Advertisement

Aberrant Varices

  • Kunio Okuda
  • Kenichi Takayasu

Abstract

Although dilatation of veins occurs anywhere within the abdomen in portal hypertension, by far the most common site of varix formation is the lower esophagus, followed in frequency by the gastric fundus and along the paraumbilical vein. The reason for the esophagus being the most common site of varix formation may be the short distance to the systemic circulation (azygos vein) along the left gastric-esophageal veins and a decreased arteriovenous flow resistance in the left gastric venous area demonstrated in cirrhosis [1]. The exact mechanism whereby an uncommon vein dilates and forms varices is not known. Probably, certain congenitally large veins simply dilate, forming varices when venous pressure increases. The general tendency would be that if one particular vein has once become a major hepatofugal pathway earlier than other veins, it will become very large up to a point beyond which it can no longer take more blood and cause other veins to become varicose. We have seen a patient with idopathic portal hypertension in whom a markedly dilated left gastric vein flowed directly into the inferior vena cava without involving the suprarenal vein, and a vascular anomaly was strongly suspected [2] (Fig. 34.1). In this section, we attempt to review the past reports on unusual varices and those from our own experience. For more details and references, the reader is referred to the excellent review by Lebrec and Benhamou [3].

Keywords

Portal Vein Portal Hypertension Esophageal Varix Varicose Vein Azygos Vein 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Koyanagi N, Inokuchi K, Nakayama S, Sakata H, Beppu K (1981) Decreased arteriovenous flow resistance in the left gastric venous area in cirrhotic patients. Eur J Clin Invest 11: 355–359PubMedCrossRefGoogle Scholar
  2. 2.
    Takashi M, Igarashi M, Hino S, Goto N, Okuda K (1984) Chronic portal-systemic encephalopathy with normal portal vein pressure possibly due to noncirrhotic portal fibrosis. Dig Dis Sci 29: 669–673PubMedCrossRefGoogle Scholar
  3. 3.
    Lebrec D, Benhamou JP (1985) Ectopic varices in portal hypertenison. Clin Gastroenterol 14: 105–121PubMedGoogle Scholar
  4. 4.
    Watanabe K, Kimura K, Matsutani S, Ohto M, Okuda K (1988) Portal hemodynamics in patients with gastric varices. A study in 230 patients with esophageal and/or gastric varices using portal vein catheterization. Gastroenterology 95: 434–440PubMedGoogle Scholar
  5. 5.
    Okuda K, Yasumoto M, Goto A, Kunisaki T (1973) Endoscopic observations of gastric varices. Am J Gastroenterol 60: 357–365PubMedGoogle Scholar
  6. 6.
    Sos T, Meyers MA, Baltaxe HA (1972) Nonfundic gastric varices. Radiology 105: 579–580PubMedGoogle Scholar
  7. 7.
    Okuda K, Iio M (1976) Radiological aspects of the liver and biliary tract. X-ray and radioisotope diagnosis. Year book, Chicago, pp 200-227Google Scholar
  8. 8.
    Fleming RJ, Seaman WB (1968) Roentgenographic demonstration of unusual extra-esophageal varices. Am J Roentgen Rad Ther Nucl Med 103: 281–289CrossRefGoogle Scholar
  9. 9.
    Olson RW, Hodgson JR, Adson MA (1963) Significance of duodenal deformity in patients with extrahepatic portal obstruction. Radiology 80: 636–640PubMedGoogle Scholar
  10. 10.
    Wheeler HB, Warren R (1957) Duodenal varices due to portal hypertension from arteriovenous aneurysm: Report of case. Ann Surg 146: 229–238PubMedCrossRefGoogle Scholar
  11. 11.
    Shearburn EW, Cooper DR (1966) Duodenal varices treated by portacaval shunt. Arch Surg 93: 425–427PubMedCrossRefGoogle Scholar
  12. 12.
