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Lee EW, Eghtesad B, Garcia-Tsao G, Haskal ZJ, Hernandez-Gea V, Jalaeian H, Kalva SP, Mohanty A, Thabut D, Abraldes JG. AASLD Practice Guidance on the use of TIPS, variceal embolization, and retrograde transvenous obliteration in the management of variceal hemorrhage. Hepatology 2024; 79:224-250. [PMID: 37390489 DOI: 10.1097/hep.0000000000000530] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/02/2023]
Affiliation(s)
- Edward Wolfgang Lee
- Department of Radiology and Surgery, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Bijan Eghtesad
- Department of General Surgery, Digestive Disease and Surgery Institute Cleveland Clinic, Cleveland, Ohio, USA
| | - Guadalupe Garcia-Tsao
- Yale University School of Medicine, Department of Internal Medicine, Section of Digestive Diseases, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Ziv J Haskal
- Department of Radiology and Medical Imaging/Interventional Radiology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). Universitat de Barcelona (UB). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
| | - Hamed Jalaeian
- Department of Interventional Radiology, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | | | - Arpan Mohanty
- Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Dominique Thabut
- AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Service d'Hépato-gastroentérologie, Paris, France
| | - Juan G Abraldes
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
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Pas M, Jogo A, Yamamoto A, Nishida N, Jogo E, Kageyama K, Sohgawa E, Miki Y. Successful treatment of rectal varices with antegrade transvenous sclerotherapy via the splenorenal shunt from the transjugular approach. Radiol Case Rep 2022; 17:4679-4684. [PMID: 36204409 PMCID: PMC9530408 DOI: 10.1016/j.radcr.2022.08.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 08/25/2022] [Indexed: 02/07/2023] Open
Abstract
A 74-year-old patient presented with hematochezia and a history of liver cirrhosis with repeated bleeding from esophageal and rectal varices. Endoscopic examination revealed multiple rectal varices with positive red color signs. Ascites, severe portosystemic thrombosis and a splenorenal shunt were diagnosed on a contrast-enhanced dynamic computed tomography examination. From a transjugular approach, we circumvented thrombosed regions by maneuvering double balloon catheters through the shunt and dilated left colic marginal vein. We managed to successfully obliterate the varices.
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Chatani S, Seki K, Sonoda A, Murakami Y, Tomozawa Y, Fujimoto T, Andoh A, Watanabe Y. Bleeding anorectal varices treated by a direct puncture approach through the greater sciatic foramen: The utility of a steerable microcatheter for reverse catheterization. Radiol Case Rep 2022; 17:1104-1109. [PMID: 35169409 PMCID: PMC8829532 DOI: 10.1016/j.radcr.2022.01.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 11/26/2022] Open
Abstract
Bleeding is less common from anorectal varices than from esophageal varices, but it is potentially life-threatening. Here, we present a case of a woman in her 70s with critical hemorrhage from anorectal varices. The endoscopic approach could not be performed due to the huge variceal formation and the transhepatic approach was also unsuitable due to the presence of portal vein thrombosis and ascites. A direct puncture to the right superior rectal vein was performed through the greater sciatic foramen under computed tomography fluoroscopic guidance. Using a steerable microcatheter, superior rectal veins were bilaterally embolized with a mixture of n-butyl cyanoacrylate and ethiodized oil, and microcoils. Endoscopy and contrast-enhanced computed tomography performed after the procedure confirmed a marked shrinkage of anorectal varices. When endoscopic or any other approaches are difficult, this technique can be a useful alternative therapeutic option.
