Background/Aims: Bleeding ectopic varices due to cirrhosis can be difficult to manage. We report our experience of uncontrolled bleeding from ectopic varices treated with transjugular intrahepatic porto-systemic shunt (TIPS).Methods: We selected the 21 cirrhotics who underwent TIPS for bleeding ectopic varices from our database: Child-Pugh grade A (2), B (11) and C (8). Site of bleeding was rectal (11), colonic (2), ileal 1, jejunal 1, duodenal 1, and stomal (5).Results: TIPS was performed successfully in 19/21 (90%) patients. All except 1 had either a reduction in portosystemic pressure gradient less than or equal to 12 mmHg (n = 12) or reduction by 25-50 % of baseline (n = 6). TIPS alone was used in 12/19: 7 of these 12 had no further bleeding; 5 (42%) rebled within 48 h, and had embolisation, 4 without further bleeding. In 7 of 19, TIPS and embolisation were performed together: 2 patients (28%) rebled; further embolisation stopped the bleeding.Conclusions: Ectopic varices do rebleed despite a reduction of porto-systemic pressure gradient less than or equal to 12 mmHg or by 25-50% of baseline, following TIPS. Embolisation stopped bleeding in all but 1 patient. We recommend performing embolisation at the time of the initial TIPS to control bleeding from ectopic varices. (C) 2004 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

Splenic artery aneurysms (SAAs) comprise 60% of visceral artery aneurysms and although they can present at any age, they most commonly present in the fifth and sixth decades of life. They are associated with multiparity and portal hypertension and are more common in women. Historically SAAs greater than 2 cm in diameter are treated surgically because the risk of rupture, particularly during pregnancy, is high. The role of transcatheter embolisation – 5 is still evolving but is likely to become increasingly important as more asymptomatic visceral aneurysms are diagnosed as a result of the ready access to ultrasound, CT and MRI.

Budd-Chiari syndrome with portal, splenic, and superior mesenteric vein thrombosis

PURPOSE:To evaluate the efficacy of colorectal stenting in the palliation of irresectable malignant colonic obstruction.MATERIALS AND METHODS:Fifteen patients underwent colorectal stenting for irresectable colonic malignancy. Sixteen stents were placed successfully in 13 patients. Two stent insertions, one a proximal transverse colon lesion, were unsuccessful. Twelve patients (80%) had clinical or radiological features of imminent obstruction. Three patients were completely obstructed. Eighty-six percent of lesions were within the rectosigmoid colon.RESULTS:Technical and clinical success was 88%. Early, minor complications occurred in two patients (13%). Late complications included migration (13%) and ingrowth (19%). The median survival was 2 months (0.5-12 months).CONCLUSION:Stenting should be considered as definitive treatment in the context of an inoperable malignant stricture of the colon. It has low morbidity and a high technical and clinical success rate and avoids emergency defunctioning surgery in high-risk patients.

The objectives of this study were (i) to identify patterns of angiographic disease in scleroderma patients with and without other vascular risk factors and (ii) to define patients with scleroderma in whom angiography and angioplasty is useful. The records of 26 patients with scleroderma who underwent angiography and angioplasty over an 8-year period were reviewed. Angiographic disease patterns were assessed using a modified Brewster classification. Angiography of the upper limb demonstrated distal disease alone in 86% of patients, both with and without other vascular risk factors such as smoking. In the lower limb there was a highly significant association between the presence of other vascular risk factors and macrovascular disease potentially amenable to angioplasty, and conversely between the absence of other vascular risk factors and distal disease in the lower limb. Good early but poor late clinical results were achieved in three of five patients who underwent angioplasty. Angiography of the upper limb is likely to demonstrate distal disease alone, and angiography and angioplasty of the lower limb may be useful only if other vascular risk factors are present.

A frequent complication in patients with end-stage liver disease is portal vein thrombosis (PVT). Although PVT is not considered an absolute contraindication to orthotopic liver transplantation (OLT), more complex surgery is required and patients have more postoperative complications and greater mortality rates. We describe 2 patients who experienced complete PVT either while waiting for liver transplantation or during the workup, resulting in acute deterioration of liver function. Recanalization of the portal vein was successfully performed in both patients using transjugular intrahepatic portosystemic stent shunt (TIPS), and patency was maintained by the addition of anticoagulation therapy. They subsequently underwent successful OLTs and remain well. In conclusion, we believe that TIPS placement can be performed safely in patients with recent PVT, ensuring the patency of the portal vein until OLT.

There has been a rapid expansion in the role of the imaging department in the placing of stents in the gastrointestinal tract for rapid relief of dysphagia, gastric outlet, duodenal and large bowel obstruction. In this article we describe the currently available stents, the indications for their placement, their relative merits and outcomes.

We describe a new and inexpensive technique of imaging the portal vein in patients with liver disease by use of carbon dioxide.

A case is described involving Sjögren's syndrome, high sustained levels of antibodies to serine proteinase 3, and cavitating lung disease. Possible diagnoses accounting for this unusual combination include a novel association of Sjögren's syndrome and Wegener's granulomatosis (suggested by the high and sustained levels of antibodies to serine proteinase 3) or a rare presentation of bronchiolitis obliterans organising pneumonia. Identification of the true nature of the patients illness facilitated more active management and a swift resolution of the clinical problem.