    Perchik L, Max TC (1963) Massive hemorrhage from varices of duodenal loop in cirrhotic patient. Radiology 80: 641–644Google Scholar
  13. 13.
    DeShazo CV, Belin RP, Lloyd JF, Walder AI (1965) Varix of duodenum simulating duodenal tumor. Minn Med 48: 1501–1503PubMedGoogle Scholar
  14. 14.
    Richter RM, Pochaczevsky R (1967) Duodenal varices. Arch Surg 95: 269–273PubMedCrossRefGoogle Scholar
  15. 15.
    Kunisaki T, Someya N, Shimokawa Y, Okuda K (1973) Varices in the distal duodenum seen by a fiber-duodenoscope. Endoscopy 5: 101–104CrossRefGoogle Scholar
  16. 16.
    Itzchak Y, Glickman MG (1977) Duodenal varices in extrahepatic portal obstruction. Radiology 124: 619–624PubMedGoogle Scholar
  17. 17.
    Hellestrom HR, Horvat BL, McCoy MM (1973) Duodenal varices with cirrhosis of the liver: Report of three cases. Am Surg 39: 518–521Google Scholar
  18. 18.
    Rappazzo JA, Kozarek RA, Altmen M (1981) Duodenal varices: Endoscopic diagnosis of an unusual source of upper gastrointestinal hemorrhage. Gastrointest Endosc 27: 227–228PubMedCrossRefGoogle Scholar
  19. 19.
    Sauerbruch T, Weinzierl M, Dietrich HP, Autes G, Eisenburg J, Paumgartner G (1982) Sclerotherapy of a bleeding duodenal varix. Endoscopy 14: 187–189PubMedCrossRefGoogle Scholar
  20. 20.
    Bloor K, Orr W (1961) A case of haemorrhage from varices in the small intestine due to portal hypertension. Br J Surg 48: 423–424CrossRefGoogle Scholar
  21. 21.
    Welbourn RB (1951–52) Benign ulcers of greater curvature associated with ulcerative colitis and cirrhosis of liver. Br J Surg 39: 303–308CrossRefGoogle Scholar
  22. 22.
    Blackburn CRB (1956) Acquired portal-pulmonary venous anastomosis complicating partial esophago-gastrectomy in patient with portal hypertension. Thorax 11: 30–35PubMedCrossRefGoogle Scholar
  23. 23.
    Madden JL, Lore JM Jr, Gerold FP, Ravid JM (1954) Pathogenesis of ascites and consideration of its treatment. Surg Gynecol Obstet 99: 385–389PubMedGoogle Scholar
  24. 24.
    Vachon A, Marion P, Morel P, Dessard P (1954) Hémorragies intestinales récidivantes par varices de l’intestin grêle avec hypotension portale et splénomegalie type Banti. Arch Mal App Digest 43: 747–750Google Scholar
  25. 25.
    Gray RK, Grollman JH (1974) Acute lower gastrointestinal bleeding secondary to varices of the superior mesenteric venous system. Radiology 111: 559–561PubMedGoogle Scholar
  26. 26.
    Agawarl D, Scholz EJ (1977) Small-bowel varices demonstrated by enteroclysis. Radiology 140: 350Google Scholar
  27. 27.
    Moncure AC, Waltman AC, Vandersalm TJ, Linton RR, Levine FH, Abbett WM (1976) Gastrointestinal hemorrhage from adhesion-related mesenteric varices. Ann Surg 183: 24–29PubMedCrossRefGoogle Scholar
  28. 28.
    Bruet A, Fingerhut A, Lopez Y, Bergue A, Tangourdecm P, Mathe C, Hillion D, Fendler JP (1983) Ileal varices revealed by recurrent hematuria in a patient with portal hypertension and Mekong schistosomiasis. Am J Gastroenterol 78: 346–350PubMedGoogle Scholar
  29. 29.
    Raithel D, Müle E (1970) Blutung aus Ileumvaricen bei portaler Hypertension. Chirung 7: 329–330Google Scholar
  30. 30.
    Börjessson B, Olsson AM, Vang JO (1974) Hemorrhage from a portal-systemic venous shunt with unusual localization in a case of portal hypertension. Scand J Gastroenterol 9: 571–573Google Scholar
  31. 31.
    Fee HJ, Taylor JB, O’Connell TX (1979) Mesenteric intestinal varices associated with portal hypertension and previous abdominal surgery. Am Surg 43: 760–762Google Scholar
  32. 32.
    Kinkhabwala M, Mousavi A, Iyer S, Adamsons R (1977) Bleeding ileal varicosity demonstrated by transhepatic portography. AJR 129: 514–516PubMedCrossRefGoogle Scholar
