Biliary strictures have been recognized as characteristic complications of chronic pancreatitis. In hospitalized patients with pancreatitis, the incidence of biliary stricture accounts for about 5% to 9%.
Interventional (i.e., surgical) therapy is clearly indicated in patients with common bile duct strictures secondary to chronic pancreatitis. Endoscopic stenting plays a role in patients who are unfit for surgery, but it is not recommended as definitive therapy, particularly with regard to the necessity of repeated endoscopic interventions due to infection, stent displacement, or stent occlusion.
Chronic hemorrhagic proctitis has been treated with a variety of methods These treatments include anti-inflammatory agents, topical steroid preparations, cautery, and laser ablation.
85-90% of patients have improvement or cessation in bleeding following an average of 3.4 applications of a 4% formalin-soaked pledget.
Hyperbaric oxygen has been successfully used for the treatment of radiation-induced injuries. Hyperbaric oxygen is used to overcome the chronic tissue hypoxia present in radiation-damaged tissues. Repetitive sessions gradually induce regrowth of fibrous tissue, capillaries, and epithelium. Hyperbaric oxygen therapy is generally well tolerated.
The treatment regimen is 60 minutes daily with 100% oxygen at 2.2 to 2.4 atmospheres. An average of 18-60 sessions is required
APC has been used in the treatment of chronic radiation-induced proctitis, and this modality has shown great promise. In a study of 40 patients with refractory hemorrhagic proctitis, APC was successful in 39 patients after one or two treatments.
Varices that occur at a site other than the gastroesophageal junction are termed ectopic varices
Ectopic varices most commonly manifest with melena or hematemesis.
The common occurrence of duodenal varices in patients with portal vein obstruction probably relates to the formation of collateral vessels around the thrombosed portal vein, which connect pancreaticoduodenal veins to retroduodenal veins, which drain into the inferior vena cava.
The other common site of ectopic varices is peristomal, in patients with inflammatory bowel disease and primary sclerosing cholangitis who have undergone a proctocolectomy with creation of an ileostomy.
Anorectal varices are reported in 10% to 40% of cirrhotic patients who undergo colonoscopy and must be distinguished from hemorrhoids. Rectal varices are dilated superior and middle hemorrhoidal veins, whereas hemorrhoids are dilated vascular channels above the dentate line. Rectal varices collapse with digital pressure, but hemorrhoids do not.
Treatment of Duodenal varices
1. Vasocactive drugs
2.Endoscopic glue injection or band ligation is the preferred approach for bleeding duodenal varices.
3. For Primary prophylaxis, A surgical portosystemic shunt is recommended in patients with Child class A cirrhosis and in patients with portal hypertension from extrahepatic portal vein thrombosis in whom a vein suitable for a shunt is available. Placement of a nonselective portosystemic shunt, such as a portacaval shunt, mesocaval shunt, or central splenorenal shunt, should be carried out in a patient with stomal varices.
The most common complication of bevacizumab is hypertension, requiring treatment (with routine oral antihypertensives) in approximately 10% of patients. Of more serious concern are two rare but serious complications: gastrointestinal perforation and arterial thromboses. Overall, 1.5% of patients receiving bevacizumab experienced a perforation in the gastrointestinal tract.
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