21/255. pregnancy, labour and delivery in a Jehovah's Witness with esophageal varices and thrombocytopenia.PURPOSE: An increasing number of women with cirrhosis are conceiving and carrying their pregnancies to term. However, the maternal mortality rate remains high (10-61%). This case report describes the management of a parturient with esophageal varices and thrombocytopenia. She was also a Jehovah's Witness. CLINICAL FEATURES: A 25-yr-old Jehovah's Witness parturient with portal hypertension and esophageal varices secondary to cryptogenic cirrhosis was referred to our obstetrical unit at eight weeks gestation. In addition she was thrombocytopenic with platelet counts ranging from 42,000-67,000 x microl(-1). Her esophageal varices were banded prophylactically on three occasions during her pregnancy. magnetic resonance imaging at 32 wk gestation showed extensive caput medusa and dominant midline varix. Therefore, the planned mode of delivery was changed from cesarean section which could result in massive hemorrhage, to elective induction of labour with an assisted second stage. The patient refused any blood product transfusion except acute hemodilution and cell saving if necessary during labour and delivery. Despite elaborate preparations for a planned vaginal delivery, she underwent an unanticipated rapid labour. Spinal analgesia was provided to facilitate smooth assisted vacuum delivery. CONCLUSION: Multidisciplinary care is the key for a successful outcome in parturients with cirrhosis. Periodic examination and banding of esophageal varices is recommended during pregnancy. Active consideration should be given to availing of the benefits of regional anesthesia.- - - - - - - - - - ranking = 1keywords = hypertension (Clic here for more details about this article) |
22/255. Splenoadrenal shunt. An original portosystemic decompressive technique.Management of gastrointestinal hemorrhage from rupture of esophageal and gastric varices due to portal hypertension remains a debated question. In patients with sclerotherapy-resistant esophagogastric varices, and preserved hepatic function, a surgical shunt is considered the treatment of choice. A 63-year-old male was admitted in our Department with a diagnosis of idiopathic fibrosis of the liver, portal hypertension, esophageal and gastric varices and previous history of variceal bleeding. A distal splenorenal shunt was planned. During the isolation, a large diameter left adrenal vein was identified. An end-to-end anastomosis utilizing the distal splenic vein and the proximal adrenal stump was performed. The procedure was uneventful. An ultrasound color-Doppler on the 3rd postoperative day, showed normal intrasplenic resistance index, demonstrating the efficacy of the shunt. A splenic angiography carried out on the 8th postoperative day showed the complete patency of the splenoadrenal shunt. At the 15th postoperative day, the patient was discharged. In patients with portal hypertension, sclerotherapy-resistant esophagogastric varices and preserved hepatic function, a surgical portosystemic shunt is mandatory. Splenoadrenal shunt, utilizing a left adrenal vein represent an excellent option in selected cases.- - - - - - - - - - ranking = 3keywords = hypertension (Clic here for more details about this article) |
23/255. Congenital arteriovenous malformation of the pancreas: its diagnostic features on images.To analyze diagnostic features on images of congenital arteriovenous malformation (AVM) of the pancreas, we analyzed the diagnostic findings in six patients with the disease, using gray-scale ultrasonography (US), color Doppler US, computed tomography, and angiography and analyzed previously reported cases. AVM characteristic findings on images were multiple, small hypoechoic nodules on US, mosaic appearance of the lesion and pulsatile wave form in the portal vein on color Doppler US, conglomerated small nodular enhancement of the lesion and early appearance of the portal vein on CT, and a racemose network and early appearance of the portal vein on angiography. Five of the six patients underwent surgery, and all resected specimens were histologically found to be AVMs of the pancreas; however, one with developed portal hypertension at surgery died of repeated bleeding from esophageal varices. From analysis of total of 35 cases including our six cases, a mosaic appearance of the lesion was found in 100% and a pulsatile wave form in the portal vein in 77.8% on color Doppler US. color Doppler US is noninvasive and useful for detecting congenital AVM of the pancreas at an early stage, preventing the portal hypertension causing esophageal varices and their rupture.- - - - - - - - - - ranking = 2keywords = hypertension (Clic here for more details about this article) |
24/255. Idiopathic myelofibrosis complicated by portal hypertension treated with a transjugular intrahepatic portosystemic shunt (TIPS).Idiopathic myelofibrosis may be accompanied by portal hypertension. The authors report a 56-year-old man with idiopathic myelofibrosis and splenomegaly complicated by hepatopathy, severe portal hypertension and recurrent variceal bleeding. A transjugular intrahepatic porto-systemic shunt (TIPS) was inserted. Variceal bleeding never recurred. A short episode of encephalopathy, which is a known complication of porto-systemic shunting, ceased promptly after conservative treatment. The patient eventually died six months later due to metabolic deterioration and hepatic failure related to his underlying hematological disease. TIPS is a promising treatment modality for alleviating symptomatic portal hypertension in hematological disorders.- - - - - - - - - - ranking = 7keywords = hypertension (Clic here for more details about this article) |
