1/35. Massive esophageal variceal hemorrhage triggered by complicated endotracheal intubation.Esophageal variceal hemorrhage is frequently a catastrophic event. The specific events that trigger variceal rupture are not well understood. Acute elevations in systemic blood pressure and increased splanchnic blood flow, however, may lead to increased intravariceal pressure followed by variceal rupture and hemorrhage. This report describes a strong temporal association between complicated endotracheal intubation and abrupt onset of life-threatening variceal hemorrhage. A 52-year-old man with a history of portal hypertension was intubated emergently for airway protection because of respiratory insufficiency due to sepsis. intubation was complicated by initial inadvertent esophageal intubation and by a peak mean arterial blood pressure of 155 mmHg. At the conclusion of the procedure, the patient sustained large volume hematemesis due to esophageal variceal rupture. This case suggests a risk of triggering variceal hemorrhage as a result of intubation-induced increase in blood pressure. A number of agents, including fentanyl, have been shown to be effective in attenuating the cardiovascular response to intubation. This case report provides strong evidence in support of administering fentanyl, or a suitable alternative adjunctive medication, before intubation of patients with documented portal hypertension and a history of esophageal variceal hemorrhage.- - - - - - - - - - ranking = 1keywords = life (Clic here for more details about this article) |
2/35. Decision analysis of prophylactic treatment for patients with high-risk esophageal varices.BACKGROUND: Clinical decision analyses were conducted to quantify the uncertainty and to identify important factors in selection of prophylactic therapy for patients with esophageal varices. methods: A Markov model compared variceal ligation, beta-blockers, and "watchful waiting" strategies in terms of bleeding-free life years. Transition probabilities were obtained from meta-analyses of published data. A hypothetical 50-year-old white man with high-risk esophageal varices and cirrhosis served as the prototypical baseline case. Traditional n-way sensitivity analyses were applied to clarify the influence of each factor, and Monte Carlo probabilistic sensitivity analyses were used to investigate clinical uncertainty. RESULTS: Probabilistic sensitivity analyses demonstrated that 77.0% of hypothetical cases had more bleeding-free life years after variceal ligation, whereas 23% had more when treated with beta-blockers. On the basis of one-way sensitivity analyses, only 2 factors (variceal bleeding rates after ligation and treatment with beta-blockers) influenced the strategy choice. CONCLUSIONS: Variceal ligation is an effective prophylactic therapy in many cases, but nearly one quarter of patients with high-risk esophageal varices and cirrhosis may benefit more from prophylactic treatment with beta-blockers. Additional clinical studies identifying key variceal bleeding risk factors may lead to more effective clinical decision making for these patients.- - - - - - - - - - ranking = 2keywords = life (Clic here for more details about this article) |
3/35. Arterio-portal shunt in liver rescued by hepatectomy after arterial embolization.Arterio-portal shunts are generally treated with transcatheter arterial embolization, as a therapeutic measure for bleeding of esophageal varices. However, transcatheter arterial embolization is frequently associated with reestablishment of arterio-portal shunts. We now report our experience with partial hepatectomy to remove the arterio-portal shunt associated with esophageal varices, which recurred after transcatheter arterial embolization. The patient was a 60-year-old female, who had massive hematemesis caused by rupture of esophageal varices. Doppler sonography and arteriography demonstrated an arterio-portal shunt in the right anterior superior segment of the liver. Temporary hemostasis was achieved with transcatheter arterial embolization, however, hemorrhage recurred one month later. The second transcatheter arterial embolization failed to manage the shunt and varices. The patient developed hepatic coma. After recovery from coma, she was referred to our hospital. We carried out partial hepatectomy, which provided remarkable hemodynamic improvement; the portal vein flow changed from hepatofugal to hepatopetal. Esophageal varices and hepatic coma have totally disappeared. This patient has had no complaint and has remained free of esophageal varices, for 3 years postoperatively. She is having a normal life. The partial hepatectomy to remove the arterio-portal shunt induced complete resolution of the arterio-portal shunt, as well as dramatic improvement in portal flow and hepatic coma. Our experience in the present case suggests that partial hepatectomy should be considered as a radical therapy for arterio-portal shunt, without insistence on transcatheter arterial embolization.- - - - - - - - - - ranking = 1keywords = life (Clic here for more details about this article) |
4/35. Bleeding duodenal varices after gastroesophageal varices ligation: a case report.Duodenal varices are rarely occurring sites of hemorrhage in patients with portal hypertension, and such hemorrhaging can be a life-threatening event. We report the case of a 58-year-old woman with cirrhosis who presented with melena after successful ligation of gastroesophageal varices 1 week earlier. Upper gastrointestinal endoscopy revealed bleeding duodenal varices in the second portion of the duodenum, which was considered to be the source of the bleeding. Endoscopic injection sclerotherapy with histoacryl and lipiodol achieved successful hemostasis. Nonetheless, the sclerosant spread to the lungs via a portosystemic shunt, causing a pulmonary embolism. This is a rare complication seldom reported in the world literature.- - - - - - - - - - ranking = 1keywords = life (Clic here for more details about this article) |
