Clinical Outcomes and Their Determinants in Patients With Gastric Variceal Bleed Undergoing Endoscopic Cyanoacrylate Injection: An Observational Study.

Background and aims: Gastric variceal bleeding (GVB), compared to esophageal varices, is rare but often massive and associated with high mortality. Endoscopic cyanoacrylate glue injection (ECGI) is the first-line treatment for GVB. Hence, we conducted this study to assess the clinical outcomes and the determinants of ECGI for gastric variceal bleeding. Methods: This was a prospective observational study of patients with ECGI for GVB between June 2019 and February 2023. The demographic characteristics, etiology and severity of cirrhosis, size, type of gastric varices, volume of cyanoacrylate used, number of sessions required, technical success, rebleeding rate, and survival at three months were studied. Results: A total of 135 patients underwent ECGI for GVB. Their mean (SD) age was 44.9 (13.6) years, with a male preponderance (n = 23, 68.1 %). Eighty-two patients (60.7 %) had cirrhosis. Their mean model for end-stage liver disease (MELD) score was 14.3 (7.3). Gastric varices were gastroesophageal varices (GOV)1 in 42 (31.1 %), GOV2 in 73 (54.1 %), and isolated gastric varices (IGV)1 in 20 (14.8 %) patients. Varices were large in 35 (25.9 %) and had F1 morphology in 89 (65.9 %) patients. The success rate of initial hemostasis was 98.5 %. The median sessions required were 1 (1-2), and the median volume of cyanoacrylate per session was 2 (1-2) ml. The procedure was associated with minor complications like transient abdominal pain in 11 (8.1 %) and fever in 2 (2.7 %) patients. Rebleeding was observed in 23 (17 %) patients. GOV2, F1 morphology, and a high MELD score were significantly associated with rebleeding. Five (3.7 %) patients died during the study; 2 (1.5 %) were due to failure to control bleeding. Conclusion: In conclusion, our study demonstrated ECGI to be very safe and effective for GVB. The technical success was high and could be achieved in fewer sessions with a smaller volume of cyanoacrylate during each session.

Acute Intestinal Obstruction as an Initial Presentation of Mesenteric Venous Thrombosis.

Intestinal ischemia commonly occurs after arterial thrombosis or embolism. Thrombosis of the mesenteric vein accounts for less than 10% of cases of intestinal ischemia. Superior mesenteric vein thrombosis (SMVT) in its chronic form is less culpable to produce intestinal ischemia as it forms sufficient collateral drainage. Intestinal obstruction due to mesenteric venous thrombosis is rare, and so far, only 12 cases have been reported. The majority of them had a distinct episode of acute abdominal pain due to ischemia and later developed bowel stricture and intestinal obstruction. Here we report a case of a 44-year-old male who presented with intestinal obstruction as an initial presentation of SMVT. The patient required surgical resection and anastomosis, and he was started on anticoagulation therapy. This case report reiterates the fact that persistent low-grade mesenteric venous ischemia may lead to bowel stricture formation at a later stage. Therefore, etiological workup and early anticoagulant therapy can be useful to improve recurrence.

Gastric adenocarcinoma presenting with multiple skeletal muscle metastases.

A 42-year-old man presented to the gastroenterology clinic with features of gastric outlet obstruction, significant weight loss, anaemia, ascites, and pain in the lower back and left thigh. CT scan of the abdomen and pelvis showed wall thickening in the antropyloric region of the stomach and enhancing soft tissue lesion in the left psoas and right gluteal region. Gastroscopy revealed a circumferential growth in the antrum and pylorus of the stomach, and biopsy from the growth was reported as moderately differentiated adenocarcinoma. Positron emission tomography-CT scan showed multiple skeletal muscle metastases all over the body. Fine-needle aspiration cytology and immunohistochemistry from the psoas lesion confirmed metastatic adenocarcinoma deposits. He underwent antropyloric stenting for his obstructive symptoms and received supportive care, finally succumbed to his illness after 6 weeks.

Sister Mary Joseph Nodule as an Initial Presentation of Pancreatic Adenocarcinoma.

Sister Mary Joseph (SMJ) nodule is a metastatic umbilical nodule seen in primary tumors of the gastrointestinal or genitourinary tract. The stomach and colon are the common gastrointestinal cancers associated with SMJ nodule. The pancreas is a rare primary site for umbilical metastasis. Moreover, malignant umbilical nodules as the first presentation in pancreatic cancer is rare. Pancreatic adenocarcinoma that metastasizes to umbilicus usually arise from the body or tail of the pancreas. The presence of SMJ nodule usually indicates poor prognosis. Umbilical nodule is a simple physical finding to the presence of an advanced intra-abdominal malignancy. Although rare, pancreatic cancer should be considered as one of the primary sites in such a situation.