  33. 33.
    Hamlyn AN, Lunzer MR, Morris JS, Puritz H, Dick R (1974) Portal hypertension with varices in unusual sites. Lancet II: 1531–1534CrossRefGoogle Scholar
  34. 34.
    Levy JS, Hardin JH, Shipp H, Keeling JH (1957) Varices of cecum as an unusual cause of gastrointestinal bleeding. Gastroenterology 33: 637–640PubMedGoogle Scholar
  35. 35.
    Hermann RE, Esselstyn CB (1967) The potential hazard of pregnancy in extrahepatic portal hypertension. Arch Surg 95: 956–959PubMedCrossRefGoogle Scholar
  36. 36.
    Feldman M, Sr, Smith VM, Warner CG (1962) Varices of colon: Report of three cases JAMA 179: 729–732PubMedCrossRefGoogle Scholar
  37. 37.
    Lopata HI, Berlin L (1966) Colon varices: Rare causes of lower gastrointestinal bleeding. Radiology 87: 1048–1049PubMedGoogle Scholar
  38. 38.
    Cornet A, Thomeret CT, Dubost G, Debesse B, Renault P, Hillemand B, Terris G (1966) Hémorragie digestive par rupture de varice du colon. Résection colique segmentaire. Guérison. Sem Hop Paris 42: 171–176PubMedGoogle Scholar
  39. 39.
    Doberneck RC, Janovski NA (1970) Isolated bleeding from colonic varices in patients with liver disease. Am J Dig Dis 15: 834–841PubMedCrossRefGoogle Scholar
  40. 40.
    Brill DR, Bolasny B, Vix VA (1969) Colonic varices: Report of a case. Am J Dig Dis 14: 801–804PubMedCrossRefGoogle Scholar
  41. 41.
    Deutsch AL, Davis GB, Berk RN (1981) Diagnosis of colonic varices by air-contrast barium enema examination. Report of a case. Gastrointest Radiol 6: 336–338CrossRefGoogle Scholar
  42. 42.
    Saitoh M, Tsai HF, Futagawa S (1989) Colonic varices in portal hypertension. J Gastroenterol Hepatol 4(Suppl): 289–290PubMedGoogle Scholar
  43. 43.
    Burbige EJ, Tarder G, Garson S, Eugene J, Frey CF (1978) Colonie varices. A complication of pancreatitis with splenic vein thrombosis. Am J Dig Dis 23: 752–755PubMedCrossRefGoogle Scholar
  44. 44.
    Triger DR, Hosking SW, Smart HL, Johnson AG (1989) Prevalence of anorectal varices in cirrhosis. Lancet I: 349–352Google Scholar
  45. 45.
    Jacob DM, Budrick MP, Onstad GP, Hitschock CR (1980) The relationship of hemorrhdoids to portal hypertension. Dis Colon Rectum 23: 567–569CrossRefGoogle Scholar
  46. 46.
    Johansen K, Bardin J, Orloff MJ (1980) Massive bleeding from hemorrhoidal varices in portal hypertension. JAMA 244: 2084–2085PubMedCrossRefGoogle Scholar
  47. 47.
    McCormack TT, Bailey HR, Simms JM, Johnson AG (1984) Rectal varices are not piles. Br J Surg 71: 163PubMedCrossRefGoogle Scholar
  48. 48.
    Mashiah S (1981) Massive bleeding from hemorrhoidal varices in portal hypertension. JAMA 246: 2323–2324PubMedCrossRefGoogle Scholar
  49. 49.
    Eade MN, Williams HA, Cooke WT (1969) Bleeding from an ileostomy caput medusae. Lancet II: 1166–1168CrossRefGoogle Scholar
  50. 50.
    Graeber GM, Ratner MH, Ackerman NB (1976) Massive hemorrhage from ileostomy and colostomy stomas due to mucocutaneous varices in patients with coexisting cirrhosis. Surgery 79: 101–110Google Scholar
  51. 51.
    Adson MA, Fulton RR (1977) The ileal stoma and portal hypertension. An uncommon site of variceal bleeding. Arch Surg 112: 501–504PubMedCrossRefGoogle Scholar
  52. 52.
    Cooper MJ, Mackie CR, Dhorajiwala J, Baker AL, Moossa AR (1981) Hemorrhage from ileal varices after total proctocolectomy. Am J Surg 141: 178–179PubMedCrossRefGoogle Scholar
  53. 53.
    Watkins RM (1981) Variceal haemorrhage from a colostomy due to portal hypertension secondary to intrahepatic métastases from rectal carcinoma. Br Med J 282: 189–190CrossRefGoogle Scholar
  54. 54.
