Shinobu Sakurai

Duodenal erosions, a common and distinctive feature of portal hypertensive duodenopathy

OBJECTIVE:The aim of the present study was to assess the presence of duodenal erosion and its clinical characteristics on endoscopy in patients with portal hypertension who had undergone endoscopic injection sclerotherapy and/or endoscopic variceal ligation for esophagogastric varices.METHODS:The subjects were 440 patients with portal hypertension, 450 with chronic hepatitis as a related control group, and 450 who underwent upper endoscopic examination as part of their routine physical examination as the controls. The underlying hepatic disease, hepatic function, and endoscopic findings of duodenal erosion among the patients with portal hypertension were studied.RESULTS:Duodenal erosion was found in 68 patients with portal hypertension (68 of 440, 15.5%), four patients with chronic hepatitis (four of 450, 0.9%), and two controls (two of 450, 0.4%). The incidence of duodenal erosion among the patients with portal hypertension was significantly higher than that in the other two groups (p < 0.01, p < 0.01, respectively). The lesions commonly observed in duodenitis are speckle erosions mainly located in the duodenal bulb. However, the most frequently seen form of duodenal erosion among the patients with portal hypertension extended from the superior portion to the descending portion, and tended to show a circular alignment along the Kerckrings folds. The patients with portal hypertension with reduced hepatic reserve capacity had more severe duodenal erosion. Endoscopic ultrasonography revealed thickening of the duodenal wall and proliferation of vascular structures within and around the wall. The histological findings of the duodenal erosion included edema and vascular dilation in the mucosal and submucosal layers.CONCLUSIONS:The location of duodenal erosion in patients with portal hypertension differs from that in patients with ordinary duodenitis. Duodenal erosion in patients with portal hypertension is considered to be one of the lesions of portal hypertensive duodenopathy.

Clinical utility of sequential imaging of hepatocellular carcinoma by contrast-enhanced power Doppler ultrasonograpy

The aim of this study was to investigate the clinical utility of sequential imaging of hepatocellular carcinoma (HCC) by contrast-enhanced power Doppler ultrasonograpy (CE-PDUS) to differentiate hepatocellular carcinoma from adenomatous hyperplasia (AH) and regenerated nodule (RN) and to predict the degree of differentiation of HCC. Fifty-one patients with 62 hepatic lesions including 33 moderately and poorly differentiated HCCs, 19 well-differentiated HCCs, seven AHs and three large RNs were examined by CE-PDUS. The imaging patterns during early arterial phase (tumor vessel image), late vascular phase (tumor perfusion image) and post-vascular phase (liver perfusion image) were classified as diffuse, basket, peripheral, central and no enhancement; as whole tumor, partial tumor and no enhancement; as whole tumor, partial tumor and no defect, respectively. The diffuse pattern in the tumor vessel image, the whole enhancement pattern in the tumor perfusion image and the whole defect pattern in the liver perfusion image were observed in moderately and poorly differentiated HCCs only. The basket pattern in the tumor vessel image and the partial defect pattern in the tumor perfusion image were observed in HCCs only. All AH/RNs showed no defect pattern in the liver perfusion image. The sequential imaging of HCC during early arterial, late vascular and post-vascular phases by CE-PDUS is clinically useful to differentiate HCC from AH/RN and to predict the degree of differentiation of HCC.

Usefulness of contrast-enhanced wide-band Doppler ultrasonograpy to diagnose alveolar echinococcosis of the liver and evaluate the effect of the treatment

Alveolar echinococcosis is a rare parasitic disease caused by Echinococcus multicularis and most commonly involves the liver. Early diagnosis and accurate evaluation of the effect of the treatment are essential to improve the prognosis of patients with alveolar echinococcosis of the liver (AEL). The aim of this study was to demonstrate the characteristic imaging of AEL by contrast-enhanced Dynamic Flow (CE-DF) employing a wide-band Doppler technique for the diagnosis and the accurate evaluation of the effect of the treatment. Four patients with five AEL lesions before treatment or during medication were examined by CE-DF. All of the five AEL lesions examined by CE-DF revealed a defect with an irregular and distinct margin like a worm-eaten defect appearance, which was never observed on other hepatic lesions, in liver perfusion image during post-vascular phase. In addition, CE-DF made it possible to measure the size of AEL lesions accurately because the margin was detected distinctly. These data suggest that CE-DF is clinically useful for the diagnosis of AEL and the evaluation of the effect of the treatment.

Endoscopic Variceal Ligation of Bleeding Rectal Varices: A Case Report

The incidence of ectopic varices in the rectum is likely to increase with improvements in the treatment and survival of patients with portal hypertension. If a patient with portal hypertension suffers massive lower gastrointestinal hemorrhage, it is important to perform a detailed endoscopic examination, as there is a possibility of rectal varices. Although a standard therapy for rectal varices has not been established, we encountered a case of rectal varices that was successfully treated with endoscopic variceal ligation alone. Endoscopic variceal ligation is minimally invasive, safe, effective, simple and reliable. Endoscopic variceal ligation is promising as a possible first line of therapy for rectal varices.

