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Management of Portal Hypertension |
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Yolanda Y. L. Yang and J. Michael Henderson |
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A 37-year-old woman with a history of hepatitis C, cirrhosis, and esophageal varices presented with hematemesis and melena. The patient had a history of a prior esophageal variceal bleeding episode 7 years ago, which required transfusion of four units of packed red blood cells (PRBC) and had been treated with endoscopic sclerotherapy. She was placed on nadolol at that time.
Question 1
If the patient had been found to have varices before any bleeding episode, she would benefit from which of the following?
A. Endoscopic treatment: sclerotherapy or band ligation. B. Transjugular intrahepatic portal systemic shunt (TIPS). C. Non-cardioselective beta-blocker.
D. A surgical shunt.
The patient re-presents one year prior to her current admission with a further variceal bleed documented at endoscopy, which required five units of PRBC. The acute episode of bleeding was managed with variceal banding, and the patient underwent a course of banding on an outpatient basis. She had no encephalopathy at that time, but did develop some ascites for a short period that responded to salt restriction, Aldactone, and Lasix. Over this past year, her liver function tests have been stable with her bilirubin at 1.0, albumin at 3.5, and a normal prothrombin time.
J.M. Henderson ( )
Division of Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
G. Geroulakos and B. Sumpio (eds.), Vascular Surgery, |
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DOI: 10.1007/978-1-84996-356-5_31, © Springer-Verlag London Limited 2011 |
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Y.Y.L. Yang and J.M. Henderson |
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Question 2
An episode of acute variceal bleeding usually requires which of the following?
A. ICU admission with hemodynamic monitoring, blood, blood products, and fluid resuscitation.
B. An emergency portacaval shunt.
C. A transjugular intrahepatic portal systemic shunt.
D. Endoscopic therapy with sclerosis and/or band ligation. E. Pharmacologic therapy.
At the present admission the patient is alert and oriented with no evidence of encephalopathy. She has well-preserved muscle mass on examination and is not clinically jaundiced. Her abdomen shows minimal ascites, with no hepatomegaly, but evidence of splenomegaly. Her laboratory studies showed a hemoglobin of 7 g/dL, AST 24, alkaline phosphatase 84, albumin 2.6, bilirubin 3.4, and international normalized ratio (INR) 1.6. She was receiving blood transfusion when examined and octreotide infusion at 50 mg/h. Esophagogastroduodenoscopy showed clot over an esophageal varix with evidence of other non-bleeding varices in both the distal esophagus and gastric fundus.
Question 3
Which of the following studies are important in evaluation and management decisions?
A. Calculation of Child’s score. B. Calculation of MELD score. C. Endoscopy.
D. Doppler ultrasound. E. Angiography.
Question 4
Which of the following statements are accurate in prevention of recurrent variceal bleeding?
A. All patients require portal decompression.
B. First-line treatment is with endoscopic band ligation and a beta-blocker. C. Variceal decompression can only be achieved with a surgical shunt.
D. Liver transplant is good treatment for variceal bleeding in patients with end-stage liver disease.
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Question 5
Decompression of gastroesophageal varices:
A. Can be achieved equally well with surgical shunt or TIPS.
B. Should only be used for patients who have failed endoscopic and pharmacologic therapy for bleeding varices.
C. Improves survival in patients with bleeding varices when compared to endoscopic therapy.
D. Is best achieved by liver transplant for all patients with variceal bleeding.
The patient presented in this case had recurring bleeding episodes through first-line treatment and was therefore a candidate for decompression. Evaluation with angiography and ultrasound showed patent splenic and portal veins and a normal left renal vein (Figs. 31.1– 31.4). The patient had an elective distal splenorenal shunt (DSRS) for variceal decompression. She was in hospital for 7 days, and was discharged following shunt catheterization (Fig. 31.5) and documentation of patency. Follow-up over the next 4 years showed some progression of her hepatitis C, but no further episodes of variceal bleeding.
Fig. 31.1 Splenic artery injection. The catheter is in the splentic artery and is injected with contrast
Fig. 31.2 Splenic vein. The contrast is followed as it flows out of the splenic vein and then cephalad in the portal vein. There is a significant umbilical vein (double shadow with the portal vein) and a small left gastric vein (off the splenic vein) filling on this study. The second, more caudal catheter is positioned within the left renal vein to aid preoperative determination of the spatial relationship between the splenic and left renal veins
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Fig. 31.3 Normal left renal vein. This study has been performed via the right jugular vein, and demonstrates the left renal vein as it heads cephalad towards the inferior vena cava
Fig. 31.4 Circumaortic left renal vein. A circumaortic left renal vein, present in 20% of the population, does not prevent construction of a DSRS. The superior and anterior component is always larger and can be used for the shunt. More problematic is a totally retroaortic vein, found in 4% of the population, which runs transversely and is more fixed in the retroperitoneum, making exposure of the anastomosis more difficult. These patients are better served with a splenocaval shunt
Fig. 31.5 Postoperative catheterization of the distal splenorenal shunt (DSRS). The tip of the catheter lies within the mobilized splenic vein, and the first bend marks the splenorenal anastomosis. The skin staples mark the extended left subcostal incision