Ectopic varices in portal

D. Sharma, S. P. Misra1 Department of Surgery, NSCB Government Medical College, Jabalpur, Madhya Pradesh, India; 1Department of , 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 like , , , colon, , 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-, they are difficult to diagnose and problematic to treat. The absence of stigmata of recent esophageal or gastric variceal 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 , 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 should in particular be evaluated further if an obvious site of gastro­ esophageal variceal bleeding is not observed at UGI . 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: , 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 . 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 and several dilated wall; while the afferent vessel was the superior or in­ 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 .[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 infusion via the superior mesenteric , 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 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 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 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 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 | Volume 67 | Issue 5 Portal hypertension and ectopic varices such a situation, other potential sites of porto-system­ venous system in patients with portal hypertension. ic anastomoses, such as that in the colon, may open, Bleeding from them is uncommon, and often mild and leading to development of colonic varices.[33] Idiopath­ self-limiting, but rarely it can be fatal. It is equally ic/primary, familial, secondary to splenic vein throm­ important to be aware of the presence of rectal varices bosis and -related colonic varices without in case rectal biopsy is needed in patients with portal portal hypertension have also been reported. hypertension.

Varices of the colon are usually segmental, involving The reported incidence of rectal varices ranges from predominantly (66%) the distribution of inferior me­ 40 to 89.3%.[39-45] No correlation has been found be­ senteric vein and less frequently (26%) the distribu­ tween the presence of and the Child’s tion of superior mesenteric area, and never confined grade of cirrhosis, intrahepatic V/s extrahepatic caus­ to transverse colon.[31] Diffuse variceal involvement of es of portal venous obstruction, the grade of esopha­ the colon is uncommon and implies an unknown geal varices, the presence of , portal hy­ cause. pertensive gastropathy, or whether or not patients re­ ceived sclerotherapy.[39,40,43-45] In case of colonic varices the differential diagnosis should include portal hypertension with chronic liver Identifying the source of lower gastrointestinal hem­ disease, , vascular anomalies or orrhage in patients with chronic and por­ postoperative complications. If this entity is not con­ tal hypertension can be challenging but the differen­ sidered, a rectal or colonic biopsy may lead to brisk tial diagnosis between and anorectal and dangerous bleeding. Apparent similarity of radio­ varices has been elucidated in many studies.[40,46] It has logical and endoscopic appearance of varices to pol­ also been documented that the prevalence of hemor­ yps, misdiagnosis and inappropriate biopsy remain the rhoids is not increased in patients with portal hyper­ potential pitfalls. Colonoscopist visualizes these varic­ tension and their presence is unrelated to the degree es as serpiginious to nodular, often bluish submucous of portal hypertension.[40,44] A careful examination is lesions. They are often missed on colonoscopy due to essential to prevent misdiagnosis and inappropriate collapse of varices during periods of or and inadvertent treatment like surgical excision of because of increase in the intraluminal pressure due varices in mistake for hemorrhoids, with disastrous to air insufflation during the endoscopic examina­ results.[40] Anorectoscopy is the initial investigation of tion.[31,34] Sensitivity of colonoscopy is greatly reduced choice. Rectal endoscopic ultrasonography, transvagi­ during periods of active bleeding and in the absence nal sonography and magnetic resonance imaging are of good bowel preparation. useful in detecting the presence and number of rectal varices.[47-49] In cases where the cause of lower GI bleeding is not clear, even after colonoscopy; venous phase of me­ The principal emergency treatment is endoscopic scle­ senteric angiogram and scintigraphic studies may be rotherapy or endoscopic ligation, failing which surgi­ useful.[31,35] If doubt persists, intraoperative colonos­ cal ligation should be performed.[50-52] Before the ad­ copy may be useful to pinpoint the problem.[36] Con­ vent of transjugular intrahepatic portosystemic shunt servative therapy consists of vasopressin and somato­ (current choice of treatment), a portosystemic shunt, statin analogue, which may be useful in the control of preferably between the inferior mesenteric vein and bleeding.[37] Sclerotherapy using a colonoscope and the vena cava or renal vein, was the treatment of transjugular intrahepatic portosystemic shunt are other choice.[53] Transjugular embolization of the inferior therapeutic alternatives.[38] mesenteric vein is an alternative to TIPS, where TIPS is not feasible.[54,55] The choice of surgical therapy in portal hypertension is portal decompression and not colonic resection; as STOMAL VARICES colectomy is associated with significantly greater mor­ tality due to risk of infection and considerable techni­ Variceal bleeding from enterostomy is an unusual com­ cal difficulty of this surgery in the presence of portal plication of portal hypertension and represents a cause hypertension.[31,34] of recurrent or intractable gastrointestinal bleeding. Presence of /varices developing around ANORECTAL VARICES a stoma may herald the presence of mild to moderate portal hypertension before other signs of hepatic de­ Anorectal varices are a rare cause of rectal bleeding compensation are evident. Once variceal communica­ and are often erroneously diagnosed as bleeding hem­ tions have been formed between the portal venous orrhoids. Although rare, rectum is the most common system of the gut and subcutaneous systemic circula­ site of lower gastrointestinal varices.[39] Rectal varices tion, heavy bleeding from dilated venous plexus may occur due to high pressure in the inferior mesenteric occur spontaneously or from microtrauma. In a review,