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Alves E Sousa F, Lopes PM, Mónica IB, Carvalho AC, Sousa P. Emborrhoid technique performed on a patient with portal hypertension and chronic hemorrhoidal bleeding as a salvage therapy. CVIR Endovasc 2022; 5:1. [PMID: 34978653 PMCID: PMC8724469 DOI: 10.1186/s42155-021-00278-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 12/08/2021] [Indexed: 11/16/2022] Open
Abstract
Background Hemorrhoidal disease most commonly manifests itself with chronic rectal bleeding and, in its most severe and refractory forms, may lead to chronic anaemia with the need for recurrent blood transfusions. The main pathogenetic mechanism involved seems to be arterial hyperflux in the terminal branches that supply the hemorrhoidal plexus. It is based on this principle, that embolization of the superior rectal artery (emborrhoid technique) has recently re-emerged, with very promising results that support its feasibility, treatment efficacy, and safety. Case presentation We report a case of a patient with both recurrent hemorrhoidal bleeding and portal hypertension with rectal varices, who underwent SRA embolization as a salvage therapy, with significant clinical improvement and no immediate or short-term complications. Conclusions We believe that the positive results from our case raise the possibility that the emborrhoid technique could be effective and safe even in patients with portal hypertension, and that it would be clinically relevant to investigate this hypothesis on larger samples with a longer follow-up.
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Affiliation(s)
- Filipa Alves E Sousa
- Department of Radiology, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal. .,Centro Hospitalar Universitário de Lisboa Central, Alameda Santo António dos Capuchos, 1169-050, Lisboa, Portugal.
| | - Pedro Marinho Lopes
- Department of Radiology, Centro Hospitalar Vila Nova de Gaia/Espinho, Oporto, Portugal
| | - Inês Bolais Mónica
- Department of General Surgery, Hospital Distrital da Figueira da Foz, Coimbra, Portugal
| | | | - Pedro Sousa
- Department of Radiology, Centro Hospitalar Vila Nova de Gaia/Espinho, Oporto, Portugal
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Lee A, Suhardja TS, Nguyen TC, Chouhan HS. Management options for rectal variceal bleeding in the setting of hepatic encephalopathy. ANZ J Surg 2020; 91:49-54. [PMID: 32407000 DOI: 10.1111/ans.15982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 12/24/2022]
Abstract
Bleeding related to rectal varices associated with portal hypertension is rare but life-threatening, and requires prompt treatment. We reviewed the literature for patients with this complex presentation and current recommendations, and commented on a case at our institution of a 68-year-old man with Child-Pugh B alcoholic liver cirrhosis and hepatic encephalopathy who presented with profuse life-threatening rectal variceal bleeding. Treatment options for rectal varices in patients with hepatic encephalopathy were reviewed and a management algorithm was devised from current knowledge in the literature. We suggest endoscopic management, and if unsuccessful then to proceed to angioembolization and/or balloon-occluded retrograde transvenous obliteration, which may be used in conjunction with surgical management. The chosen therapeutic option may depend on the clinical condition of the patient, the cause of portal hypertension and clinical expertise or facilities available. Given that transjugular intra-hepatic portosystemic shunting is contraindicated in patients with hepatic encephalopathy, management of life-threatening rectal variceal bleeding should be multimodal.
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Affiliation(s)
- Alice Lee
- Colorectal Surgery Unit, Monash Health, Dandenong Hospital, Melbourne, Victoria, Australia
| | - Thomas Surya Suhardja
- Colorectal Surgery Unit, Monash Health, Dandenong Hospital, Melbourne, Victoria, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Thang Chien Nguyen
- Colorectal Surgery Unit, Monash Health, Dandenong Hospital, Melbourne, Victoria, Australia
| | - Hanumant S Chouhan
- Colorectal Surgery Unit, Monash Health, Dandenong Hospital, Melbourne, Victoria, Australia
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Chung W, Maurice J, Patch D. Twitter debate: controversies in the management of portal hypertension. Frontline Gastroenterol 2020; 12:77-79. [PMID: 33456744 PMCID: PMC7790013 DOI: 10.1136/flgastro-2019-101400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/03/2020] [Accepted: 01/08/2020] [Indexed: 02/04/2023] Open
Abstract
The latest 'Controversies in…' series for the Frontline Gastroenterology Twitter debates addressed the challenges of managing patients with portal hypertension, facilitated by Hepatologist and Liver Transplant physician Dr David Patch from the Royal Free London. Key topics discussed include basic principles of managing a patient with variceal bleeding, techniques for treating oesophageal and ectopic varices, pitfalls of vasoactive therapy, indications for transjugular intrahepatic portosystemic shunt, and a brief discussion of portal vein thrombosis. This article aims to summarise key areas of discussion from the event.
