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An ‘illuminating’ CT
  1. R H Westbrook,
  2. D Joshi,
  3. A Prachalias
  1. Institute of Liver Studies, King's College Hospital, London, UK
  1. Correspondence to Dr R H Westbrook, Institute of Liver Studies, King's College Hospital, Denmark Hill, London SE59RS, UK; rachel.westbrook{at}nhs.net

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Clinical case

A 56-year-old man with moderate fibrosis (F4, Ishak Fibrosis Score) secondary to non-alcohol-related fatty liver disease was transferred to our centre for the management of bleeding gastric varices. At the time of his index variceal bleed in June 2008, oesophago-gastro-duodenoscopy (OGD) demonstrated a large bleeding type 2 gastro-oesophageal fundal varix. Haemostasis was achieved with the injection of N-butyl-2-cyanoacrylate (histoacryl glue) and lipoidal and commencement of β blockers. He remained well until March 2010 when he represented with haematemesis. Repeat OGD showed active bleeding from the fundal gastric varix. Haemostasis was not achieved despite four repeat OGDs with a total of 19 ml of histoacryl glue and lipoidal injection.

The patient was assessed for a transjugular intrahepatic portosystemic shunt procedure and therefore underwent a contrast-enhanced abdominal CT scan (figures 1 and 2). Portal pressure studies revealed a short gastric varix pressure of 38 mm Hg, splenic vein pressure of 22 mm Hg, portal confluence pressure of 13 mm Hg and an inferior vena cava and right atrial pressure of 9 mm Hg.

Question

What does figure 1 demonstrate and what do the portal pressure studies indicate?

See page 1132 for answer

Answer

From question on page 1067

Figures 1 and 2 demonstrate intrahepatic histoacryl glue and lipoidal deposition in all branches of the intrahepatic portal vein but with patent extrahepatic portal vasculature. Splenomegaly and splenic varices are evident. The portal pressure study results are consistent with segmental left-sided portal hypertension. The histoacryl glue and lipoidal were deposited in the intrahepatic portal veins following drainage along a pressure gradient from the short gastric varices via the left gastric system into the portal vein.

Gastric varices resulting from segmental splenic hypertension are a rare and challenging cause of upper gastrointestinal bleeding especially in patients with a pre-existing diagnosis of underlying liver disease.1 A splenic vein thrombosis secondary to pancreatic disease is the most common aetiology, but multiple rare causes have been reported.2 Pressure studies are diagnostic with elevated pressures limited to the splenic and short gastric veins. Conventional treatment for variceal haemorrhage is often unsuccessful and splenectomy is usually required.3 Patients without a malignant cause usually have an excellent prognosis due to the absence of significant underlying liver disease.4 Our patient ultimately underwent a splenectomy and remained well on follow-up.

References

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Footnotes

  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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