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Gastrointestinal Bleeding as a Result of Portal Hypertension

  • Jonathan Marshall
Chapter

Abstract

TIPS (transjugular intrahepatic portosystemic shunt) was first performed in the early 1980s to treat esophageal varices, but additional indications for the procedure have developed since then. In acute variceal hemorrhage, TIPS is currently implemented in the setting of failed endoscopic intervention and has demonstrated low procedural complication rates, low rebleeding rates, excellent primary patency of the TIPS stent, and low rates of TIPS-induced encephalopathy. Additional techniques have been developed to manage those patients with poor hepatic anatomy and those patients with complicated gastric varices.

Keywords

Transjugular intrahepatic shunt (TIPS) Direct intracaval intrahepatic shunt (DIPS) Variceal hemorrhage Gastric varices Stomal varices Balloon retrograde total obliteration (BRTO) Coil-assisted retrograde total obliteration (CARTO) Stomal varices Encephalopathy Viatorr 

References

  1. 1.
    Copelan A, Kapoor B, Sands M. Transjugular intrahepatic portosystemic shunt: indications, contraindications, and patient work-up. Semin Intervent Radiol. 2014;31:235–42.CrossRefGoogle Scholar
  2. 2.
    Holland LL, Brooks JP. Toward Rational Fresh Frozen Plasma Transfusion: The effect of plasma transfusion on coagulation test results. American Journal of Clinical Pathology. 2006;126:133–39.Google Scholar
  3. 3.
    Gaba R. Transjugular intrahepatic portosystemic shunt creation with embolization or obliteration for variceal bleeding. Tech Vasc Interventional Rad. 2016;19:21–35.CrossRefGoogle Scholar
  4. 4.
    Berzigotti A, Seijo S, Reverter E, Bosch J. Assessing portal hypertension in liver diseases. Expert Rev Gastroenterol Hepatol. 2013;7(2):141–55.CrossRefGoogle Scholar
  5. 5.
    Garcia-Tsao G, Groszmann RJ, Fisher RL, Conn HO, Atterbury CE, Glickman M. Portal pressure, presence of gastroesophageal varices and variceal bleeding. Hepatology. 1985;5(3):419–24.CrossRefGoogle Scholar
  6. 6.
    Zheng M, Chen Y, Bai J, et al. Transjugular intrahepatic portosystemic shunt versus endoscopic therapy in the secondary prophylaxis of variceal rebleeding in cirrhotic patients: meta-analysis update. J Clin Gastroenterol. 2008;42(5):507–16.CrossRefGoogle Scholar
  7. 7.
    Petersen BD, Clark WI. Direct intracaval portosystemic shunts. Tech Vasc Interv Radiol. 2008;4:230–4.Google Scholar
  8. 8.
    Alam H, Kim D, Provido H, Kirkpatrick J. Portal vein thrombosis in the adult: surgical implications in an era of dynamic imaging. Am Surg. 1997;63:681–4.PubMedGoogle Scholar
  9. 9.
    Valla D, Condat B. Portal vein thrombosis in adults: pathophysiology, pathogenesis and management. J Hepatol. 2000;32:865–71.CrossRefGoogle Scholar
  10. 10.
    Condat B, Pessione F, Hillaire S, et al. Current outcome of portal vein thrombosis in adults: risk and benefit of anticoagulant therapy. Gastroenterology. 2001;120:490–7.CrossRefGoogle Scholar
  11. 11.
    Janssen HLA. Changing perspectives in portal vein thrombosis. Scand J Gastroenterol. 2000;232(suppl):69–73.Google Scholar
  12. 12.
    Hollingshead M, et al. Transcatheter thrombolytic therapy for acute mesenteric and portal vein thrombosis. J Vasc Interv Radiol. 2005;16(5):651–61.CrossRefGoogle Scholar
  13. 13.
    Pascal JP, Cales P, Multicentre Study Group. Propranolol in the prevention of first upper gastrointestinal tract haemorrhage in patients with cirrhosis of the liver and oesophageal varices. N Engl J Med. 1987;317:856–61.CrossRefGoogle Scholar