Introduction via the left femoral artery revealed an intraluminal filling defect in the right common femoral artery. On Various methods have been developed to secure haesurgical exploration the Angio-Seal device (collagen plug and anchor) was found to be located entirely mostasis at arteriotomy sites including percutaneous suture closure, manual compression and collagen plug within and occluding the lumen of the femoral artery. The device was removed and the femoral arteriotomy devices. In this report we described a case of delayed limb ischaemia following the use of a haemostatic sutured. The patient made an uneventful recovery. Six weeks post-operatively, the patient was asymptomatic; collagen plug device. and had a full complement of peripheral pulses in his right leg.

In elderly diabetic patients with renal cholesterol atheroembolism, a common precipitant is manipulation of atherosclerotic vessels during vascular surgery or angiography. It can also result from thrombolytic and anticoagulant therapy, sometimes after a considerable delay1. Spontaneous cholesterol embolism is uncommon-found by Cross2 in 1.9% of serial necropsies, always in patients over 60 years of age. The clinical features are varied and make diagnosis difficult. Risk factors for renal cholesterol atheroembolism are advanced age (mean 66 years), hypertension, coronary atherosclerosis and renal impairment3. Spontaneous renal atheroembolism often leads to progressive decline in renal function, early dialysisdependence and high mortality3; however, renal function can recover4. Flash pulmonary oedema often points to underlying atheromatous renal artery occlusion, and we suspect that this was present in our patient. Regarding treatment, there is some evidence that a statin can stabilize atherosclerotic plaques, reduce the propensity for atheroembolism and thus preserve renal function5. Recurrent spontaneous cholesterol atheroembolism, characterized here by short-lived episodes of acute renal failure and pulmonary oedema, does not seem to have been described previously. This possibility should be considered in any elderly diabetic patient with established atherosclerotic disease who presents with impaired renal function and pulmonary oedema.

BACKGROUNDThrombocytopenia in cirrhotic patients may be due to deficient production of thrombopoietin.AIMSTo determine the relation between thrombopoietin and thrombocytopenia in cirrhotic patients before and after orthotopic liver transplantation.METHODSThrombopoietin concentrations and platelet counts were measured in 43 cirrhotic patients and 21 normal controls and serially for 14 days after transplantation in 23/43 patients.RESULTS27 of the 43 patients had thrombocytopenia (platelet count less than 120 × 109/l; group 1) whereas 16 patients had normal platelet count (group 2). Thrombopoietin concentrations were lower in group 1 than in group 2 (92.5 (20.3–286.3) v 226.6 (30.1–848.3) pg/ml, p=0.003) and normal controls (92.5 (20.3–286.3)v 158.3 (22.5–232.9) pg/ml, p=0.028). Post-transplantation thrombopoietin concentrations increased with a peak at day 5. The rise was significant in patients with low pretransplantation platelet count (89.1 (21.29–247.6) to 545.1 (66.2–2569) pg/ml; n=16, p=0.001) but not in those with normal platelet count (262.8 (30.1–848.3) to 315.1 (114–954.6) pg/ml; n=7, p=0.47). No correlation was found pretransplantation between spleen volume and platelet count (r=−0.11, p=0.6) or thrombopoietin concentrations (r=−0.04, p=0.8). However, pretransplantation thrombopoietin concentrations correlated with platelet count (r=0.47, p=0.0015), whereas an inverse correlation was found between peak thrombopoietin concentrations and nadir platelet count (r=−0.41 p=0.049) post-transplantation.CONCLUSIONSInadequate thrombopoietin production may contribute to cirrhotic thrombocytopenia. Thrombopoietin production is restored after liver transplantation leading to the resolution of thrombocytopenia.

A spontaneous portosystemic shunt from the left gastric vein to the left renal vein caused by portal hypertension.E Dick and A WatkinsonAudio Available | Share

BACKGROUND:In view of the changing nature of transjugular liver biopsy, we performed an audit of the safety, adequacy and clinical impact of such biopsies in our centre over a 2-year period from 1995 to 1997.METHODS:One hundred and fifty-seven transjugular biopsies were carried out in 145 patients, with prothrombin time >5 s over control and/or platelet count <50 x 10(9)/L and/or gross ascites.RESULTS:Major complications were two (1.3%) capsular perforations, which were easily plugged with coils without sequelae. Biopsy sample was adequate for histological diagnosis in 90%, inadequate in 6% and technically unsuccessful in 4% of cases. Mean biopsy size was 14.8+/-7.7 (1-51) mm. Adequacy did not differ between cases with and without cirrhosis. Transjugular biopsy had a clinical impact (specific diagnosis or influence on patient's management) in 50% of acute liver disease, 62% of chronic liver disease and 87% of transplant patients (P<0.001). In chronic liver disease, it had a significantly greater clinical impact in cases trying to establish the stage rather than diagnosis (84% vs. 35%, P<0.001).CONCLUSIONS:Transjugular liver biopsy is a safe procedure for high-risk patients providing an adequate liver sample even in cirrhosis. It has a clinical impact in more than 80% of transplant patients and for staging chronic liver disease, but in only 50% (acute) or 35% (chronic) of liver disease when a diagnosis is sought.