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1/310. Duodenal ulceration into the cystic artery with massive hemorrhage.

    This is a case presentation of a unique cause of intestinal bleeding. A duodenal ulcer eroded into the superficial branch of the cystic artery, causing massive intestinal hemorrhage. The patient, a 76-year-old woman, presented with left upper abdominal and left back pain secondary to cystic lesions in the pancreas body and tail. Stress after operation and complication of leakage of pancreatic juice after distal pancreatectomy with splenectomy and diclofenac sodium administration may have caused a deep peptic ulcer to erode the cystic artery. We performed a transfixing ligation of the bleeding vessel, serosal suture of ulcer of the gallbladder, and simple closure of the duodenal ulcer with covering greater omentum. There were no serious complications after the operation, and the patient made an uneventful recovery.
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ranking = 1
keywords = deep
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2/310. Ileal varices associated with recurrent bleeding in a patient with liver cirrhosis.

    We report a rare case of massive and recurrent bleeding from ileal varices in a patient with hepatitis c virus-positive liver cirrhosis. A 66-year old woman, who had undergone laparotomy and blood transfusion 36 years before (because of an extrauterine pregnancy) and endoscopic sclerotherapy for esophageal varices 1 year previously, was admitted to our hospital with loss of bright red blood per rectum. The bleeding was massive and recurrent, and frequent blood transfusions were required. Endoscopic studies failed to find the bleeding site. In the venous phase of selective superior mesenteric angiography, mesenteric varices in the lower part of the abdominal cavity were observed. laparotomy was performed to control the repeated bleeding which had lasted for more than 1 month. Varices communicating with the right ovarian vein were found on the ileal wall and segmental resection of the ileum was performed. Histological examination demonstrated a massive varicose vein and several dilated veins in the submucosa. The patient's postoperative course was favorable, with no hemorrhagic events during a follow-up of more than 6 months after surgery. Ileal varices should be considered in the diagnosis of a patient who presents with lower gastrointestinal bleeding and portal hypertension.
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ranking = 678.53402537486
keywords = vein
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3/310. Pitfalls of transhepatic portal venography and therapeutic coronary vein occlusion.

    Coronary vein occlusions via transhepatic portography for bleeding esophageal varices was attempted in 24 patients. Problems occurred that either prevented the attempt or resulted in less than adequate occlusion. These included blood flow in the left gastric (coronary) vein toward the liver due to occluded or stenotic splenorenal shunts, spontaneous left gastric vein to inferior vena cava shunts, and failure of powdered Gelfoam and heat-treated autogenous clot to cause permanent occlusion. Of 89 total transhepatic portographies, 65 for diagnosis and 24 for occlusion, major complications occurred in two.
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ranking = 1583.246059208
keywords = vein
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4/310. Pancreatic arteriovenous malformation observed to bleed from the bile duct and a duodenal ulcer: report of a case.

    A 48-year-old man with recurrent episodes of biliary colic and subsequent pancreatitis was admitted to undergo a cholecystectomy. A gastroduodenal fiberscopic examination was performed because of massive melena on the seventh day after admission. It revealed a shallow ulcer on the posterior wall of a duodenal bulbus with rubor and an exposed vessel, which was clipped endoscopically to stop the bleeding. Further observations showed the papilla of Vater to be bleeding from the papilla. A contrast-enhanced abdominal computed tomography scan demonstrated a dilatation of the common bile duct and several dilated vasculatures around the portal vein, some of which drained into the portal vein. Based on the angiography findings, a diagnosis of arteriovenous malformation in the pancreas head was obtained and an embolization of the gastroduodenal artery was performed. Although the melena subsided, he underwent a pylorus-preserving pancreatoduodenectomy to prevent the recurrence of hemorrhaging. The histopathological findings of the bile duct revealed inflammatory cell infiltration and a detachment of the epithelium, except in a small part of the bile duct. A rupture of a damaged vessel inside the bile duct was observed, which was thought to be the cause of hemobilia. Sections of the pancreatic head demonstrated an inflammatory lesion with fibrosis and saponification as well as a large degree of arteriovenous anastomosis. The patient was discharged on the 35th day after the operation following an uneventful postoperative course.
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ranking = 452.35601691657
keywords = vein
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5/310. Intra-operative enteroscopy for obscure gastrointestinal bleeding.

    Small bowel enteroscopy has been reported useful in the non-surgical evaluation of the small intestine in patients with obscure gastrointestinal bleeding but findings may be limited due to incomplete small bowel intubation and a lack of tip deflection. Intra-operative enteroscopy (IOE) is accepted as the ultimate diagnostic procedure for complete evaluation of the small bowel in these patients. Two patients with obscure gastrointestinal bleeding and deep anemia underwent IOE during surgical exploration. Angiodysplastic lesion with a diameter of 3 cm was found at jejunum in the first patient and segmental jejunal resection was performed. Enteroscopy showed red punctate lesions with a diameter of 1-3 mm located at proximal jejunum and extending to the ileum in the second patient. Total jejunal resection was performed. There was no recurrence of gastrointestinal bleeding during 36 months follow-up.
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ranking = 1
keywords = deep
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6/310. Endoscopic management of bleeding ectopic varices with histoacryl.