5/35. Splenic embolization in treatment of portal vein occlusion deferring liver transplantation.The number of liver transplantations performed in this country is limited to the availability of cadaver liver donors, which are always short of demand. Deterioration of patient's clinical condition during the long wait for a compatible donor usually casts a poor prognosis on the patient. We report a 6-year-old girl who underwent splenic artery embolization as an alternative procedure due to a life-threatening clinical condition while liver graft was not immediately available. She was a case of idiopathic portal hypertension with portal vein occlusion that had resulted in splenomegaly, pancytopenia, gastric and esophageal varices. Living graft transplantation was contraindicated due to portal vein lesion. She was listed as high-urgency for liver transplantation as she developed repeated esophageal variceal bleeding requiring frequent sclerotherapy and admission to the intensive care unit. Prevention of the ongoing worsening clinical complications, improvement of hematological disorders and correction of hypersplenism was achieved right after splenic artery embolization. The patient resumed normal daily life and has been successfully eliminated from the waiting list of liver transplantation. We conclude that this is a safe and effective alternative to splenectomy that might call of further liver transplantation.- - - - - - - - - - ranking = 2keywords = life (Clic here for more details about this article) |
6/35. Gastric microcirculation and acute gastric mucosal lesions in patients with hepatic cirrhosis.We endoscopically investigated gastric microcirculation using a laser-Doppler flowmeter and acute gastric mucosal lesions (AGML) during a 3-year follow-up period in patients with hepatic cirrhosis. Gastric microcirculation tends to decrease in patients with hepatic cirrhosis, especially when gastric mucosal hemorrhage or mucosal petechiae are observed endoscopically. Total gastric resection was performed for gastric hemorrhage due to AGML in three patients, two of whom had good liver function--child's grade A--and survived more than 5 years with a good quality of life, but one patient with child's grade C experienced poor quality of life and died within 2 years after surgery. We conclude that decreased gastric microcirculation plays a role in the occurrence of AGML in patients with hepatic cirrhosis. Total gastric resection should be carefully considered for hemorrhagic gastritis in patients with child's grade C hepatic cirrhosis.- - - - - - - - - - ranking = 2keywords = life (Clic here for more details about this article) |
7/35. An evidence-based medicine approach to beta-blocker therapy in patients with cirrhosis.disease management strategies have gained attention in recent years because of their potential to improve health-related quality of life and prevent excessive resource use. Despite recognition as an important cause of mortality, cirrhosis with portal hypertension has not been widely discussed as a condition amenable to planned care management. Given the effect of variceal hemorrhage as the most immediate life-threatening complication of portal hypertension, a number of high-quality controlled clinical trials have confirmed the efficacy of beta-blocker therapy for primary and secondary prophylaxis. Despite the existence of practice guidelines that incorporate this information, specific clinical scenarios that demand consideration for beta-blocker therapy have not been well described. In this article, a number of hypothetical patient-based cases drawn from the authors' experiences are utilized to illustrate these issues.- - - - - - - - - - ranking = 2keywords = life (Clic here for more details about this article) |
8/35. Transjugular intrahepatic portacaval stent shunt as a rescue treatment for life-threatening variceal bleeding in a cirrhotic patient with severe liver failure.Variceal bleeding in cirrhotic patients with severe liver failure that is not controllable by endoscopic sclerotherapy is a life-threatening situation. We report the case of a patient with decompensated cirrhosis (Pugh class C) who bled repeatedly from gastric varices despite multiple sessions of sclerotherapy. The portal vein was catheterized by a transjugular approach. A tract between a hepatic vein and the portal vein was created after balloon dilatation, and this opening was stented with an expandable stainless steel Palmaz stent. The portal vein pressure decreased from 35 mm Hg to 19 mm Hg after shunting. Gastric varices also were embolized. Two months later, bleeding had not recurred; the shunt remained opened and the marked decrease in portal pressure still persisted. endoscopy showed the disappearance of gastric varices. This procedures could become a life-saving therapeutic option for such critically ill cirrhotic patients.- - - - - - - - - - ranking = 6keywords = life (Clic here for more details about this article) |
9/35. Terlipressin-related acute myocardial infarction: a case report and literature review.Acute ST-segment elevation myocardial infarction after the administration of terlipressin in patients with hemorrhagic esophageal varices is a rare but life-threatening complication. We report the case of a 73-year-old female patient with esophageal variceal bleeding complicated with acute ST-segment elevation myocardial infarction after intravenous injection of terlipressin. We discuss the underlying mechanisms of terlipressin-related acute myocardial infarction and review the literature.- - - - - - - - - - ranking = 1keywords = life (Clic here for more details about this article) |
10/35. death related to albendazole-induced pancytopenia: case report and review.albendazole is a benzimidazole with wide spectrum coverage as an antiparasitic drug. Reported side effects have been minimal. We report the case of a patient who died with severe prolonged pancytopenia beginning during the third week of therapy for a pulmonary echinococcal cyst. This case was a 68-year-old man who presented with a large cystic lung mass. His medical history was significant for child-Pugh class B cirrhosis. A prolonged course of albendazole was initiated. Two weeks later, the patient presented in septic shock with severe pancytopenia. The patient was initially resuscitated, but died after 10 days with no marrow recovery. autopsy was consistent with albendazole-induced pancytopenia. This is the third human case of pancytopenia and the first death reported in relation to albendazole-induced pancytopenia. neutropenia seems to be related more to higher dosage and longer duration of use. albendazole sulfoxide peak dose and half life are significantly prolonged by liver disease and concomitant administration of certain drugs. The severity and duration of albendazole-induced pancytopenia in this case was likely related to the underlying liver disease. Frequent serial monitoring of blood counts and cessation of medication with any evidence of marrow toxicity in such patients is warranted.- - - - - - - - - - ranking = 1keywords = life (Clic here for more details about this article) |
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