The purpose of this study was to clarify the mechanism of “diffuse A-V shunts” that occur in the spleen. The subjects were 204 patients with chronic liver disease (13 of whom were positive for diffuse A-V shunts in the spleen) and 108 patients with non-chronic liver disease. The method used was to examine the relationship between splenomegaly and peripheral vascular resistance (RI) and blood flow velocity of the splenic peripheral artery observed using Doppler ultrasound. As a result, ①there was a positive correlation between peripheral arterial blood flow velocity in the spleen and the degree of splenomegaly regardless of the presence or absence of chronic liver disease (rs＝.480, rs＝.471 respectively). ②There was no correlation between splenic peripheral arterial RI and degrees of splenomegaly in non-chronic liver disease, but a positive correlation (rs＝.528) was observed in chronic liver disease. Splenomegaly in non-chronic liver disease is considered to be an “active” state of increased splenic arterial blood flow that requires blood, whereas chronic liver disease is considered to be a “passive” state of increased splenic arterial blood flow. ③The RI of the splenic peripheral artery was high in patients with chronic liver disease in whom splenic “diffuse A-V shunt” was observed. Thus, this phenomenon tended to be observed in more “passive” conditions of splenic artery hyperperfusion. This phenomenon is thought to occur when the limits of peripheral parenchymal perfusion capacity are exceeded.

It has been difficult to obtain good EUS images of esophageal varices (EVs) using the water-filling EUS technique. The purpose of this study was to evaluate the usefulness of gel-immersion EUS for EVs compared with water-filling EUS. We retrospectively evaluated EUS image quality, procedure time, diagnostic ability of local veins in the EVs, and adverse events in EVs patients who underwent EUS prior to endoscopic treatment. EUS image quality was rated on a 4-point scale from 4 (very good) to 1 (poor), and operators were classified as “expert” if they had more than 10 years of medical experience and “non-expert” if they had less than 10 years of medical experience. Eighteen gel-immersion-EUS and 17 water-filling EUS patients were included in this study, and there was no difference in operators between the two groups. Image quality scores were higher for gel-immersion-EUS at 4 (3-4) and water-filling EUS at 2 (1-3) (p < 0.001). Diagnostic ability of Pv was also higher with gel-immersion-EUS (p = 0.03). Procedure time was 6.5 (4-14) minutes for gel-immersion-EUS and 4 (2-10) minutes for water-filling EUS with gel-immersion-EUS (p < 0.001). No adverse events occurred in either case. gel-immersion-EUS for EVs was safe and could be performed safely with good image quality.

In conclusion, in hemodynamic diagnosis by EUS for EVs, gel-immersion-EUS provided better EUS images and better evaluation of Pv than water-filling EUS, even for non-expert operators.

We have explored the use of transjugular intrahepatic portosystemic shunt (TIPS) as a treatment option for idiopathic portal hypertension in four patients at our hospital. Although TIPS has been shown to be an effective means of managing this condition overseas, its use in Japan has been limited to date, owing to a lack of insurance coverage and concerns regarding the potential for a deterioration of hepatic function. However, we have achieved successful outcomes in the patient treated in this way, with improvements in her thrombosis, varices, and ascites. Although hepatic encephalopathy developed, it was manageable, and there was no subsequent decline in liver function or recurrence of ascites in the patients. This suggests that TIPS may represent a promising therapeutic option for Japanese patients, slowing the progression of her portal vein thrombosis. Although opinions vary regarding the optimal timing of TIPS, it is worth considering as a means of reducing portal blood pressure in Japanese patients.