    Bleeding from antral and duodenal varices is an uncommon feature in patients with portal hypertension. We report a patient with cirrhosis and portal vein thrombosis, who had a massive bleed from antral and duodenal varices. Bleeding was controlled with endoscopic injection of varices using histoacryl. Endoscopic treatment and the relatively uncommon occurrence of antral and duodenal varices are highlighted.
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ranking = 2396.2472859178
keywords = thrombosis, vein thrombosis, vein
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7/310. Congenital hepatic arterioportal fistula complicated with gastrointestinal bleeding treated with transcatheter embolization: case report.

    Congenital hepatic arterioportal fistula (HAVF) is extremely rare in children. We present a patient with congenital hepaticoportal arteriovenous fistula complicated with gastrointestinal bleeding treated using transcatheter arterial embolization. Our patient was the youngest (2 days old) case ever reported with congenital HAVF and the first one to receive arterial embolization for HAVF during childhood. The 3-year-old girl was suggested of having congenital HAVF using Doppler ultrasonography. However, her family refused further investigation, and she was lost to follow-up. Three years later, she was sent to our hospital due to melaena. Repeated ultrasonography revealed dilated intrahepatic portal vein with arterial flow demonstrated using Doppler imaging. No esophageal varices or gastric or duodenal ulcer was seen during endoscopy. angiography showed a HAVF and transcatheter embolization was done simultaneously. Follow-up at one and two weeks post-embolization revealed no more shunt flow within the portal vein, though cystic like dilatation of the portal vein persisted, and no thrombosis was observed. This case emphasizes that transcatheter arterial embolization can be easily and successfully used for treating childhood congenital HAVF. Abnormal dilatation of the portal vein in children needs doppler evaluation and possibly angiography.
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ranking = 2313.550369727
keywords = thrombosis, vein
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8/310. Use of adrenal vein conduit for splenorenal shunts: a case report.

    We report a case with extrahepatic portal venous obstruction (EHPVO), who presented with recurrent bleeding following a previous devascularization procedure and needed an emergency distal spleno-renal shunt (DSRS). Due to technical difficulty because of previous scarring, the adrenal vein was used as a conduit between the splenic vein and renal vein. The shunt's patent and the patient has been bleed-free for 2 years.
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ranking = 1583.246059208
keywords = vein
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9/310. Portal hypertension secondary to arterio-portal fistulae: two unusual cases.

    A 62-year-old male presented with variceal haemorrhage. Investigation demonstrated a fistula between the left gastric artery and portal vein with a porto-systemic gradient of 35 mm Hg. Variceal bleeding was controlled by a transcatheter embolisation of the fistula, but the patient died of septicaemia three weeks later. The second patient, a 42-year-old male who presented with variceal bleeding was shown to have diffuse arterio-venous fistulae involving the right lobe of the liver with a portosystemic gradient of 25 mm Hg. In this case the variceal bleeding was successfully controlled by insertion of a transjugular intrahepatic portosystemic shunt (TIPS). The pathogenesis of portal hypertension in arterioportal fistulae and the role of interventional radiological techniques in the management of variceal bleeding in these patients is discussed.
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ranking = 226.17800845829
keywords = vein
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10/310. Combination of transileocolic vein obliteration and balloon-occluded retrograde transvenous obliteration is effective for ruptured duodenal varices.

    Duodenal varices are a rare site of hemorrhage in patients with portal hypertension, but their rupture is a serious and often fatal event. We report a 65-year-old woman who presented with hematemesis and melena. She was admitted to our department because of prolonged shock, despite having received transfusion of a large volume of blood. Upper gastrointestinal endoscopy revealed nodular varices with active bleeding in the second portion of the duodenum. Endoscopic injection sclerotherapy (EIS) was performed using a tissue adhesive agent, alpha-cyanoacrylate monomer, with only temporary benefit. However, anemia continued to progress after the procedure. Therefore, we combined transileocolic vein obliteration (TIO) with balloon-occluded retrograde transvenous obliteration (B-RIO), using 5% ethanolamine oleate with iopamidol to obliterate the varices. Complete hemostasis was achieved without complications. Neither recurrence of varices nor further bleeding has occurred for over 3 years. We conclude that combined TIO and B-RTO, which can obstruct both the feeding and the draining vessels of duodenal varices to retain the sclerosing agent completely in the varices, is a safe and effective hemostatic measure for ruptured duodenal varices, when EIS has failed to accomplish complete hemostasis.
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ranking = 1130.8900422914
keywords = vein
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