TIPS for the management of stomal variceal bleeding due to cirrhotic and non-cirrhotic portal hypertension

2021 ◽  
Author(s):  
Dominik J. Kaczmarek ◽  
Patrick Kupczyk ◽  
Michael Schultheiß ◽  
Johannes Chang ◽  
Christian Jansen ◽  
...  
Keyword(s):  
Portal Hypertension ◽  
Coil Embolization ◽  
Ileal Conduit ◽  
Rare Complication ◽  
Case Series ◽  
Local Therapy ◽  
Gastric Varices ◽  
Ectopic Varices ◽  
Medical Centers ◽  
Intrahepatic Portosystemic Shunt

Abstract Background Portal hypertension (PH) is associated with the development of esophageal or gastric varices, which can cause bleedings with high mortality. Varices can also manifest at sites of stomata. These parastomal varices can cause recurrent variceal bleedings (VB) despite local therapies. We present a case series of parastomal VB due to PH that were managed with implantation of transjugular intrahepatic portosystemic shunt (TIPS). Methods We retrospectively included all patients (pt) from 2 tertiary medical centers with parastomal VB between January 2014 and February 2020 who underwent the TIPS procedure. Results Nine pt were included. Seven pt had liver cirrhosis, mostly alcohol-related. Two pt had non-cirrhotic PH due to porto-sinusoidal vascular disease (PSD). Four pt had a colostomy, 1 an ileostomy, and 4 an ileal conduit. Malignancy was the leading cause of stoma surgery. All 9 pt suffered from recurrent parastomal VB despite non-selective beta-blocker and/or local therapy (e.g., compression, coagulation, suture ligation, or surgical stoma revision). All pt received TIPS implantation. In 7 pt, TIPS implantation led to sustainable hemostasis. Two pt suffered a bleeding relapse that was attributable to TIPS dysfunction. TIPS revision with coil embolization of the varices terminated the VB sustainably in both pt. Conclusions In pt presenting with recurrent stomal bleedings, parastomal varices as a rare complication of PH must be taken into consideration as an underlying cause. In our case series, we managed to sustainably cease parastomal VB by TIPS implantation with or without coil embolization of the ectopic varices.

Management of Gastric and Ectopic Varices: The Endoscopist's Perspective

2020 ◽  
Vol 04 (02) ◽  
pp. 110-121
Author(s):  
Zachary Henry
Keyword(s):  
Portal Hypertension ◽  
Case Reports ◽  
Rare Complication ◽  
Treatment Options ◽  
Specific Treatment ◽  
Case Series ◽  
Vascular Anatomy ◽  
Rectal Varices ◽  
Ectopic Varices ◽  
Definitive Therapy

AbstractGastric and Ectopic varices are a rare complication of portal hypertension and represent a complex, heterogeneous system of vascular shunts. Bleeding from these shunts can be severe and life-threatening, with poorly standardized treatment algorithms to follow in their management. When bleeding occurs, it is important to follow standard diagnostic procedures for portal hypertensive bleeding and always obtain imaging of the underlying vascular anatomy to help guide therapy. Potential treatment methods will depend on these imaging findings as well as the location of the varix within the gastrointestinal tract. While gastric varices have more data to support specific treatment options, duodenal and rectal varices have only case reports and case series to guide their care. In addition, stomal varices are a very rare complication of portal hypertension and have limited data to support any one treatment modality. Gastric and ectopic varices are best approached in a multidisciplinary fashion after discussion with hepatologists and interventional radiologists to overcome the uncertainty in choosing a definitive therapy.

scholarly journals Beyond the scope and the glue: update on evaluation and management of gastric varices

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Cyriac Abby Philips ◽  
Rizwan Ahamed ◽  
Sasidharan Rajesh ◽  
Tom George ◽  
Meera Mohanan ◽  
...  
Keyword(s):  
Portal Hypertension ◽  
Variceal Bleeding ◽  
Endovascular Procedures ◽  
Gastric Varices ◽  
Current Evidence ◽  
Ultrasound Guided ◽  
Algorithmic Approach ◽  
Evidence Based Treatments ◽  
Intrahepatic Portosystemic Shunt ◽  
Shed Light

