This set of three fluoroscopic angiograms (a, b, and c) documents the interventional management of portal hypertension complications in a patient with cirrhosis. Image (a) is a post-TIPS (Transjugular Intrahepatic Portosystemic Shunt) angiogram demonstrating a dilated, tortuous left testicular vein (arrow) originating from the splenic vein, contributing to a clinically significant varicocele. Image (b) shows contrast enhancement of large, bulbous gastric varices (arrow) as a manifestation of portosystemic collateralization. Image (c) displays the result of therapeutic embolization; radiopaque embolic coils are clearly visible within the gastric varices (arrow) and the varicocele (arrowhead). The absence of contrast filling in these areas in the final angiogram indicates successful vascular occlusion. This sequence illustrates the use of TIPS and subsequent targeted embolization to manage symptomatic varices and ectopic venous congestion associated with portal hypertension. Educational concepts include vascular anatomy, complications of cirrhosis, and the radiographic appearance of embolic materials.

Dual-panel fluoroscopic imaging of the abdomen demonstrating the interventional management of ectopic varices in a patient with portal hypertension. Figure A (pre-embolization) shows an anteroposterior fluoroscopic view with a contrast-enhanced cluster of dilated, tortuous, and irregular venous structures (indicated by a yellow arrow) in the duodenal region. These duodenal varices are supplied by a portosystemic shunt involving the superior mesenteric vein. Figure B (post-embolization) illustrates the results of transhepatic coil embolization. Dense, radiopaque metallic coils are now visible within the variceal nest (indicated by the yellow arrow), effectively occluding the abnormal vessels. A catheter used for the intervention is visible traversing the mid-abdomen. These images highlight the role of interventional radiology in treating rare sites of variceal bleeding associated with cirrhosis and portal hypertension when conventional endoscopic therapy is insufficient.

This composite clinical figure presents a comparative study of two patients (Case 1: A-C; Case 2: D-F) undergoing management for portal hypertension and liver cirrhosis. Panels A and D show endoscopic views of the middle/lower esophagus and gastric fundus, identifying prominent, tortuous varicose veins (esophageal and gastric varices) and signs of portal hypertensive gastropathy. Panels B and E demonstrate 3D reconstructed abdominal angiographies (CT angiography), highlighting significant vascular abnormalities including a widened portal vein, collateral venous circulation around the stomach and spleen, and abnormal perfusion shadows in the right hepatic lobe. Panels C and F are axial abdominal CT scans obtained after transjugular intrahepatic portosystemic shunt (TIPS) placement. White arrows in the CT images indicate the successful positioning of the intrahepatic stents within the liver parenchyma, designed to decompress the portal pressure. The images collectively illustrate the diagnostic progression from direct visualization of varices to vascular mapping and post-interventional radiological verification of shunt placement in patients with complications of chronic liver disease.

A composite medical image illustrating the diagnosis and treatment of portal hypertension. (A) Coronal CT scan shows splenomegaly and prominent esophageal varices in the absence of liver cirrhosis. (B) Endoscopic view (EGD) of the gastroesophageal junction reveals dilated, tortuous esophageal varices with a 'white nipple sign,' indicating a recent hemorrhage and fibrin clot formation. (C) Coronal CT scan highlights portal vein thrombosis, characterized by a filling defect in the portal venous system, which serves as the etiology for pre-hepatic portal hypertension. (D) Intraoperative fluoroscopic image demonstrates the placement of a portal vein stent via an interventional radiology approach. (E) Follow-up coronal CT scan displays the successful resolution of previously noted esophageal varices and restoration of vascular flow following the stenting procedure. This series provides an educational overview of non-cirrhotic portal hypertension management, from diagnostic imaging and endoscopic stigmata of bleeding to therapeutic intervention and radiological follow-up.

A pair of endoscopic clinical photographs illustrating the esophagus before and after endoscopic variceal ligation (EVL). Image A shows moderately enlarged, beads-like (F2) esophageal varices protruding into the esophageal lumen. The varices appear as dilated, tortuous, and nodular-shaped venous structures with an irregular surface, typical of severe portal hypertension. Image B demonstrates the immediate post-EVL state, characterized by significant oozing hemorrhage and fresh blood pooling within the lumen, which obscures the underlying mucosal details. This side-by-side comparison highlights the clinical presentation of esophageal varices and the potential complication of immediate post-procedural bleeding during or after band ligation. The educational focus is on identifying variceal morphology and recognizing complications of therapeutic endoscopy in the management of portal hypertension.

This composite figure demonstrates the efficacy of endoscopic band ligation (EBL) for severe esophageal varices through longitudinal diagnostic imaging and endoscopy. Panes (a), (b), and (c) are axial contrast-enhanced CT scans at the level of the distal esophagus. Image (a) shows the baseline state with prominent, dilated esophageal varices (arrowed). Sequential scans at 1 week (b) and 1 month (c) post-treatment demonstrate progressive attenuation and reduction in the diameter of the variceal vessels. Panes (d) and (e) provide direct endoscopic visualization of the esophageal lumen. Image (d) illustrates baseline severe esophageal varices characterized by large, tortuous protrusions into the lumen (arrowed). Image (e), captured 1 month after endotherapy, shows a significant therapeutic response, with a reduction in variceal size and a smoother, less congested esophageal mucosal lining. This comparison highlights the role of both cross-sectional imaging (CTPV) and direct endoscopy in monitoring treatment outcomes for portal hypertension complications.

This set of four endoscopic images illustrates the stages of Endoscopic Variceal Ligation (EVL) for the management of esophageal varices. (1, 2) Baseline diagnostic images show multiple, large, tortuous, serpentine esophageal varices with visible 'red signs' (cherry red spots), indicating a high risk of imminent hemorrhage. (3) Procedural view showing the application of multiband ligators; a variceal cord is successfully suctioned into the ligator cap and strangulated with an elastic rubber band, forming a polypoid pseudo-polyp. (4) Follow-up surveillance endoscopy performed 3 months post-procedure demonstrates successful eradication of the varices. The esophageal lumen is patent with a smoother mucosal surface and visible white scarring (fibrosis) at the previous ligation sites, which represents healed tissue and reduced vascular engorgement. This sequence serves as a clinical guide for gastroenterology training in the identification, interventional treatment, and post-procedural healing of portal hypertension-induced variceal disease.