Indian J Surg | October 2005 | Volume 67 | Issue 5 243 Sharma D, et al. the average interval found was 48 months for ileosto­ attention should be paid to stoma care and the pre­ mies, 38 months for ileal conduits and 23 months for vention of trauma from appliances. patients with a colostomy.[56] BILIARY VARICES Proper diagnosis requires careful inspection of the muco-cutaneous region of the stoma for venous bleed­ Gallbladder varices are often seen in portal hyperten­ ing sites and endoscopy examination of the stoma to sion, more often in extra hepatic portal vein obstruc­ rule out the presence of recurrent bowel disease or tion patients.[62,63] Gallbladder varices do not correlate other lesions like arteriovenous malformations, polyp with size of esophageal varices, number of sessions of or Crohn’s disease.[57] sclerotherapy, presence or absence of gastric varices, portal gastropathy, Child Pugh grade or splenorenal The emergent treatment of bleeding of the colostomy shunt placement.[63] These collaterals cause some gall­ must combine several methods, quite often consecu­ bladder stasis but do not impede gallbladder function tively: local compression, ligation, and sclerotherapy.[58] and hence seem unlikely to contribute to for­ Palliative local measures, like suture ligature or scle­ mation.[62] Their clinical significance is their propen­ rotherapy, however, remain the treatment of choice in sity to bleed during biliary surgery; thus, the operat­ the high-risk, cirrhotic patient who is unlikely to sur­ ing surgeon should be aware of them. The color flow vive a major operation and may increase the interval Doppler is the gold standard procedure for the diag­ between bleeding episodes and decrease the severity nosis, although angiography, computerized tomogra­ of bleeding.[57,59] The hemorrhage can be managed tem­ phy and magnetic resonance have also been report­ porarily in most patients with local measures. Once ed.[64] bleeding is controlled, the treatment must be primari­ ly medical (hygienic and dietary habits, b-adrenergic varices are seen more frequently in left he­ blocking agents), but complementary surgery is invar­ patic duct, possibly due to the joining of iably necessary because of recurrence of bleeding. to the left branch of portal vein adjacent to the left hepatic vein.[65] The resultant filling defect in the ERCP There is no consensus on which of the various surgi­ has to be differentiated from sclerosing cholangitis and cal options is best, but by and large, the type of further malignancy.[65,66] Due to their propensity to bleed, bal­ surgical treatment is determined by the severity of the loon dilatation is probably best avoided in these pa­ underlying liver disease and the patient’s life expect­ tients and placement of pigtail biliary endoprostheses ancy.[56] Mucocutaneous disconnection (MCD) is sim­ is preferred over straight stents with side flaps.[67] Usu­ ple, quick, repeatable and associated with a lower ally biliary varices are found incidentally during im­ morbidity and intraoperative blood loss than stomal aging, but their presence calls for a search for portal relocation. In the select group of patients that cannot vein thrombosis. Rarely they can give rise to obstruc­ be managed conservatively, MCD is favored and relo­ tive jaundice or . cation considered only if MCD is technically impossi­ ble i.e. improperly placed stoma, symptomatic peris­ INTRAPERITONEAL HEMORRHAGE FROM tomal and those with poor appliance fit.[60] It ECTOPIC VARICES should be kept in mind that repeated use of local op­ erative procedures leads to the formation of scar tis­ Intraperitoneal hemorrhage from ectopic varices is a sue and causes problems in the care of the stoma. Al­ rare occurrence. In cirrhotic patients, sudden onset of though stomal manipulation is the most commonly abdominal pain in combination with hypotension and performed procedure, portosystemic shunting has the falling hematocrit in the absence of external blood loss lowest incidence of both rebleeding and need for ad­ should result in ultrasonography of the abdomen. The ditional procedures and provides the longest mean main differential diagnosis is acute . Any postoperative survival and is the choice in patients who free fluid present should be aspirated and when blood are good surgical candidates.[56] In particular, the ab­ is encountered the patient must be operated upon sence of postoperative encephalopathy in the ileosto­ immediately.[68] Spontaneous hemorrhage from anteri­ my group may be attributed to the absence of colon, or abdominal wall varices has also been documented the major source of bacteria generated nitrogenous into the rectus abdominus muscle and peritoneal cav­ products. Transjugular intrahepatic portosystemic ity.[69] Exploratory laparotomy and suture ligation of shunt and stomal varices embolization are effective the bleeding varix seems to give the greatest likelihood alternatives in case of recurrent bleeding of stomal of survival. Angiography with special attention to the varices.[61] venous phase may demonstrate the varices, in addi­ tion, vasopressin infusion in the superior mesenteric The overall prognosis mainly depends on the function artery can be tried, which may permit stabilizing the of the liver, the deterioration of which is accelerated patient before surgery.[70] Patient’s remaining liver func­ by the successive hemorrhagic accidents. Particular tion and the ability to withstand surgery determine

