insights into the management of anorectal disease in the coronavirus 2019 disease era Waseem Amjad Albany Medical Center Et al. Let us know how access to this document benefits ou.y Follow this and additional works at: https://escholarship.umassmed.edu/covid19 Part of the Digestive System Diseases Commons, Gastroenterology Commons, Infectious Disease Commons, Telemedicine Commons, and the Virus Diseases Commons Repository Citation Amjad W, Haider R, Malik A, Qureshi W. (2021). Insights into the management of anorectal disease in the coronavirus 2019 disease era. COVID-19 Publications by UMMS Authors. https://doi.org/10.1177/ 17562848211028117. Retrieved from https://escholarship.umassmed.edu/covid19/285 Creative Commons License This work is licensed under a Creative Commons Attribution-Noncommercial 4.0 License This material is brought to you by eScholarship@UMMS. It has been accepted for inclusion in COVID-19 Publications by UMMS Authors by an authorized administrator of eScholarship@UMMS. For more information, please contact [email protected]. TAG0010.1177/17562848211028117Therapeutic Advances in GastroenterologyW Amjad, R Haider 1028117research-article20212021 Advances and Future Perspectives in Colorectal Cancer Special Collection Therapeutic Advances in Gastroenterology Review Ther Adv Gastroenterol Insights into the management of anorectal 2021, Vol. 14: 1–13 https://doi.org/10.1177/17562848211028117DOI: 10.1177/ disease in the coronavirus 2019 disease era https://doi.org/10.1177/1756284821102811717562848211028117 © The Author(s), 2021. Article reuse guidelines: Waseem Amjad, Rabbia Haider, Adnan Malik and Waqas T. Qureshi sagepub.com/journals- permissions Abstract: Coronavirus 2019 disease (COVID-19) has created major impacts on public health.
    [Show full text]