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Affiliation(s)
- William Chung
- The Royal Free Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, Hampstead, London, UK
| | - James Maurice
- The Royal Free Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, Hampstead, London, UK,Department of Gastroenterology, Barts Health NHS Trust, London, UK
| | - David Patch
- The Royal Free Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, Hampstead, London, UK
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7
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Garrido M, Gonçalves B, Ferreira S, Rocha M, Salgado M, Pedroto I. Treating Untreatable Rectal Varices. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2019; 26:420-424. [PMID: 31832497 DOI: 10.1159/000496121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 12/08/2018] [Indexed: 12/20/2022]
Abstract
Background Rectal varices are portosystemic collaterals that arise as a complication of portal hypertension. Despite their significant prevalence among cirrhotic patients, clinically important bleeding occurs only in a minority. Various treatment options are available, with endoscopic therapies being widely used, and both interventional radiology and surgery being considered for refractory bleeding rectal varices. Case We report the case of a 61-year-old male with hepatic cirrhosis and bleedingrectal varices refractory to endoscopic therapy, successfully managed with a combination of transjugular intrahepatic portosystemic shunt (TIPS) and selective variceal embolization. Conclusions Radiological techniques are effective options for refractory bleeding. Adding embolization to TIPS implantation could represent a valid adjunctive measure for haemostasis of recurrent rectal variceal bleeding.
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Affiliation(s)
- Mónica Garrido
- Department of Gastroenterology, Porto University Hospital Centre, Porto, Portugal
| | - Belarmino Gonçalves
- Department of Interventional Radiology, Portuguese Oncology Institute, Porto, Portugal
| | - Sofia Ferreira
- Liver Transplant Unit, Porto University Hospital Centre, Porto, Portugal
| | - Marta Rocha
- Department of Gastroenterology, Porto University Hospital Centre, Porto, Portugal
| | - Marta Salgado
- Department of Gastroenterology, Porto University Hospital Centre, Porto, Portugal.,Institute of Biomedical Sciences of Abel Salazar (ICBAS), University of Porto, Porto, Portugal
| | - Isabel Pedroto
- Department of Gastroenterology, Porto University Hospital Centre, Porto, Portugal.,Institute of Biomedical Sciences of Abel Salazar (ICBAS), University of Porto, Porto, Portugal
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Rudman HA, Stott MC, Loh MY, Clark EC. Rectal varices due to chronic inferior mesenteric vein thrombosis caused by external compression in a large hiatus hernia containing the pancreas. Ann R Coll Surg Engl 2018; 100:e171-e173. [PMID: 29909661 DOI: 10.1308/rcsann.2018.0083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A 79-year-old woman presented with a large fresh rectal bleed. Computed tomography revealed that she had a large type IV hiatus hernia, which contained the stomach and pancreas. Compression of the inferior mesenteric vein and splenic vein had led to thrombosis within these vessels and retrograde flow within the inferior mesenteric vein. This had led to the formation of portosystemic rectal varices. Ectopic varices occasionally form in the rectum, often in the context of liver cirrhosis. At the time of writing, ours is the first reported case of portosystemic rectal varices formulated in response to obstruction of vessels within a hiatus hernia.
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Affiliation(s)
- H A Rudman
- Department of General Surgery, Stepping Hill Hospital , Stockport , UK
| | - M C Stott
- Department of General Surgery, Stepping Hill Hospital , Stockport , UK
| | - M Y Loh
- Department of Radiology, Stepping Hill Hospital , Stockport , UK
| | - E C Clark
- Department of General Surgery, Stepping Hill Hospital , Stockport , UK
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