Usefulness of Transjugular Intrahepatic Portosystemic Shunt in the Management of Bleeding Ectopic Varices in Cirrhotic Patients

Vidal, Vincent; Joly, Laure; Perreault, Pierre; Bouchard, Louis; Lafortune, M; Pomier‐Layrargues, Gilles

doi:10.1007/s00270-004-0346-4

Cited by 97 publications

(74 citation statements)

References 21 publications

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“…[5]. None of the factors such as Child-Pugh score, pre-TIPSS or the type of stent used (covered-uncovered) are significantly associated with either risk of recurrence of bleeding from ectopic varices or death in the larger series.…”

Section: Discussionmentioning

confidence: 82%

“…If these measures are ineffective or not possible and if the varices are accessible radiologically, VE may be tried. The procedure-related complications rate is generally low (about 3%) [5].…”

Section: Discussionmentioning

confidence: 99%

“…Nevertheless, patients with ectopic varices may re-bleed after TIPSS despite initial achievement of hemodynamic targets and the presence of a patent functioning shunt in situ. In some series, re-bleeding more commonly occurs in those patients who have a TIPSS procedure without concomitant variceal embolization (VE) [4] versus those who do, but this is still controversial as other series do not report this [5]. In the event of re-bleeding, if the varices are accessible, local treatment may be tried first.…”

Section: Discussionmentioning

confidence: 99%

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Bleeding ileal varices: a rare cause of chronic anemia in liver cirrhosis

et al. 2010

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A 70-year-old man was admitted to our hospital for severe microcytic anemia (Hb 5.9 g/dL, MCV 74 fl). The medical history included hepatic cirrhosis due to previous alcohol abuse with known portal hypertension, hemorrhoids and oesophageal varices. During the prior year, he had been admitted three times to the hospital due to ascites, treated with evacuative paracentesis for his microcytic anemia with low ferritinemia, each time he was transfused with blood and treated for 2 months with oral iron for an improvement in the hemoglobin level and in iron metabolism parameters. Two esophagogastroduodenoscopies (EGDs) and two colonoscopies did not show bleeding lesions, and even faecal occult blood testing was negative on multiple samples.He was on treatment with canrenoate 400 mg/die, furosemide 25 mg/die, and propranolol 80 mg/die. During immediate prior weeks, he reported general malaise, heart palpitations and weakness. He did not report any blood loss with stool, nor hematuria or hematemesis. He was afebrile, and the other vital signs were normal. He was pale, and there was no jaundice. Abdominal ultrasonography (US) showed slight free peritoneal fluid. He was initially transfused with two units of packed red blood cells and an intravenous administration of iron was started. The faecal occult blood test on three samples was negative, a new EGDs showed oesophageal varices without signs of recent bleeding; colonoscopy revealed a normal mucosa with hemorrhoids.In order to study the entire intestine, capsule endoscopy (CE) was performed; it revealed severe hyperemia of jejunoileal mucosa with multiple big blue varices in the ileum, without active bleeding (Fig. 1).Due to the persistence of anemia, and the need for frequent blood transfusion, along with a lack of response to betablockers, a transjugular intrahepatic portosystemic shunt (TIPSS) procedure was performed with no complications. The patient underwent a CE 5 days after showing the disappearance of the multiple varices (Fig. 2); the anemia improved quickly, and no further blood transfusion has been necessary up to the present. DiscussionPortal hypertensive enteropathy (PHE) is present in 5-11% of patients with portal hypertension and chronic active bleeding [1]; the presence of varices and of areas of mucosa with a reticulate pattern should be considered manifestations of portal hypertension in the small bowel. Ectopic varices are an unusual cause of gastrointestinal hemorrage and can account for up to 5% of variceal bleeding; acute bleeding is associated with a high mortality. These varicescan occur at different sites in the gastrointestinal tract, including the duodenum, small bowel, colon and peristomal locations.Endoscopic diagnosis of ileal PHE and ileal varices is impossible to achieve with a standard endoscope, and

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Section: Discussionmentioning

confidence: 82%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Bleeding ileal varices: a rare cause of chronic anemia in liver cirrhosis

et al. 2010

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“…8 Although all these measures may help solve the acute phase, they do not decrease the risk of hemorrhagic recurrence and its severity; thus, the need to evaluate other, more effective end treatments are deemed necessary. Although more invasive than the treatments mentioned above, measures such as portacaval shunt surgery and placement of TIPS present a higher rate of definitive solution.…”

Section: Discussionmentioning

confidence: 99%

“…6,7 However, while these measures solve the acute stage, they don't decrease the risk of recurrence of the bleeding. 8 Transjugular intrahepatic portosystemic shunt (TIPS), selective embolization, or surgical shunt solutions should be considered in cases of recurrent bleeding varices. 8,9 The first of the aforementioned measures is currently accepted as one of the methods of choice.…”

Section: Introductionmentioning

confidence: 99%

Bleeding due to ectopic varices in a urinary diversion: A multidisciplinary diagnostic and therapeutic challenge

Acosta

Reyes

Menéndez

2015

CUAJ

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The ectopic varices in patients with portal hypertension are those that occur at any level of the gastrointestinal (GI) tract, regardless of the varices that occur at the esophageal level. These ectopic varices account for 2-5% of the causes of GI bleeding varices. The risk of bleeding is quadrupled compared to the esophagogastric area, with a mortality of up to 40%. The transjugular intrahepatic portosystemic shunt, should be considered in cases secondary to recurrent bleeding varices.We present a case report of an urological emergency of bleeding in a urinary diversion secondary to ectopic varices successfully treated through the placement of transjugular intrahepatic portosystemic shunt. The condition described here is rare, but important, as it can be a life-threatening complication of portal hypertension. This kind of complication should be known by urologic surgeons managing patients with urinary diversions.

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