    Ellis H, Griffiths PWW, MacIntyre A (1958) Haemoperitoneum—a record of 129 consecutive patients with notes on some unusual cases. Br J Surg 45: 606–610PubMedCrossRefGoogle Scholar
  55. 55.
    Gross W, Kaffarnik H, Strik WO (1963) Intra-peritoneale Blutung als Folge einer Leberzirrhose. MMW 105: 529–530Google Scholar
  56. 56.
    Rothschild JJ, Gelernt I, Sloan W (1968) Ruptured mesenteric varix in cirrhosis—unusual cause for hemoperitoneum. N Engl J Med 278: 97–98PubMedCrossRefGoogle Scholar
  57. 57.
    Miller J, Dineen J (1968) Ruptured abdominal varix. N Engl J Med 278: 508PubMedGoogle Scholar
  58. 58.
    Ross AP (1970) Portal hypertension presenting with haemoperitoneum. Br Med J 1: 544PubMedCrossRefGoogle Scholar
  59. 59.
    Mall, K, Grundies H (1974) Haemoperitoneum als Folge portader Hypertension. Med Klin 69: 2075–2076PubMedGoogle Scholar
  60. 60.
    Doromal NM, Middleton P, Keshishian JN (1975) Massive intraperitoneal hemorrhage and intrahepatic arteriovenous fistula in hepatic cirrhosis. J Med Soc NJ 72: 830–832Google Scholar
  61. 61.
    Shapero TF, Bourne RH, Goodall RG (1978) Intraabdominal bleeding from variceal vessels in cirrhosis. Gastroenterology 74: 128–129PubMedGoogle Scholar
  62. 62.
    Lyon DT, Mantia AG, Schubert TT (1979) Hemoperitoneum from a ruptured varix cirrhosis. Am J Gastroenterol 71: 611–616PubMedGoogle Scholar
  63. 63.
    Sprayregen S, Brandt LJ, Bohm S, Stechel R (1978) Bleeding intraperitoneal varix. Demonstration by arteriography and successful treatment with infusion of vasopressin into the superior mesenteric artery. Angiology 29: 857–861PubMedCrossRefGoogle Scholar
  64. 64.
    Fox L, Cane SA, Bidari C, Jones A (1982) Intra-abdominal hemorrhage from ruptured varices. Arch Surg 117: 953–955PubMedCrossRefGoogle Scholar
  65. 65.
    Noda T (1984) Angioarchitectural study of esophageal varices. Virchow Arch [A] 404: 381–392CrossRefGoogle Scholar
  66. 66.
    Vianna A, Hayes PC, Moscoso G, Driver M, Portmann B, Westaby D, Williams R (1987) Normal venous circulation of the gastroesophageal junction. A route to understanding varices. Gastroenterology 93: 876–889PubMedGoogle Scholar
  67. 67.
    Takashi M, Igarashi M, Hino S, Musha H, Takayasu K, Arakawa M, Nakashima T, Ohnishi K, Okuda K (1985) Esophageal varices: Correlation of left gastric venography and endoscopy in patients with portal hypertension. Radiology 155: 327–331PubMedGoogle Scholar
  68. 68.
    Jonsson K, Rian RL (1970) Pseudotumoral esophageal varices associated with portal hypertension. Radiology 97: 593–597PubMedGoogle Scholar
  69. 69.
    Takayasu K, Kobayashi C, Takashi M, Okuda K (1982) Paraesophageal varices mimicking a mediastinal tumor. J Clin Gastroenterol 4: 163–166PubMedCrossRefGoogle Scholar
  70. 70.
    Barzilai R, Kleckner MS (1950) Hemocholecyst following ruptured aneurysm of portal vein. Arch Surg 72: 725–727Google Scholar
  71. 71.
    Leonsins AJ, Siew S (1960) Fusiform aneurysmal dilatation of the portal vein. Postgrad Med J 36: 70–74CrossRefGoogle Scholar
  72. 72.
    Hermann RE, Shafer WH (1965) Aneurysm of the portal vein and portal hypertension. Ann Surg 162: 1101–1104PubMedCrossRefGoogle Scholar
  73. 73.
    Thomas TV (1967) Aneurysm of the portal vein: Report of two cases. One resulting in thrombosis and spontaneous rupture. Surgery 61: 550–555PubMedGoogle Scholar
  74. 74.
    Liebowitz HR, Roussellt LM (1967) Saccular aneurysm of portal vein with agnogenic myeloid metaplasia. NY State J Med 67: 1443–1447Google Scholar
  75. 75.
    Wenz W, Beckenbach H, Daum R (1971) Die kindliche Pfortader bei Erkrankungen der Oberbauchorgane. Eur J Pediatr 9: 354–362Google Scholar
  76. 76.
    Vine HS, Sequeira JC, Widrich WC, Sachs BA (1979) Portal vein aneurysm. AJR 132: 557–560PubMedCrossRefGoogle Scholar