Enlarging splenic vein aneurysm associated with increasing portal hypertension

To the Editor: Since splenic vein aneurysm was initially reported by Lowenthal et al.1 in 1953, fewer than ten cases have been reported in the English-language literature. Moreover, splenic vein aneurysm that develops progressively and expands is very rare.2 Here, we report a recently observed case of splenic vein aneurysm that developed and enlarged with the advance of portal hypertension. A 48-year-old woman was admitted to Asahikawa Medical College Hospital in 1989 for the purpose of treating esophageal varices. She was diagnosed as having idiopathic portal hypertension by several examinations, including liver biopsy under laparoscopy, and angiography. The esophageal varices were treated by endoscopic injection sclerotherapy (EIS) three times in 1989 and twice in 1992. In 1992, there was no abnormal finding in the splenic vein on computed tomography (CT). However, a 15mm-diameter saccular dilatation of the splenic vein was initially detected by magnetic resonance imaging (MRI) in 1995 (Fig. 1a). Moreover, this saccular dilatation gradually enlarged, and the diameter had increased to 35 mm on contrast-enhanced CT in 1999 (Fig. 1a). This saccular dilatation of the splenic vein was confirmed as an aneurysm by gray-scale endoscopic ultrasonography (EUS) (Fig. 2a) and by portal venogram after celiac angiography (Fig. 2b). The patient has been treated for this aneurysm with the oral administration of propranolol (a b-blocker) to decrease the portal pressure. Surgical treatment, has not been performed according to the patient’s wishes, although we fully informed her of various risks, including the risk of rupture. In April 2005, the aneurysm had not changed in size compared with findings in August 1999 (Fig. 1a). The mechanism whereby aneurysm of the portal venous system develops is still unclear. Long-standing portal hypertension has been reported as one possible mechanism.3 However, aneurysm of the portal venous system has been found in younger patients without portal hypertension, so congenital vascular anomalies have been thought to be another possible mechanism.4 As shown in Fig. 1, our patient showed progression of splenomegaly on CT and MRI and thrombopenia after EIS for the treatment of esophageal varices. These phenomena suggested that the interruption of portal blood flow through the left gastric vein by EIS may have caused exacerbation of the portal hypertension and increased blood flow toward the spleen. Furthermore, development and enlargement of the splenic vein aneurysm was observed in parallel with the progression of splenomegaly and thrombopenia (Fig. 1a, b). Therefore, it was considered that the exacerbation of portal hypertension had caused the development and enlargement of the splenic vein aneurysm in our patient, although there was a possibility that she had a latent congenital vascular anomaly. The rupture1,3,5 of an aneurysm is directly connected to sudden death. However, the standards for indications and selection of treatment for portal venous system aneurysms, including surgical treatment, have not been established. We will urge our patient to undergo removal of the splenic vein aneurysm, with the formation of a spleno-renal shunt or splenectomy, if the aneurysm suddenly enlarges.

Adrenal adenoma mimicking a submucosal tumor of the stomach

The widespread use of diagnostic imaging modalities has increased the incidental detection of adrenal masses. We experienced a case of adrenal adenoma that was detected incidentally on mass X‐ray examination of the stomach, with findings that were initially suggestive of a gastric submucosal tumor. Only a few cases of adrenal adenoma that resembles a gastric submucosal tumor on diagnostic imaging have been reported. In addition, only a few papers have described the endoscopic ultrasonography findings of adrenal tumors. As the preoperative endoscopic ultrasonography findings of the tumor in our patient correspond with the features of the cut surface of the resected tumor, endoscopic ultrasonography appears to be useful as a new imaging technique in the diagnosis of adrenal adenoma. As endoscopic ultrasonography is minimally invasive, it can be performed in an outpatient setting to collect useful information. As adrenal tumors can be visualized relatively easily, the presence of adrenal lesions should also be searched for when endoscopic ultrasonography is performed for biliary or pancreatic disorders.

7152 Clinical study of rectal varices-examination of characteristics of rectal varices having susceptibility to hemorrhage-.

[Backgroud and Aim] Since it is now possible for cases of portal hypertention to live for a long period of time accompanying the progress made in various treatments in recent years, there is a high possibility of rectal varices occupying an important position as a cause of lower digestive tract bleeding that occurs in these cases. There are many aspects relating to the etiology and pathology of rectal varices that remain unknown, however and a treatment has yet to be established.We conducted a clinical study of rectal varices to examine characteristic findings of varices having susceptibility to hemorrhage. [Subjects] The patients consisted of 28 cases of rectal varices among 413 cases of portal hyper-tension under observation at our institution (13 men, 15women, mean age: 62.8yr(range 46-78 ). [Results] Esophageal varices were observed in all 28 cases ,and hepatocellular carcinoma was observed in 4 cases. Bleeding from rectal varices was observed in 13 of 28 cases (46%), bleeding was treated by preservative hemostasis in 6 cases, surgical ligation in 3 , PSE in 1, combined EVL and EIS in 1, EIS alone in 1, and EVL alone in 1. When the 28 cases were examined according to the Child-Pughclassification, bleeding from rectal varices was observed in 6 of 16 classified as Child A, 7 of 11 classified as Child B, and 0 of 1 classified as Child C. Although the rate of bleeding tended to increase with exacerbation of hepatic function, there were no significant differences observed. In addition, an examination of the presence of complication by internal hemorrhoid revealed that, in contrast to internal hemorrhoid only being observed in 2 of 15 non-hemorrhagic cases, it was observed in 11 of 13 hemorrhagic cases,indicating a significant difference. [Conclusions] An examination of the characteristics of hemorrhagic rectal varices revealed that the rate of bleeding tends to increase with exacerbation of hepatic function. In addition, complication by internal hemorrhoid was significantly higher in hemorrhagic cases.With respect to the susceptibility to hemorrhage in rectal varices, it is believed that not only the morphology of the varix itself, but also numerous other factors, such as the status of hepatic function, other collateral circulation paths including the esophagus and stomach and the presence of internal hemorrhoid, are involved.