244 Indian J Surg | October 2005 | Volume 67 | Issue 5 Portal hypertension and ectopic varices the ultimate prognosis. 7. Itzac Y, Glickman MG. Duodenal varices in extrahepatic portal obstruction. Radiology 1977;124:619-24. 8. Saurbrunch T, Wienzierl M, Dietrich HP, Antes G, Eisenburg CUTANEOUS VARICEAL BLEEDING J, Baumgarter G. Sclerotherapy for a bleeding varix. Endoscopy 1982;14: 187-9. In portal hypertension, three types of cutaneous por­ 9. Khouqeer F, Morrow C, Jordan P. Duodenal varices as a cause tosystemic collaterals may develop the ‘classical’ Caput of massive upper gastrointestinal bleeding. Surgery Medusae, enterostomal varices and scar or adhesion­ 1987;102:548-52. [71] 10. Barbish AW, Ehrinpreis MN. Successful endoscopic injection related abdominal collaterals. Very few cases have sclerotherapy of a bleeding duodenal varix. Am J Gastroenterol been documented of a varicose umbilical vein with 1993;88:90-2. external hemorrhage significant enough to cause he­ 11. Shiraishi M, Hiroyasu S, Higa T, Oshiro S, Muto Y. Successful modynamic instability.[72,73] and hemor­ management of ruptured duodenal varices by means of rhagic , ending in a fatality may complicate the endoscopic variceal ligation:report of a case. Gastrointest [72] Endosc 1999;49:255-7. clinical course. Local measures (direct pressure, 12. Haruta I, Isobe Y, Ueno E, Toda J, Mitsunaga A, Noguchi S, et suture ligation and sclerotherapy) and medical thera­ al. Balloon-occluded retrograde transvenous obliteration py should be applied early in the resuscitation of the (BRTO), a promising nonsurgical therapy for ectopic varices:a patient. Once stable, definitive treatment has to be in­ case report of successful treatment of duodenal varices by stituted otherwise rebleeding is a certainty. Transjug­ BRTO. Am J Gastroenterol 1996;91:2594-7. 13. Jonnalagadda SS, Quiason S, Smith OJ. Successful therapy of ular intrahepatic portosystemic shunt, umbilical vein bleeding duodenal varices by TIPS after failure of embolization and mesocaval shunt surgery have all sclerotherapy. Am J Gastroenterol 1998;93:272-4. shown good results, with stoppage of bleeding and 14. Richardson JD, McInnis WD, Pestana C. Duodenal varices. Am disappearance of cutaneous varices.[72,74,75] Surg 1976;42:201-3. 15. Baranda J, Pontes JM, Portela F, Silveira L, Amaro P, Ministro P, et al. Mesenteric causing portal MISCELLANEOUS hypertension and bleeding duodenal varices. Eur J Gastroenterol Hepatol 1996;8:1223-5. Upper esophageal varices occur infrequently and may 16. Cappell MS, Price JB. Characterization of the syndrome of small rarely cause massive upper gastrointestinal hemor­ and large intestinal variceal bleeding. Dig Dis Sci 1987;32:422­ rhage.[76] This case serves to stress the importance of a 7. 17. Sano K, Shuin T, Takebayashi S, Sugawara T, Moriyama M, through examination of the cervical portion of the es­ Kinoshita Y, et al. A case of vesical varices as a ophagus during routine endoscopy. Varices of the gas­ of portal hypertension and manifested gross hematuria. J Urol tric antrum are seen in a small proportion of patients 1989;141:369-71. and are distributed equally amongst the etiologies of 18. Edwards EA. Functional anatomy of the porta-systemic portal hypertension.