  77. 77.
    Ohnishi K, Nakayama T, Saito M, Nomura F, Koen H, Tamura J, Iwasaki I, Okuda K (1984) Aneurysm of the intrahepatic branch of the portal vein. Report of two cases. Gastroenterology 86: 169–173PubMedGoogle Scholar
  78. 78.
    Schild H, Schweden F, Braun B, Lang H (1982) Angeursy of the superior mesenteric vein. Radiology 145: 641–642PubMedGoogle Scholar
  79. 79.
    Shuford WH, Weens HS (1958) Azygos vein dilatation simulating mediastinal tumor. Am J Roentgen Rad Ther Nucl Med 80: 225–230Google Scholar
  80. 80.
    Takayasu K, Moriyama N, Shima Y, Muramatsu Y, Goto H, Yamada T, Makuuchi M, Yamasaki S, Okazaki N (1984) Spontaneous portal-hepatic venous shunt via an intrahepatic portal vein aneurysm. Gastroenterology 86: 945–948PubMedGoogle Scholar
  81. 81.
    Takayasu K, Moriyama N, Suzuki M, Yamada T, Fukutake T, Shima Y, Kobayashi C, Musha H, Okuda K (1983) False-positive liver scans due to portal hypertension: Correlation with percutaneous transhepatic portograms in 33 patients. Radiology 147: 211–214PubMedGoogle Scholar
  82. 82.
    Kreek MJ, Raziano JV, Hardy RE, Joffries GH (1967) Portal hypertension with bleeding vaginal varices. Ann Intern Med 66: 756–759PubMedCrossRefGoogle Scholar
  83. 83.
    Eriksson LS, Hardstedt PWW, MacIntyre A (1982) Massive haemorrhage from vaginal varicose veins in patient with liver cirrhosis. Lancet I: 1180CrossRefGoogle Scholar
  84. 84.
    Williams SM, Burnett DA, Mazer MJ (1982) Radiographic demonstration of common bile duct varices. Gastrointest Radiol 7: 69–70PubMedCrossRefGoogle Scholar
  85. 85.
    Holmlund D, Lunderström B (1977) Extrahepatic obstruction of the portal vein with bleeding from the gallbladder. Report of a case. Acta Radiol [Diagn] [Stockh] 18: 680–684Google Scholar
  86. 86.
    Dan SJ, Train JS, Cohen BA, Mitty HA (1983) Common bile duct varices: Cholangiographic demonstration of a hazardous portogystemic communication. Am J Gastroenterol 78: 42–43PubMedGoogle Scholar
  87. 87.
    Ohnishi K, Hatano H, Nakayama T, Kohno K, Okuda K (1983) An unusual portal systemic shunt, most likely through a patent ductus venosus. A case report. Gastroenterology 85: 962–965PubMedGoogle Scholar
  88. 88.
    Ohkubo H, Okuda K, Takayasu K, Musha H, Hara T, Hirashima T (1978) Cruveilhier-Baumgarten syndrome presenting with precordial murmur and thrill. Report of a case diagnosed by percutaneous transhepatic portography. Am J Dig Dis 23: 65s–68sCrossRefGoogle Scholar
  89. 89.
    Takayasu K, Moriyama N, Yamada T, Kobayashi C, Musha H, Okuda K (1984) Sonographic detection of large spontaneous spleno-renal shunts and its clinical significance. Br J Radiol 57: 565–570PubMedCrossRefGoogle Scholar
  90. 90.
    Ohnishi K, Saito M, Sato S, Sugita S, Tanaka H, Okuda K (1986) Clinical utility of pulsed Doppler flowmeter in patients with portal hypertension. Am J Gastroenterol 81: 1–8PubMedGoogle Scholar
  91. 91.
    Okuda K, Kimura K, Takayasu K (1982) Percutaneous transhepatic portography and sclerotherapy. Semin Liver Dis 2: 57–66PubMedCrossRefGoogle Scholar
  92. 92.
    Horiguchi Y, Kitano T, Takagawa H, Imai H, Itoh M, Miyakawa S, Nakamura Y, Miura K, Itoh K (1988) A large inferior mesenteric-caval shunt via the internal iliac vein. Gastroenterol Jpn 23: 684–687PubMedGoogle Scholar

Copyright information

© Springer Japan 1991

Authors and Affiliations

  • Kunio Okuda
    • 1
  • Kenichi Takayasu
    • 2
  1. 1.Department of MedicineChiba University HospitalChiba 280Japan
  2. 2.Department of Diagnostic RadiologyNational Cancer Center HospitalTokyo 104Japan

Personalised recommendations