Gastric fundal varices with an exposed microcoil after the combined BRTO and PTO therapy

 

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A 74-year-old man was admitted to our hospital with tarry stool as his chief complaint. He had been suffering from liver cirrhosis (type C) and had a clinical history of receiving treatment for hepatocellular carcinoma. Emergency upper endoscopic examination revealed gastric fundal varices with an erosion, in which a red spot was observed ([Fig. 1]) [1]. There were no other lesions which would result in tarry stool, including the esophageal varices. We therefore concluded that this red spot had caused gastric variceal hemorrhage. We performed a combined balloon-occluded retrograde transvenous obliteration (BRTO) procedure and percutaneous transhepatic obliteration (PTO) [2]. Percutaneous transhepatic portographic images showed that the afferent vein of the gastric varices consisted mainly of the posterior gastric vein ([Fig. 2 a]) and short gastric vein ([Fig. 2 b]), and that the efferent vein was the gastrorenal shunt [3]. Some microcoils were placed in the short gastric vein [4]. An occlusive balloon catheter was inserted through the gastrorenal shunt. The sclerosing agent used for BRTO was slowly infused through the posterior gastric vein in a antegrade manner [2]. In addition, some microcoils were also placed in the posterior gastric vein. Follow-up endoscopic examination after 10 days showed that the microcoil was exposed in the gastric erosion, and contrast-enhanced abdominal computed tomographic images revealed no enhancement of the gastric varices. We therefore concluded that the gastric varices were completely thrombosed ([Fig. 3]). Follow-up endoscopic examination after 2 months showed disappearance of the gastric varices ([Fig. 4]).

Fig. 1 Emergency upper endoscopic examination revealed a gastric fundal varices and b a red spot in the erosion at the top of the varices.

Fig. 2 Percutaneous transhepatic portographic images demonstrated that the gastric varices consisted mainly of a the posterior gastric vein and b the short gastric vein.

Fig. 3 Endoscopic examination after 10 days revealed exposure of the microcoil.

Fig. 4 Endoscopic examination after 2 months showed that the gastric fundal varices had been eradicated.

Although endoscopic treatment options for gastric variceal hemorrhage, such as the injection of cyanoacrylate-based tissue adhesives, alcohol, sclerosants, and the use of band ligation, have been studied, the efficacy or superiority of one therapy over another remains controversial [5]. However, combined BRTO and PTO therapy can obstruct both the feeding and the draining veins of gastric varices, and we suggest that this method can be more effective than the alternatives [2]. In addition, exposure of the microcoil in gastric varices is rare, but is one of the signs of thrombus formation in gastric varices.

Endoscopy_UCTN_Code_CCL_1AB_2AD_3AZ

References

• 1 Sarin S K, Lahoti D, Saxena S P. et al . Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients.  Hepatology. 1992;  16 1343-1349
  CrossrefPubMedGoogle Scholar
• 2 Arai H, Abe T, Takagi H. et al . Efficacy of balloon-occluded retrograde transvenous obliteration, percutaneous transhepatic obliteration and combined techniques for the management of gastric fundal varices.  World J Gastroenterol. 2006;  12 3866-3873
  PubMedGoogle Scholar
• 3 Kiyosue H, Mori H, Matsumoto S. et al . Transcatheter obliteration of gastric varices. Part 1. Anatomic classification.  Radiographics. 2003;  23 911-920
  PubMedGoogle Scholar
• 4 Kiyosue H, Mori H, Matsumoto S. et al . Transcatheter obliteration of gastric varices. Part 2. Strategy and techniques based on hemodynamic features.  Radiographics. 2003;  23 921-937
  CrossrefPubMedGoogle Scholar
• 5 Qureshi W, Adler D G, Davila R. et al . ASGE Guideline: the role of endoscopy in the management of variceal hemorrhage, updated July 2005.  Gastrointest Endosc. 2005;  62 651-655
  CrossrefPubMedGoogle Scholar

H. Kawamoto

Department of Gastroenterology and Hepatology
Okayama University Graduate School of Medicine
Dentistry, and Pharmaceutical Sciences

2-5-1 Shikata-cho
Okayama
700-8558
Japan

Fax: +81-86-223-5991

Email: h-kawamo@md.okayama-u.ac.jp