  14. 14.
    Ideo I, Bellati G, Fesce E, Grimoldi D. Nadolol can prevent the first gastrointestinal bleeding in cirrhotics: a prospective randomised study. Hepatology. 1988;8:6–9.CrossRefGoogle Scholar
  15. 15.
    Lebrec D, Poynard T, Capron JP, Hillon P, Geoffrey P, Roulot D, Chaput JC, et al. Nadolol for prophylaxis of gastrointestinal bleeding in patients with cirrhosis. A randomised trial. J Hepatol. 1988;7:118–25.CrossRefGoogle Scholar
  16. 16.
    Italian Multicentre Project for Propranolol in the Prevention of Bleeding. Propranolol prevents first gastrointestinal bleed in non-ascitic cirrhotic patients. Final report of a multicentre randomised trial. J Hepatol. 1989;9:75–83.Google Scholar
  17. 17.
    Conn HO, Grace ND, Bosch J, Groszmann RJ, Rodes J, Wright SC, Matloff DS, et al. Propranolol in the prevention of the first haemorrhage from oesophagogastric varices. A multicenter randomised clinical trial. Hepatology. 1991;13:902–12.CrossRefGoogle Scholar
  18. 18.
    D’Amico G, Pagliaro L, Bosch J. The treatment of portal hypertension: a meta analytical review. Hepatology. 1995;22:332–53.PubMedGoogle Scholar
  19. 19.
    Tesdal IK, Filser T, Weiss C, Holm E, Dueber C, Jaschke W. Transjugular intrahepatic portosystemic shunts: adjunctive embolotherapy of gastroesophageal collateral vessels in the prevention of variceal rebleeding. Radiology. 2005;236(1):360–7.CrossRefGoogle Scholar
  20. 20.
    García-Pagán JC, Caca K, Bureau C, Early TIPS (Transjugular Intrahepatic Portosystemic Shunt) Cooperative Study Group, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010;362(25):2370–9.CrossRefGoogle Scholar
  21. 21.
    Forauer AR, McLean GK. Transjugular intrahepatic portosystemic shunt constraining stent for the treatment of refractory postprocedural encephalopathy: a simple design utilizing a Palmaz stent and Wallstent. J Vasc Interv Radiol. 1998;9:443–6.CrossRefGoogle Scholar
  22. 22.
    Pomier-Layrargues G. TIPS and hepatic encephalopathy. Semin Liver Dis. 1996;16:315–20.CrossRefGoogle Scholar
  23. 23.
    Sanyal AJ, Freedman AM, Shiffman ML, Purdum PP, Luketic VA, Cheatham AK. Portosystemic encephalopathy after transjugular intrahepatic portosystemic shunt: results of a prospective controlled study. Hepatology. 1994;20:46–55.PubMedGoogle Scholar
  24. 24.
    Garcia N Jr, Sanyal AJ. Medical management of complications secondary to portal hypertension. In: Patel NH, Haskal ZJ, Kerlan Jr RK, editors. SCVIR syllabus volume XI: portal hypertension—diagnosis and interventions. 2nd ed. Fairfax: Society of Cardiovascular and Interventional Radiology; 2001. p. 47–62.Google Scholar
  25. 25.
    Madoff D, Wallace JM, Kamran A, Saxon RR. TIPS-related hepatic encephalopathy: management options with novel endovascular techniques. Radiographics. 2004;24:21–37.CrossRefGoogle Scholar
  26. 26.
    Van der Rijt CC, Schalm SW, Schat H, et al. Overt hepatic encephalopathy precipitated by zinc deficiency. Gastroenterology. 1991;100:1114–8.CrossRefGoogle Scholar
  27. 27.
    Zuckerman DA, Darcy MD, Bocchini TP, Hildebolt CF. Encephalopathy after transjugular intrahepatic portosystemic shunting: analysis of incidence and potential risk factors. AJR Am J Roentgenol. 1997;169:1727–31.CrossRefGoogle Scholar
  28. 28.
    Duan XH, et al. Comparison of Percutaneous Transhepatic Variceal Embolization (PTVE) followed by partial splenic embolization versus ptve alone for the treatment of acute esophagogastric variceal massive hemorrhage. J Vasc Intervent Radiol. 2014;25(12):1858–65.CrossRefGoogle Scholar
