Upper gastrointestinal ectopic variceal bleeding treated with various endoscopic modalities

Abstract

Rationale:Ectopic variceal bleeding is a rare (2–5%) but fatal gastrointestinal bleed in patients with portal hypertension. Patients with ectopic variceal bleeding manifest melena, hematochezia, or hematemesis, which require urgent managements. Definitive therapeutic modalities of ectopic varices are not yet standardized because of low incidence. Various therapeutic modalities have been applied on the basis of the experiences of experts or availability of facilities, with varying results.Patient concerns:We have encountered eight cases of gastrointestinal ectopic variceal bleeding in five patients in the last five years.Diagnoses:All patients were diagnosed with liver cirrhosis presenting melena or hematemesis.Interventions:All patients were treated with various endoscopic modalities (endoscopic variceal obturation [EVO] with cyanoacrylate in five cases, endoscopic variceal band ligation (EVL) in two cases, hemoclipping in one case).Outcomes:Satisfactory hemostasis was achieved without radiologic interventions in all cases. EVO and EVL each caused one case of portal biliopathy, and EVL induced ulcer bleeding in one case.Lessons:EVO generally accomplished better results of variceal obturations than EVL or hemoclipping, without serious adverse events. EVO may be an effective modality for control of ectopic variceal bleeding without radiologic intervention or surgery.

Duodenal Varix Rupture – A Rare Cause of Fatal Gastrointestinal Hemorrhage: A Case Report and Review of Literature

“…Furthermore, repeat injection therapy can increase the risk of perforation due to the thin structure of duodenal wall. [9] EVL is lower on the list likely due to concerns of ligation when the varix is large, difficulty in obtaining good views, and accessibility to collateral vessels with severe bleeding. [9] Hemoclipping on the other hand, which was selected for our case has the advantage of occluding the blood vessel by applying direct mechanical pressure and therefore is useful in the coagulopathic patients.…”

“…[9] EVL is lower on the list likely due to concerns of ligation when the varix is large, difficulty in obtaining good views, and accessibility to collateral vessels with severe bleeding. [9] Hemoclipping on the other hand, which was selected for our case has the advantage of occluding the blood vessel by applying direct mechanical pressure and therefore is useful in the coagulopathic patients. [9-11] Furthermore, the effectiveness of hemoclipping has been shown to be similar to band ligation, however no head to head studies exist to compare between these interventions.…”

The causes of upper gastrointestinal bleeding and urgent gastroscopy at the Center for Emergency Medicine of the Clinical Center Kragujevac

“…The world generally accepts the trend that endoscopy is the first line of treatment to stop the bleeding from the upper parts of the gastrointestinal tract. Endoscopic methods are often supplemented by using the antisecretory therapy, although there are experts who believe that the administration of erythromycin as a prokinetic may have a positive influence on hemostasis from the gastrointestinal tract [20]. Contemporary guides advise the use of proton pump inhibitors and erythromycin, as adjuvant therapy for endoscopy with the purpose of hemostasis [21].…”

Endoscopy in Management of Portal Hypertension

“…Use of APC with EBL may be considered for the prevention of variceal occurrence, as has been reported in the treatment of ileocolonic anastomotic varices [45]. Hemostatic clip placement has been reported for ectopic variceal therapy [46]. Hemobilia, due to choledochal varices, can be lifethreatening.…”