[GastrointestinaI Findings in Liver Diseases]
1. Esophageal varix
The most common gastrointestinal findings in patients with chronic liver disease is esophageal varix. Description of esophageal varix was originally proposed by Japaneses doctors, and there are a few modified methods.
At Samsung Medical Center, we try to describe as much information as possible, like the form, the location, the color, the existence of red color sign, the bleeding signs, the mucosal change. Followings are some examples.
- Esophageal varix, FlLmCb, RCS3, spurting bleeding
- Esophageal varix, FsLlCw, RCS0, scar
If you want to see how we describe esophageal varix at Samsung Medical Center, press here.
2. Early esophageal varix
In patients with chronic liver diseases, there may be faint linear bluish venous distentions at the far distal esophagus. The clinical significance is uncertain. I would use the term 'early esophageal varix'. In this issue, there may be some arguments.
애독자 의견: LC 환자에서 varix라고 보기에는 어려우나 보여주신 사진과 같이 향후 varix로 발전할 수 있는 phlebectasia가 보이는 경우 early esophageal varix라고 진단을 주시는 분들이 있습니다. 저간의 사정을 잘 아는 제 삼자라면 이 의미를 잘 유추할 수 있겠으나, 그렇지 않은 경우는 환자에게 과다한 warning을 하여 불안에 떨게 만들거나, 심지어는 EVL을 하라고 입원을 강요하는 경우도 있습니다. 말미에 말씀하신 바와 같이 향후 definite varix로 progression할 가능성은 있으나. 아직 이 단독으로는 임상적 의미가 크지 않은 병변을 early esophageal varix라고 명명하시면, 혹 독자들 중 일부가 이를 치료의 대상으로 여기지 않을까 하는 우려가 되어 좁은 소견을 올립니다.
3. Bleeding from esophageal varix
Bleeding is the most important complication of esophageal varix. If you are lucky (or unlucky), you can see a spurting. Band ligation is the treatment of choice.
Alcoholic LC with variceal bleeding 환자로 EVL를 시행하기 위하여 내시경을 시행하였습니다. Incisor teeth로부터 33cm 6시 방향에 varix로부터 pumping하는 bleeding이 관찰되었습니다. Band ligation을 위해 cap을 장착하고 출혈병소에 접근하였으나 가운데 그림처럼 cap안으로 blood가 차 올라 시술을 시행할 수 없었습니다. 우선 병소의 아래쪽에 2개의 band ligation을 시행하였으며 active bleeding은 멎었습니다. Esophagogastric juction부위에서 몇 개의 band ligation을 더 시행한 후 출혈병소에 대한 band ligation을 시행하였습니다. 활동성 출혈이 있는 variceal bleeding의 경우 본 증례처럼 병소보다 아래쪽에서 우선적으로 band ligation을 하여 지혈부터 시도하는 것이 좋을 때가 있습니다.
4. Bleeding from hematocyst near anastomosis site after Ivor-Lewis operation
Early esophageal cancer was found near multiple esophageal varix, so Ivor-Lewis operation was done. A few months after the surgery, the patient developed massive upper GI bleeding. In endoscopy, there was a hematocyst just below the anastomosis site. It may be related with the portal hypertension.
5. Blood flow in portal hypertension
6. Surgical or interventional methods for esopahgel/gastric varix
7. Gastric varix
Gastric varices are found in about one in five patients with portal hypertension. About 5% tl 10% of patients with gastric varices may not have esophageal varices.
Gastric varices are more difficult to detect by endoscopy especially if they are small and isolated. Small varices in the fundus are often mistaken for a mucosal fold. Their identity as varices is based on their shape (grapelike clusters) and their bluish tinge. [Ginsberg textbook 2005]
Sometimes, gastric varix can be mistaken as a SMT. Never try to take biopsy from suspicious gastric varix. It may be fatal.
If you want to see how we describe gastric varix at Samsung Medical Center, press here.
8. Evidence of recent bleeding from gastric varix
This is a very rare finding. An ulcer with exposed vessel was seen on top of gastric varix.
Balloon-occluded retrograde transvenous obliteration (BRTO) is one of treatment methods for gastric varix. Ethanolamine oleate is commonly used as the sclerosing agent.
PTVO (percutaneous transhepatic variceal obliteration) is an alternative modality for gastric varix when BRTO is impossible.
11. Fatal bleeding from duodenal varix
In portal hypertension, varices can also develop in other parts of the GI tract including the anorectal region, colon, and small intestine. Portal hypertensive gastropathy, colopathy, and enteropathy are other sequelae.
Primay duodenal varices are rare and are usually found incidentally at the time of endoscopy, more often in patients with extrahepatic portal vein obstruction or in cirrhotics with portal vein thrombosis. Usually the afferent vessel of the duodenal varices is the superior or inferior pancreaticoduodenal vein originating in the portal vein trunk or superior mesenteric vein. The efferent vain drains into the inferior vena cava. In a review of 169 cases of bleeding ectopic varices, 17% occurred in the duodenum, 17% in the jejunum or ileum, 14% in the colon, 8% in the rectum, and 9% in the peritoneum. [Ginsberg textbook 2005]
12. Classification of portal hypertensive gastropathy
Endoscopic findings of portal hypertensive gastropathy include reddening, moasic pattern, discrete red spots, diffuse hemorrhagic lesion. There are many classifications, but they are seldom used.
13. Portal hypertensive gastropathy
If you want to see how we describe portal hypertensive gastropathy at Samsung Medical Center, press here.
14. Gastrointestinal findings of hepatocellular carcinoma
1. Extrahepatic metastasis in HCC (30-75%)
- Lung, lymph nodes, bones, heart
- 3 routes: direct invasion, hematogenous metastasis, lympogenous meta
2. Gastrointestinal involvement (4-12%)
- M/C site: duodenum, stomach, colon, jejunum
- Contiguous GI tract via adhesion to the serosal side by a bulky tumor mass
- Associated with an extremly poor prognosis
- M/C symptom: bulky tumor burden & persistant occult or flank GI tract bleeding
15. Bleeding from duodenal invasion of hepatocellulcar carcinoma
Direct invasion of the duodenum by HCC is rare. Sometimes it may cause a severe GI bleeding. In a prospective study from Hong Kong, 26 of the 55 HCC patients (47%) who presented with GI hemorrhage had bleeding from varices. Peptic ulceration was the second most common cause. Direct tumor invasion into the GI tract was found in only three patients. All three patients had tumors invading the duodenum.
16. Duodenal invasion of embryonal cell carcinoma of liver
17. Huge gastric mass due to HCC recur
18. HCC metastasis to the colon
Colonic metastasis from HCC is quite rare. There are only a few case reports (Kozaki 2008, Cosenza 1998, Fukui 1992).
19. Anal varix in a patient with liver cirrhosis
In the lower GI tract, collaterals between the superior hemorrhoidal vein (portal) and the middle and inferior hemorrhoidal veins (systemic) result in anal and rectal varices. Hemorrhoids must be differentiated from anal varices; the former appear as purple, well-vascularized mucosa in the lower 4 cm of the anal canal. Varices in the anal canal appear as either discrete vein or saccular blue or slate grey swellings. Rectal varicex start above the pectinate line and are easy to diagnose. [Ginsberg textbook 2005]
a fatal case
20. Rectal varix in a patient with liver cirrhosis
21. Extrinsic compression due to liver cyst
22. Extrinsic compression due to liver hemangioma