[77] They rarely bleed and may be communications. Arch Intern Med 1951;88:137-54. 19. Ohtani T, Kajiwara E, Suzuki N, Kawasaki A, Sadoshima S, ignored during sclerotherapy of esophageal varices, Sakata H, et al. Ileal varices associated with recurrent bleeding however, if required, sclerotherapy is the treatment of in a patient with liver cirrhosis. J Gastroenterol 1999;34:264­ choice.[78,79] Rarely, idiopathic varices have been report­ 8. ed throughout the gastrointestinal tract.[80] Significant 20. Agarwal D, Scholz FJ. Small-bowel varices demonstrated by varices can occur outside the gastrointestinal tract and enteroclysis. Radiology 1981;140:350. 21. Hansen ME, Coleman RE. Scintigraphic demonstration of have been described in kidney, lungs, tracheobronchial gastrointestinal bleeding due to mesenteric varices. Clin Nucl tree, mediastinum and vagina; giving rise to unusual Med 1990;15:488-90. hemorrhage as well as diagnostic difficulties on imag­ 22. Cutler CS, Rex DK, Lehman GA. Enteroscopic identification ing.[81-86] of ectopic small bowel varices. Gastrointest Endosc 1995;41:605-8. 23. Zimmer W, Yucel EK. Mesenteric varices:evaluation with color REFERENCES flow Doppler and magnetic resonance angiography. Magn Reson Imaging 1993;11:1063-6. 1. Lebrec D, Benhamou JP. Ectopic varices in portal hypertension. 24. Lopez MJ, Cooley JS, Petros JG, Sullivan JG, Cave DR. Complete Clin Gastroenterol 1985 Jan;14:105-21. intraoperative small-bowel endoscopy in the evaluation of 2. Hashizume M, Tanoue K, Ohta M, Ueno K, Sugimachi K, occult gastrointestinal bleeding using the sonde enteroscope. Kashiwagi M, et al. Vascular anatomy of duodenal Arch Surg 1996;131:272-7. varices:angiographic and histopathological assessments. Am 25. Yuki N, Kubo M, Noro Y, Kasahara A, Hayashi N, Fusamoto H, J Gastroenterol 1993;88:1942-5. et al. Jejunal varices as a cause of massive gastrointestinal 3. Jimenez SM, Pallares MH, Romero CR, Pinar MA, Gomez PM, bleeding. Am J Gastroenterol 1992;87:514-7. Herrerias GJ. Digestive hemorrhage caused by duodenal 26. Ozaki CK, Hansen M, Kadir S. Transhepatic embolization of varices. Rev Esp Enferm Dig 1994;85:209-11. superior mesenteric varices in portal hypertension. Surgery 4. Tanaka T, Kato K, Taniguchi T, Takagi D, Takeyama N, Kitazawa 1989;105:446-8. Y. A case of ruptured duodenal varices and review of the 27. Paquet KJ, Lazar A, Bickhart J. Massive and recurrent literature. Jpn J Surg 1988;18:595-600. gastrointestinal hemorrhage due to jejunal varices in an 5. Heaton ND, Khawaja H, Howard ER. Bleeding duodenal afferent loop-diagnosis and management. varices. Br J Surg 1991;78: 1450-1. Hepatogastroenterology 1994;41:276-7. 6. Eleftheriadis E. Duodenal varices after sclerotherapy for 28. Fee HJ, Taylor JB, O’Connell TX. Bleeding esophageal varices. Am J Gastroenterol 1988;83:439-41. associated with portal hypertension and previous abdominal