  29. 29.
    Xu RY, Liu B, Lin N. Therapeutic effects of endoscopic variceal ligation combined with partial splenic embolization for portal hypertension. World J Gastroenterol. 2004;10:1072–4.CrossRefGoogle Scholar
  30. 30.
    Saad WE, Lippert A, Saad NE. Ectopic varices: anatomical classification, hemodynamic classification, and hemodynamic-based management. Tech Vasc Interv Radiol. 2013;16(2):108–25.CrossRefGoogle Scholar
  31. 31.
    Kocher N, Tripathy D, McAvoy NC, et al. Bleeding ectopic varices in cirrhosis: the role of transjugular intra-hepatic portosystemic stent shunts. Aliment Pharmacol Ther. 2008;28:294–303.CrossRefGoogle Scholar
  32. 32.
    Hashimoto N, Akhoshi T, Yoshida D, et al. The efficacy of balloon-occluded retrograde transvenous obliteration on small intestinal variceal bleeding. Surgery. 2010;148:145–50.CrossRefGoogle Scholar
  33. 33.
    Vidal V, Joly L, Perreault P, et al. Usefulness of transjugular intrahepatic portosystemic shunt in the management of bleeding ectopic varices in cirrhotic patients. Cardiovasc Intervent Radiol. 2006;29:216–9.CrossRefGoogle Scholar
  34. 34.
    Watanabe K, Kimura K, Matsutani S, Ohto M, Okuda K. Portal hemodynamics in patients with gastric varices. Gastroenterol. 1988;95:434–40.CrossRefGoogle Scholar
  35. 35.
    Sarin SK, Lahori D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification, and natural history of gastric varices: a long-term follow up study in 568 portal hypertension patients. Hepatology. 1992;16:1343–9.CrossRefGoogle Scholar
  36. 36.
    Saad WE, Darcy MD. Transjugular intrahepatic portosystemic shunt (TIPS) versus balloon-occluded retrograde transvenous obliteration (BRTO) for the management of gastric varices. Semin Intervent Radiol. 2011;28:339–49.CrossRefGoogle Scholar
  37. 37.
    Saad WE. Vascular anatomy and the morphologic and hemodynamic classifications of gastric varices and spontaneous portosystemic shunts relevant to the BRTO procedure. Tech Vasc Interv Radiol. 2013;16:60–100.CrossRefGoogle Scholar
  38. 38.
    Saad WE, Wagner CC, Lippert A, et al. Protective value of TIPS against the development of hydrothorax/ascites and upper gastrointestinal bleeding after balloon-occluded retrograde transvenous obliteration (BRTO). Am J Gastroenterol. 2013;108:1612–9.CrossRefGoogle Scholar
  39. 39.
    Olson E, Yune HY, Klatte EC. Transrenal-vein reflux ethanol sclerosis of gastroesophageal varices. AJR Am J Roentgenol. 1984;143(3):627–8.CrossRefGoogle Scholar
  40. 40.
    Kitamoto M, Imamura M, Kamada K, et al. Balloon-occluded retrograde transvenous obliteration of gastric fundal varices with hemorrhage. AJR Am J Roentgenol. 2002;178(5):1167–74.CrossRefGoogle Scholar
  41. 41.
    Ninoi T, Nakamura K, Kaminou T, et al. TIPS versus transcatheter sclerotherapy for gastric varices. AJR Am J Roentgenol. 2004;183(2):369–76.CrossRefGoogle Scholar
  42. 42.
    Ninoi T, Nishida N, Kaminou T, et al. Balloon-occluded retrograde transvenous obliteration of gastric varices with gastrorenal shunt: long-term follow-up in 78 patients. AJR Am J Roentgenol. 2005;184(4):1340–6.CrossRefGoogle Scholar
  43. 43.
    Akahoshi T, Hashizume M, Tomikawa M, et al. Long-term results of balloon-occluded retrograde transvenous obliteration for gastric variceal bleeding and risky gastric varices: a 10-year experience. J Gastroenterol Hepatol. 2008;23(11):1702–9.CrossRefGoogle Scholar
  44. 44.
    Fukuda T, Hirota S, Sugimura K. Long-term results of balloonoccluded retrograde transvenous obliteration for the treatment of gastric varices and hepatic encephalopathy. J Vasc Interv Radiol. 2001;12(3):327–36.CrossRefGoogle Scholar
