Portal hypertension: Imaging of portosystemic collateral pathways and associated image-guided therapy

Portal hypertension is a common clinical syndrome, defined by a pathologic increase in the portal venous pressure. Increased resistance to portal blood flow, the primary factor in the pathophysiology of portal hypertension, is in part due to morphological changes occurring in chronic liver diseases. This results in rerouting of blood flow away from the liver through collateral pathways to low-pressure systemic veins. Through a variety of computed tomographic, sonographic, magnetic resonance imaging and angiographic examples, this article discusses the appearances and prevalence of both common and less common portosystemic collateral channels in the thorax and abdomen. A brief overview of established interventional radiologic techniques for treatment of portal hypertension will also be provided. Awareness of the various imaging manifestations of portal hypertension can be helpful for assessing overall prognosis and planning proper management.

Optimizing management of pancreaticopleural fistulas

AIM:To evaluate the management of pancreaticopleural fistulas involving early endoscopic instrumentation of the pancreatic duct.METHODS:Eight patients with a spontaneous pancre-aticopleural fistula underwent endoscopic retrograde cholang iopancreatography(ERCP) with an intentionto stent the site of a ductal disruption as the primarytreatment. Imaging features and management were evaluated retrospectively and compared with outcome.RESULTS:In one case,the stent bridged the site of aductal disruption. The fistula in this patient closed with in3 wk. The main pancreatic duct in this case appearednormal,except for a leak located in the body of the pancreas. In another patient,the papilla of Vater couldnot be found and cannulation of the pancreatic ductfailed. This patient underwent surgical treatment. In the remaining 6 cases,it was impossible to insert a stentinto the main pancreatic duct properly so as to coverthe site of leakage or traverse a stenosis situated down-stream to the fistula. The placement of the stent failed because intraductal stones(n = 2) and ductal strictures(n = 2) precluded its passage or the stent was too short to reach the fistula located in the distal part of the pancreas(n = 2) . In 3 out of these 6 patients,the pancre-aticopleural fistula closed on further medical treatment.In these cases,the main pancreatic duct was normalor only mildly dilated,and there was a leakage at the body/tail of the pancreas. In one of these 3 patients,additional percutaneous drainage of the peripancre atic fluid collections allowed better control of the leakageand facilitated resolution of the fistula. The remaining3 patients had a tight stenosis of the main pancreatic duct resistible to dilatation and the stent could not beinserted across the stenosis. Subsequent conservative treatment proved unsuccessful in these patients. Aftera failed the rapeutic ERCP,3 patients in our series developed superinfection of the pleural or peripancreatic fluid collections. Four out of 8 patients in our series required subsequent surgery due to a failed non-operative treat-ment. Distal pancreatectomy with splenectomy was performed in 3 cases. In one case,only external drainage of the pancreatic pseudocyst was done because of diffuse peripancreatic inflammatory infiltration precluding safe dissection. There were no perioperative mortalities.There was no recurrence of a pancreati copleural fistulain any of the patients.CONCLUSION:Optimal management of pancreaticopleural fistulas requires appropriate patient selection that should be based on the underlying pancreatic ductab normalities.

Conservative management of perforated duodenal diverticulum: A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.

Should anticoagulants be administered for portal vein thrombosis associated with acute pancreatitis?

Venous complications in patients with acute pancreatitis typically occur as a form of splenic,portal,or superior mesenteric vein thrombosis and have been detected more frequently in recent reports.Although a well-organized protocol for the treatment of venous thrombosis has not been established,anticoagulation therapy is commonly recommended.A 73-year-old man was diagnosed with acute progressive portal vein thrombosis associated with acute pancreatitis.After one month of anticoagulation therapy,the patient developed severe hematemesis.With endoscopy and an abdominal computed tomography scan,hemorrhages in the pancreatic pseudocyst,which was ruptured into the duodenal bulb,were confirmed.After conservative treatment,the patient was stabilized.While the rupture of a pseudocyst into the surrounding viscera is a well-known phenomenon,spontaneous rupture into the duodenum is rare.Moreover,no reports of upper gastrointestinal bleeding caused by pseudocyst rupture in patients under anticoagulation therapy for venous thrombosis associated with acute pancreatitis have been published.Herein,we report a unique case of massive upper gastrointestinal bleeding due to pancreatic pseudocyst rupture into the duodenum,which developed during anticoagulation therapy for portal vein thrombosis associated with acute pancreatitis.

An endoluminal aortic prosthesis infection presenting as pneumoaorta and aortoduodenal fistula

Herein, we present a case of pneumoaorta and aorto-duodenal fistula (ADF) caused by an endoluminal aortic prosthesis infection. An 82-year-old man underwent endovascular aneurysm repair with a stent graft to exclude a 5.1-cm abdominal aortic aneurysm. Three months after the index procedure, the patient was taken to the emergency department at a medical university hospital. He presented with a 2-d history of bloody diarrhea. An endoluminal aortic stent graft infection was diagnosed, and an ADF was identified. The patient died of septic shock despite emergency surgery and intensive care. When encountered, stent graft infections require appropriate antibiotics and graft explantation.The diagnosis of an ADF is important, and surgery remains the most effective management if septic shock presents despite conservative treatment.

65 CASES OF PRESERVING PYLORUS PANCREATODUODENECTOMY：EXPERIENCE AND PROBLEMS

Sixty-five patients with neoplasm (62 cases) or pancreatitis (3 cases) were treated with preserving pylorus pancreatoduodenectomy (PPPD) from 1984 to 1991. One postoperative death occurred. Follow-up studies were performed in 35 patients who had been treated by PPPD or the standard Whipple's procedure; they were questioned carefully concerning clinical symptoms. Further studies were porformed in 20 patients with or without pylorus preservation (10 patients, respectively). Nutritional status and gastrointestinal digestive and absorptive functions were evaluated by detemination of serum components, gastric analysis, barium emptying time, D-xylose absorption test,14CO2 breath test, PABA, and other methods. The results demonstrated malnutrition and postgastrectomy syndromes in some patients after the standard Whipple' s procedure, but not in those with PPPD. The quality of life was better in the latter. Pylorus preservation may be the main reason for this above difference. Delayed gastric emptying in the early postoperative period was a complication in some patients(21%) treated by PPPD.We recommend PPPD for pancreatoduodenectomy.

Ligamentotaxis for comminuted fracture of capitate： a case report

We present the technical report for treat- ment of comminuted fracture of the capitate with ligamentotaxis. The base of third metacarpal was found to be fractured with comminution of the capitate. The decrease in carpal height index and comminution of the third metacar- pal base lead to dilemma between conservative treatment and surgical management of this particular injury. The sur- gical management was chosen to maintain the carpal height index of the wrist to prevent the late degenerative changes.The patient was applied with external fixator in distraction mode expanning the wrist joint for six weeks, and the wrist was mobilised after removal of the fixator. It is shown that the external fixator in distraction mode expanning the wrist joint is a good alternative method for treatment of capitate fracture.