Indian J Surg | October 2005 | Volume 67 | Issue 5 245 Sharma D, et al.

surgery. Am Surg 1977;43:760-2. 50. Iwase H, Kyogane K, Suga S, Morise K. Endoscopic 29. Moncure AC, Waltman AC, Vandersalm TJ, Linton RR, Levine ultrasonography with color Doppler function in the diagnosis FH, Abbott WM. Gastrointestinal hemorrhage from adhesion- of rectal variceal bleeding. J Clin Gastroenterol 1994;19:227­ related mesenteric varices. Ann Surg 1976;183:24-9. 30. 30. Feldman M, Smith VM, Warner CG. Varices of colon. Report 51. Levine J, Tahiri A, Banerjee B. Endoscopic ligation of bleeding of three cases. JAMA 1962;179:729-30. rectal varices. Gastrointest Endosc 1993;39:188-90. 31. Gudjonsson H, Zeiler D, Gamelli RL, Kaye MD. Colonic varices. 52. Herman BE, Baum S, Denobile J, Volpe RJ. Massive bleeding Report of an unusual case diagnosed by radionuclide scanning, from rectal varices. Am J Gastroenterol 1993;88:939-42. with review of the literature. Gastroenterology 1986;91:1543- 53. Fick TE, van Buuren HR, Huisman AM, Schreve RH, Terpstra 7. OT. Intermittent bleeding from anorectal varices. Neth J Surg 32. Fouch PG, Sirak MW. Colonic variceal hemorrhage after 1985;37:187-9. endoscopic injection sclerosis of esophageal varices: a report 54. Katz JA, Rubin RA, Cope C, Holland G, Brass CA. Recurrent of three cases. Am J Gastroenterol 1984;79:756-60. bleeding from anorectal varices:successful treatment with a 33. Naef M, Holzinger F, Glattli A, Gysi B, Baer HU. Massive transjugular intrahepatic portosystemic shunt. Am J gastrointestinal bleeding from colonic varices in a patient with Gastroenterol 1993;88:1104-7. portal hypertension. Dig Surg 1998;15:709-12. 55. Demirel H, Pieterman H, Lameris JS, van Buuren HR. 34. Katz LB, Shakeed A, Messer J. Colonic variceal Transjugular embolization of the inferior mesenteric vein for hemorrhage:diagnosis and management. J Clin Gastroenterol bleeding anorectal varices after unsuccessful transjugular 1985;7:67-9. intrahepatic portosystemic shunt. Am J Gastroenterol 35. Izsak EM, Finlay JM. Colonic varices. Three case reports and 1997;92:1226-7. review of the literature. Am J Gastroenterol 1980;73:131-6. 56. Conte JV, Arcomano TA, Naficy MA, Holt RW. Treatment of 36. Villarreal HA, Marts BC, Longo WE, Ure T, Vernava AM, Joshi bleeding stomal varices. Report of a case and review of the S. Congenital colonic varices in the adult. Report of a case. literature. Dis Colon Rectum 1990;33:308-14. Dis Colon Rectum 1995;38:990-2. 57. Graeber GM, Ratner MH, Ackerman NB. Massive hemorrhage 37. Chakravarty BJ, Riley JW. Control of colonic variceal from ileostomy and colostomy stomas due to mucocutaneous hemorrhage with a somatostatin analogue. J Gastroenterol varices in patients with coexisting cirrhosis. Surgery Hepatol 1996;11:305-6. 1976;79:107-10. 38. Uemoto S, Martin AJ, Fleming W, Habib NA. The use of 58. Wolfsen HC, Kozarek RA, Bredfeldt JE, Fenster LF, Brubacher transjugular intrahepatic portosystemic shunt and surgical LL. The role of endoscopic injection sclerotherapy in the portocaval H-shunt for the treatment of colorectal variceal management of bleeding peristomal varices. Gastrointest bleeding. Hepatogastroenterology 1995;42:557-60. Endosc 1990;36:472-4. 39. Goenka MK, Kochhar R, Nagi B, Mehta SK. Rectosigmoid 59. Hesterberg R, Stahlknecht CD, Roher HD. Sclerotherapy for varices and other mucosal changes in patients with portal massive enterostomy bleeding resulting from portal hypertension. Am J Gastroenterol 1991;86:1185-9. hypertension. Dis Colon Rectum 1986;29:275-7. 