Double-balloon enteroscopy-facilitated cyanoacrylate-injection endotherapy of small-bowel varices: an international experience from 2 European tertiary centers (with videos).

BACKGROUND AND AIMS: Small-bowel varices (SBVs) are an uncommon consequence of portal hypertension. Radiologic intervention is usually considered for first-line management. When radiologic intervention is not possible, management options become very limited. The aim of this study was to evaluate the usefulness of double-balloon enteroscopy (DBE)-facilitated cyanoacrylate-injection endotherapy of SBVs. METHODS: This was a retrospective review of DBE-facilitated cyanoacrylate-injection endotherapy of SBVs (December 2015 to October 2016). RESULTS: Ten DBEs were performed in 6 patients (4 women; median age, 68.5 years). No radiologic or surgical options were deemed feasible. Thirteen nests of SBVs were identified and injected with cyanoacrylate glue without hemorrhagic or embolic adverse events. At the 30-day follow-up after therapy, only 1 patient had experienced a mild recurrence of mid-gut bleeding; this was managed conservatively. One patient presented with acute GI bleeding 7 months later, and a repeat DBE with cyanoacrylate-injection endotherapy was successfully performed. One patient succumbed to his underlying advanced cholangiocarcinoma after 2 months. The remaining patients had a median follow-up of 12 months without any recurrent GI bleeding. CONCLUSIONS: DBE-facilitated cyanoacrylate-injection endotherapy of SBVs appears to be a safe and effective option when other first-line options are not feasible.

Midgut neuroendocrine tumors: imaging assessment for surgical resection.

Midgut neuroendocrine tumors (MNETs) are rare, and the primary tumor is usually small and difficult to visualize at imaging. Patients often present late with extensive liver and nodal metastases and may experience symptoms secondary to the release of active substances by the primary tumor, such as serotonin and its metabolites, which have local and systemic effects. Locally, this causes desmoplasia and vascular encasement and may lead to small bowel obstruction and ischemia, with significant morbidity and mortality. Systemically, the release of active substances into the circulation can cause flushing, diarrhea, and abdominal pain (carcinoid syndrome); these substances can be detected in urine and blood serum and used as markers for diagnosis and treatment follow-up. MNETs retain expression of specific peptide receptors such as somatostatin receptors, which will bind to synthetic somatostatin analogs such as octreotide. This feature is useful for functional imaging of patients with MNETs and for peptide receptor radionuclide therapy using somatostatin analogs. Resection of the primary tumor is advocated, even in patients with extensive metastases, because it may prevent development of local complications, can help control systemic symptoms, and has been shown to confer some survival advantage. Computed tomography and functional imaging are used to identify the primary tumor and assess its resectability. The main factors governing resectability are patient comorbidities (eg, carcinoid heart disease), vascular involvement, and desmoplasia.

Radiological findings in gastrointestinal scleroderma.

Gastrointestinal involvement is the most common visceral organ manifestation in systemic sclerosis. Symptoms from the gastrointestinal tract are very frequent among scleroderma patients and in many cases present a therapeutic challenge. However, gastrointestinal involvement may also be asymptomatic, presenting with complications later in the disease course. Early recognition of gastrointestinal scleroderma is therefore important both for symptomatic control and prevention of complications. Gastrointestinal imaging alongside clinical assessment forms the mainstay of diagnosis. Radiological investigations, traditionally plain radiographs and barium studies, with the more recent advances in computed tomography, magnetic resonance imaging and ultrasound, provide means for accurate evaluation of visceral organ involvement and more effective patient care. Awareness of the characteristic images is important not only for radiologists but also for the treating physicians and gastroenterologists.

Peritoneal lymphomatosis: a rare presentation of follicular lymphoma mimicking peritoneal carcinomatosis.

Patients presenting with ascites associated with peritoneal disease have a wide differential diagnosis including both malignant and non-malignant related causes. We present the unusual case of a patient, clinically deteriorating, whose malignant peritoneal disease was due to an underlying follicular lymphoma. An urgent staging CT scan followed by a peritoneal biopsy allowed the patient to start chemotherapy within days of acute presentation to the hospital. This case emphasises the importance of obtaining tissue diagnosis urgently in these patients to ensure that the correct treatment can be started in a timely manner.