  45. 45.
    Sonomura T, Sato M, Kishi K, et al. Balloon-occluded retrograde transvenous obliteration for gastric varices: a feasibility study. Cardiovasc Intervent Radiol. 1998;21(1):27–30.CrossRefGoogle Scholar
  46. 46.
    Kiyosue H, Matsumoto S, Onishi R, et al. Balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices: therapeutic results and problems [in Japanese]. Nippon Igaku Hoshasen Gakkai Zasshi. 1999;59(1):12–9.PubMedGoogle Scholar
  47. 47.
    Koito K, Namieno T, Nagakawa T, Morita K. Balloon-occluded retrograde transvenous obliteration for gastric varices with gastrorenal or gastrocaval collaterals. AJR Am J Roentgenol. 1996;167(5):1317–20.CrossRefGoogle Scholar
  48. 48.
    Chikamori F, Kuniyoshi N, Kawashima T, Takase Y. Gastric varices with gastrorenal shunt: combined therapy using transjugular retrograde obliteration and partial splenic embolization. AJR Am J Roentgenol. 2008;191(2):555–9.CrossRefGoogle Scholar
  49. 49.
    Kumamoto M, Toyonaga A, Inoue H, et al. Long-term results of balloon-occluded retrograde transvenous obliteration for gastric fundal varices: hepatic deterioration links to portosystemic shunt syndrome. J Gastroenterol Hepatol. 2010;25(6):1129–35.CrossRefGoogle Scholar
  50. 50.
    Chikamori F, Kuniyoshi N, Shibuya S, Takase Y. Eight years of experience with transjugular retrograde obliteration for gastric varices with gastrorenal shunts. Surgery. 2001;129(4):414–20.CrossRefGoogle Scholar
  51. 51.
    Hirota S, Matsumoto S, Tomita M, Sako M, Kono M. Retrograde transvenous obliteration of gastric varices. Radiology. 1999;211(2):349–56.CrossRefGoogle Scholar
  52. 52.
    Shimoda R, Horiuchi K, Hagiwara S, et al. Short-term complications of retrograde transvenous obliteration of gastric varices in patients with portal hypertension: effects of obliteration of major portosystemic shunts. Abdom Imaging. 2005;30(3):306–13.CrossRefGoogle Scholar
  53. 53.
    Takuma Y, Nouso K, Makino Y, Saito S, Shiratori Y. Prophylactic balloon-occluded retrograde transvenous obliteration for gastric varices in compensated cirrhosis. Clin Gastroenterol Hepatol. 2005;3(12):1245–52.CrossRefGoogle Scholar
  54. 54.
    Arai H, Abe T, Takagi H, Mori M. Efficacy of balloon-occluded retrograde transvenous obliteration, percutaneous transhepatic obliteration and combined techniques for the management of gastric fundal varices. World J Gastroenterol. 2006;12(24):3866–73.CrossRefGoogle Scholar
  55. 55.
    Arai H, Abe T, Shimoda R, Takagi H, Yamada T, Mori M. Emergency balloon-occluded retrograde transvenous obliteration for gastric varices. J Gastroenterol. 2005;40(10):964–71.CrossRefGoogle Scholar
  56. 56.
    Cho SK, Shin SW, Lee IH, et al. Balloon-occluded retrograde transvenous obliteration of gastric varices: outcomes and complications in 49 patients. AJR Am J Roentgenol. 2007;189(6):W365–72.CrossRefGoogle Scholar
  57. 57.
    Chikamori F, Kuniyoshi N, Shibuya S, Takase Y. Transjugular retrograde obliteration for chronic portosystemic encephalopathy. Abdom Imaging. 2000;25(6):567–71.CrossRefGoogle Scholar
  58. 58.
    Park KS, Kim YH, Choi JS, et al. Therapeutic efficacy of balloon-occluded retrograde transvenous obliteration in patients with gastric variceal bleeding [in Korean]. Korean J Gastroenterol. 2006;47(5):370–8.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Jonathan Marshall
    • 1
  1. 1.Department of RadiologyErie County Medical CenterBuffaloUSA

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