40. Hosking SW, Smart HL, Johnson AG, Triger DR. Anorectal 60. Beck DE, Fazio VW. Grundfest-Broniatowski S. Surgical varices, haemorrhoids, and portal hypertension. Lancet management of bleeding stomal varices. Dis Colon Rectum 1989;1:349-52. 1988;31:343-6. 41. Chawla Y, Dilawari JB. Anorectal varices—their frequency in 61. Lagier E, Rousseau H, Maquin P, Olives JP, Le Tallec C, Vinel cirrhotic and non-cirrhotic portal hypertension. Gut JP. Treatment of bleeding stomal varices using transjugular 1991;32:309-11. intrahepatic portosystemic shunt. J Pediatr Gastroenterol Nutr 42. Heaton ND, Davenport M, Howard ER. Incidence of 1994;18:501-3. hemorrhoids and anorectal varices in children with portal 62. Chawla A, Dewan R, Sarin SK. The frequency and influence hypertension. Br J Surg 1993;80:616-8. 43. Ganguly S, Sarin SK, Bhatia V, Lahoti D. The prevalence and of gallbladder varices on gallbladder functions in patients with spectrum of colonic lesions in patients with cirrhotic and portal hypertension. Am J Gastroenterol 1995;90:2010-4. noncirrhotic portal hypertension. 1995;21:1226- 63. Rathi PM, Soni A, Nanivadekar SA, Sawant P, Bhatnagar MS, 31. Upadhyay AP. Gallbladder varices:diagnosis in children with 44. Misra SP, Dwivedi M, Misra V. Prevalence and factors portal hypertension on duplex sonography. J Clin Gastroenterol influencing hemorrhoids, anorectal varices, and colopathy in 1996;23:228-31. patients with portal hypertension. Endoscopy 1996;28:340-5. 64. Safadi R, Sviri S, Eid A, Levensart P. Gallbladder varices: a 45. Misra SP, Dwivedi M, Misra V. Effect of esophageal variceal case report and review of the literature. Eur J Med Res sclerotherapy on hemorrhoids, anorectal varices and portal 1996;1:506-8. colopathy. Endoscopy 1999;31:741-4. 65. Dilawari JB, Chawla YK. Pseudosclerosing cholangitis in extra 46. Weinshel E, Chen W, Falkenstein DB, Kessler R, Raicht RF. hepatic portal vein obstruction. Gut 1992;33:272-6. Hemorrhoids or rectal varices:defining the cause of massive 66. Bayraktar Y, Balkanci F, Kayhan B, Ozenc A, Serap A, Telatar rectal hemorrhage in patients with portal hypertension. H. Bile duct varices or pseudocholangiocarcinoma sign in Gastroenterology 1986;90:744-7. portal hypertension due to cavernous transformation of portal 47. Dhiman RK, Choudhuri G, Saraswat VA, Mukhopadhyay DK, vein. Am J Gastroenterol 1992;87:1801-6. Khan EM, Pandey R, et al. Endoscopic ultrasonographic 67. Tighe M, Jacobson I. Bleeding from bile duct varices:an evaluation of the rectum in cirrhotic portal hypertension. unexpected hazard during therapeutic ERCP. Gastrointest Gastrointest Endosc 1993;39:635-40. Endosc 1996;43:250-2. 48. Malde H, Nagral A, Shah P, Joshi MS, Bhatia SJ, Abraham P. 68. Jhung JW, Micolonghi TS. Ruptured mesenteric varices in Detection of rectal and pararectal varices in patients with portal hepatic cirrhosis: a rare cause of intraperitoneal hemorrhage. hypertension: efficacy of transvaginal sonography. Am J Surgery 1985;97:377-80. Roentgenol 1993;161:335-7. 69. Hunt JB, Appleyard M, Thursz M, Carey PD, Guillou PJ, 49. Katz JA, Rubin RA, Cope C, Holland G, Brass CA. Recurrent Thomas HC. Intraperitoneal haemorrhage from anterior bleeding from anorectal varices:successful treatment with a abdominal wall varices. Postgrad Med J 1993;69:490-3. transjugular intrahepatic portosystemic shunt. Am J 70. Sprayragen S, Brandt LJ, Bohm S, Stechel R. Bleeding Gastroenterol 1993;88:1104-7. intraperitoneal varix: demonstration by angiography and