Abstract Gastric varices are encountered less frequently than esophageal varices. Nonetheless, gastric variceal bleeding is more severe and associated with worse outcomes. Conventionally, gastric varices have been described based on the location and extent and endoscopic treatments offered based on these descriptions. With improved understanding of portal hypertension and the dynamic physiology of collateral circulation, gastric variceal classification has been refined to include inflow and outflow based hemodynamic pathways. These have led to an improvement in the management of gastric variceal disease through newer modalities of treatment such as endoscopic ultrasound-guided glue-coiling combination therapy and the emergence of highly effective endovascular treatments such as shunt and variceal complex embolization with or without transjugular intrahepatic portosystemic shunt (TIPS) placement in patients who are deemed ‘difficult’ to manage the traditional way. Furthermore, the decisions regarding TIPS and additional endovascular procedures in patients with gastric variceal bleeding have changed after the emergence of ‘portal hypertension theories’ of proximity, throughput, and recruitment. The hemodynamic classification, grounded on novel theories and its cognizance, can help in identifying patients at baseline, in whom conventional treatment could fail. In this exhaustive review, we discuss the conventional and hemodynamic diagnosis of gastric varices concerning new classifications; explore and illustrate new ‘portal hypertension theories’ of gastric variceal disease and corresponding management and shed light on current evidence-based treatments through a ‘new’ algorithmic approach, established on hemodynamic physiology of gastric varices.

scholarly journals A73 PHARYNGEAL VARICES AS A COMPLICATION OF PORTAL HYPERTENSION: A CASE SERIES

2020 ◽  
Vol 3 (Supplement_1) ◽  
pp. 86-88
Author(s):  
J Ghaith ◽  
P James ◽  
F Wong
Keyword(s):  
Portal Hypertension ◽  
Portal Vein ◽  
Esophageal Varices ◽  
Splenic Vein ◽  
Case Series ◽  
Brachiocephalic Vein ◽  
Splenic Vein Thrombosis ◽  
Vein Thrombosis ◽  
Ectopic Varices ◽  
Collateral Vessels

Abstract Background One of the complications of portal hypertension, with or without the presence of cirrhosis, is the development of varices along the length of the gastrointestinal tract. The commonest sites are along the esophagus or in the stomach. Ectopic varices in the small and large bowels can also be observed, but ectopic varices in the pharynx are extremely uncommon. Aims To present a case series and review the literature regarding pharyngeal varcies. Methods - Results Three elderly female patients presented for esophagogastric varices surveillance gastroscopy were diagnosed with pharyngeal varices. One patient has hepatitis C cirrhosis, while the other two non-cirrhotic patients have myeloproliferative neoplasm (MPN). None of the patients had thromboses of the portal vein or its tributaries. All three patient have concomitant esophageal varices, but only one required band ligation of her esophageal varices. All patients are asymptotic except for mild dysphagia. No patient has bled from their pharyngeal varices to date. Two patients have had prophylactic treatment of their portal hypertension with non-selective beta blocker (NSBB), while the third one has not received NSBB prophylaxis because of her age. Conclusions Pharyngeal varices are extremely rare. To date, there are three case reports in the literature, however, we have been able to identify three cases in our practice. The previous two cases reported possible left-sided portal hypertension with splenic vein thrombosis, leading to the development of collateral vessels including a gastrocaval shunt, which by some contiguous route connects to the brachiocephalic vein; and a third case was a complication of neck dissection surgery. In our case series, none of our patients had splenic vein thrombosis. However, none of them has had a careful CT angiogram to delineate the portal vein tributaries and the collateral vessels, which may further help to define their pathogenesis. It is unclear whether NSBB would be effective as primary prophylaxis against their bleeding, The plan is to continue to monitor these patients to learn about the natural history of these pharyngeal varices. Funding Agencies None

Transjugular intrahepatic portosystemic shunt in the treatment of ectopic varices secondary to portal hypertension

2003 ◽  
Vol 124 (4) ◽  
pp. A665
Author(s):  
Ramasamy Saravanan ◽  
Manu Nayar ◽  
Peter Rowlands ◽  
Richard Mc Williams ◽  
Howard Smart ◽  
...  
Keyword(s):  
Portal Hypertension ◽  
Transjugular Intrahepatic Portosystemic Shunt ◽  
Portosystemic Shunt ◽  
Ectopic Varices ◽  
Intrahepatic Portosystemic Shunt