25/255. Endoscopic localization and management of colonic bleeding in patients with portal hypertension.In patients with portal hypertension, vascular lesions in the colon may develop that have been collectively termed portal hypertensive colopathy. Endoscopic diagnosis of these lesions is now established, but the management of hemorrhage from them is not. We report five cases of endoscopic management of bleeding colonic vascular lesions in patients with portal hypertension. endoscopy data from January 1, 1996 to June 30, 1999 identified 158 patients with portal hypertension who underwent colonoscopy. Forty-five of these 158 patients had portal hypertensive colopathy (angiodysplasias or varices). Those who had colonoscopic hemostasis attempted were identified and reviewed. Five patients underwent colonoscopic intervention for bleeding. Initial hemostasis was achieved in four of five cases. Repeat endoscopic intervention was necessary in three of the four cases. One patient required surgery. In patients with portal hypertension, colonic vascular lesions may develop. Hemorrhage from these lesions is rare. colonoscopy is effective for localization and diagnosis of bleeding vascular lesions and permits simultaneous hemostatic intervention.- - - - - - - - - - ranking = 8keywords = hypertension (Clic here for more details about this article) |
26/255. Arterioportal fistula: a rare cause of portal hypertension and abdominal pain.Esophageal varices are commonly caused by portal hypertension secondary to cirrhosis. We report the case of a 71-year-old woman who presented with esophageal variceal bleeding due to portal hypertension caused by an arteriovenous fistula. The fistula, which was probably brought about by a liver biopsy performed 18 years previously, was complicated by bleeding. Since this event, the patient has reported right upper quadrant pain. Embolization resulted in elimination of the varices as well as abdominal discomfort.- - - - - - - - - - ranking = 6keywords = hypertension (Clic here for more details about this article) |
27/255. Urgent distal splenorenal shunt in low-body weight patients.The authors report two patients with extrahepatic portal hypertension and repeated massive bleeding from esophageal varices who underwent urgent distal splenorenal shunting (DSRS) after having proved refractory to medical treatment, endoscopic sclerotherapy, and ligation of esophageal varices. Their ages and weights were 18 months/10 kg, and 11 months/6.4 kg, respectively. The splenic veins were 6 and 4 mm in diameter. During follow-up of 4 and 3 years, respectively, the shunts have remained patent in both patients as demonstrated by Doppler Ultrasound. gastrointestinal hemorrhage has not recurred, splenomegaly regressed, and platelet and white blood cell counts increased gradually. Neither patient developed a significant encephalopathy, and liver function tests showed no significant changes throughout the observed period. The authors considered the shunting feasible despite the relatively narrow splenic veins. In both patients the anatomic position of the splenic vein--more caudal to the posterior wall of the pancreas--facilitated its isolation. In the smaller infant, the inferior mesenteric vein was sutured to gain a satisfactory segment of splenic vein. The successful use of a DSRS to control actively bleeding varices in a child weighing 6.4 kg has not been previously reported.- - - - - - - - - - ranking = 1keywords = hypertension (Clic here for more details about this article) |
28/255. Lessons to be learned: a case study approach a case study of the temporal onset of pulmonary hypertension with pre-existent cirrhotic portal hypertension.We report the occurrence of pulmonary hypertension in a 37-year-old male patient with cirrhosis of the liver, portal hypertension and oesophageal varices. Although this is a rare combination, previous reports have shown that the association of portal and pulmonary hypertension is not coincidental; the temporal onset of primary pulmonary hypertension is hard to predict and our patient was asymptomatic for a number of years. The pathogenesis of portal hypertension leading to pulmonary hypertension is not known. diagnosis is difficult because the clinico-pathological symptoms in both conditions are similar. Treatment is limited to calcium channel blockers, vasodilators, nitrous oxide and prostacyclin, although most patients will eventually require visceral transplantation.- - - - - - - - - - ranking = 14keywords = hypertension (Clic here for more details about this article) |
29/255. Endoscopic variceal ligation for intractable esophageal variceal bleeding in children with idiopathic extrahepatic portal vein occlusion: report of three cases.Extrahepatic portal vein occlusion (EPVO) is an important cause of extrahepatic portal hypertension and variceal hemorrhage in children. We report 3 children with a diagnosis of EPVO and intractable esophageal variceal bleeding who underwent scheduled endoscopic variceal ligation (EVL) and prophylactic propranolol therapy for eradication of esophageal varices. Complete variceal obliteration was achieved in all 3 children following 3-4 treatment sessions. There were no significant complications or gastrointestinal hemorrhage during a follow-up period of 9 to 31 months after variceal eradication. In conclusion, EVL and long-term propranolol prophylaxis is safe and effective in eradicating bleeding esophageal varices in children with EPVO.- - - - - - - - - - ranking = 1keywords = hypertension (Clic here for more details about this article) |
30/255. A case of Castleman's disease with "downhill" varices in the absence of superior vena cava obstruction.Downhill esophageal varices", classically defined as those that develop in the upper region of the esophagus, are less common than the "uphill" type, which is usually produced by portal hypertension. Various causes of downhill varices have been reported, but mediastinal tumor is the most common responsible lesion. Castleman's disease, or angiofollicular lymph node hyperplasia, is a rare pathological process of unknown etiology that usually develops in the mediastinum. We report the case of a 60-year-old woman whose large esophageal varices were detected incidentally. The cause was a mediastinal mass which was diagnosed as Castleman's disease on histopathological examination of a surgical specimen. This patient's varices most likely formed as a result of copious blood drainage from the tumor into the esophageal veins. Evidence for this was the lack of the classic downhill pattern, the absence of superior vena cava obstruction, and the fact that the varices resolved after the tumor was removed. It is our opinion that this type of varices should be renamed, and we suggest that "overflow varices" would be an appropriate term.- - - - - - - - - - ranking = 1keywords = hypertension (Clic here for more details about this article) |
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