246 Indian J Surg | October 2005 | Volume 67 | Issue 5 Portal hypertension and ectopic varices

successful treatment with infusion of vasopressin in to the Endoscopic management of bleeding ectopic varices with superior mesenteric artery. Angiology 1978;29:857-61. histoacryl. HPB Surg 1999;11:171-3. 71. van Buuren HR, Fick TE, Schalm SW. Recurrent bleeding from 80. Del Piano M, Montino F, Manfredda I, Occhipinti P. Varices of cutaneous venous collaterals in portal hypertension. Gut the entire gastrointestinal tract. Gastrointest Endosc 1988;29:1279-81. 1993;39:822-4. 72. Bahner DR Jr, Holland RW 3rd. Exsanguinating hemorrhage 81. Erden A, Ozcan H, Aytac S, Sanlidilek U, Cumhur T. Intrarenal from a caput medusae:cutaneous variceal bleeding. J Emerg varices in portal hypertension:demonstration by color Doppler Med 1992;10:19-23. imaging. Abdom Imaging 1996;21:549-50. 73. Lewis CP, Murthy S, Webber SM, Chokhavatia S. Hemorrhage 82. Man KM, Keeffe EB, Brown CR, Egawa H, Esquivel CO. from recanalized umbilical vein in a patient with cirrhosis. Pulmonary varices presenting as a solitary lung mass in a Am J Gastroenterol 1999;94:280. patient with end-stage liver disease. Chest 1994;106:294-6. 74. Fitzgerald JB, Chalmers N, Abbott G, Lee SH, Warnes TW, 83. Youssef AI, Escalante-Glorsky S, Bonnet RB, Chen YK. Youngs GR, et al. The use of TIPS to control bleeding caput Hemoptysis secondary to bronchial varices associated with medusae. Br J Radiol 1998;71:558-60. alcoholic liver cirrhosis and portal hypertension. Am J 75. Bell R, Thompson JF, Waugh RC, Grimm MC, Gallagher ND. Gastroenterol 1994;89:1562-3. Control of life-threatening bleeding from caput medusae by 84. Henrion J, Lebrec D, Nahum H, Benhamou JP. Pseudotumoral umbilical vein embolization. Lancet 1989;1:736. varices of the mediastinum in portal hypertension. Report of 76. Tincani E, Criscuolo C, Zenesini A, Bondi M. An unusual site a case. Gastroenterol Clin Biol 1979;3:453-5. of bleeding from esophageal varices. Recenti Prog Med 85. Waldenberger P, Propst A, Propst T, Konigsrainer A, Vogel W, 1998;89:301-3. Jaschke W. Unusual thoracic collaterals of gastro-oesophageal 77. Chen YM, Wu WC, Ott DJ. Antral varices. Am J Gastroenterol varices in a patient with end-stage liver disease. Ital J 1986;81:1191-2. Gastroenterol 1996;28:25-7. 78. Shah SR, Desai CS, Mathur SK. Incidence and fate of antral 86. Kreek MJ, Raziano JV, Hardy RE, Jeffries GH. Portal varices. Eur J Gastroenterol Hepatol 1999;11:1041-3. hypertension with bleeding vaginal varices. Ann Intern Med 79. Bhasin DK, Sharma BC, Sriram PV, Makharia G, Singh K. 1967;66:756-9.

ANNOUNCEMENT

Dear Members,

History of Surgery is very old though Modern Medicine is introduced in India by Britishers in early 19th Century. Medical Schools/Colleges gradually came into existence after 1860's, the Medical Clinics and Hospital started in various parts of the country much before this. The same have developed into some big institutions and serving its people around with dedication and in its own tradition.

Please give articles of historical importance with their achievement in surgery regarding the institution and surgeons of great reputatoin and their work.

Similarly we wish to start the following subjects. Please give articles on these topics comprehensively :­ • Case Reports - Summary (5 cases) • Eminent Surgeons and Institutions • Controversies in Surgery • Difficult Case from Diagnosis or Surgical point of view • Newer Technique • Conference Proceedings

Please give your comments and suggestion to improve journal.

Sincerely yours,

Dr. Satish Shukla Chairman/Editor IJS

Indian J Surg | October 2005 | Volume 67 | Issue 5 247