Case Series Regarding Parastomal Variceal Bleeding: Presentation and Management

2018 ◽  
Vol 17 (5) ◽  
pp. 0-10
Author(s):  
John Romano ◽  
Charles V. Welden ◽  
Jordan Orr ◽  
Brendan McGuire ◽  
Mohamed Shoreibah
Keyword(s):  
Portal Hypertension ◽  
High Risk ◽  
Literature Review ◽  
Variceal Bleeding ◽  
Coil Embolization ◽  
Case Series ◽  
Treatment Modalities ◽  
Post Procedure ◽  
Lost To Follow Up

Parastomal variceal bleeding (PVB) is a serious complication occurring in up to 27% of patients with an ostomy and concurrent cirrhosis and portal hypertension. The management of PVB is difficult and there are no clear guidelines on this matter. TIPS, sclerotherapy, and /or coil embolization are all therapies that have been shown to successful manage PVB. We present a case series with five different patients who had a PVB at our institution. The aim of this case series is to report our experience on the management of this infrequently reported but serious condition. We also conducted a systemic literature review focusing on the treatment modalities of 163 patients with parastomal variceal bleeds. In our series, patient 1 had embolization and sclerotherapy without control of bleed and expired on the day of intervention due to hemorrhagic shock. Patient 2 had TIPS in conjunction with embolization and sclerotherapy and had no instance of rebleed 441 days after therapy. Patient 3 did not undergo any intervention due to high risk for morbidity and mortality, the bleed self-resolved and there was no further rebleed, this same patient died of sepsis 73 days later. Patient 4 had embolization and sclerotherapy and had no instance of rebleed 290 days after therapy. Patient 5 had TIPS procedure and was discharged five days post procedure without rebleed, patient has since been lost to follow-up.

scholarly journals Endoscopic ultrasound-guided treatment of gastric varices with coil embolization and absorbable hemostatic gelatin sponge: a novel alternative to cyanoacrylate

2020 ◽  
Vol 08 (02) ◽  
pp. E221-E227 ◽  
Author(s):  
Ahmad Najdat Bazarbashi ◽  
Thomas J. Wang ◽  
Christopher C. Thompson ◽  
Marvin Ryou
Keyword(s):  
Endoscopic Ultrasound ◽  
Coil Embolization ◽  
Case Series ◽  
Gastric Varices ◽  
Gelatin Sponge ◽  
High Morbidity ◽  
Technical Success ◽  
Radiographic Findings ◽  
Systemic Embolization

Abstract Background and study aims Bleeding from gastric varices (GV) carries high morbidity and mortality. Current endoscopic therapies are premised on cyanoacrylate injection which is technically challenging and carries risk of embolization. We present a case series of endoscopic ultrasound (EUS)-guided coil injection in combination with hemostatic absorbable gelatin sponge (AGS) for treatment of bleeding gastric varices. Patients and methods This was a retrospective review of EUS-guided coil injection for bleeding GV since November 2017. After EUS-guided needle puncture, hemostatic coils were serially injected until significant reduction of Doppler flow. Under fluoroscopic guidance, test contrast was injected to confirm absence of run-off, at which time AGS, converted into a liquid slurry, was injected as hemostatic reinforcement. Results Ten consecutive patients underwent EUS-guided coil embolization reinforced by AGS. Technical success, defined as uncomplicated injection of coils and sponge was achieved in 100 % (10/10). Mean follow-up was 6 months 73–397 days; No patients rebled or required reintervention on GV. The complication rate was 10 % (1/10; severe abdominal pain without radiographic findings); otherwise, there were no cases of systemic embolization. Nine of 10 patients (90 %) had follow-up EUS (mean 80 days); 100 % (9/9) revealed near-obliteration of GV. Conclusion EUS-guided coil embolization in combination with hemostatic AGS is a novel method for management of bleeding GV with high clinical and technical success rates, low risk for complications and favorable safety profile when compared to cyanoacrylate. This technique theoretically minimizes embolic complications and need for re-intervention. Further studies are required to compare this modality.

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