Variable efficacy of TIPSS in the management of ectopic variceal bleeding: a multicentre retrospective study

Management of ectopic variceal bleeding with transjugular intrahepatic portosystemic shunt: a systematic review of case reports

Ectopic varices account for 5% of variceal bleedings and occur outside the gastro-esophageal region. This review evaluates the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) for ectopic variceal management. A comprehensive search through PubMed, Scopus, Web of Science, and Embase was conducted until January 16, 2023, using relevant keywords. Case reports and case series with fewer than 10 patients on TIPS for ectopic variceal management were included. The quality assessment followed the Joanna Briggs Institute checklist for case reports. This systematic review evaluated 43 studies involving 50 patients with ectopic varices undergoing TIPS. Patients had a mean age of 54.3 years, half were female, and two were pregnant. Alcoholic liver disease (48%) and hepatitis C infection (26%) were common causes of portal hypertension. Ascites and splenomegaly were reported in 32% and 28% of the patients, respectively. Rectal, oral, and stomal variceal bleeding accounted for 62%, 16%, and 22% of the patients, respectively. Ectopic varices were mainly located in the duodenum (28%) and rectum (26%) regions. Complications affected 42% of the patients, re-bleeding in eleven and hepatic encephalopathy in seven. The follow-up lasted 12 months on average, and finally, 5 received a liver transplant. Mortality post-TIPS was 18%. Despite complications and a notable mortality rate, favorable outcomes were observed in almost half of the patients with ectopic variceal bleeding managed with TIPS. Further research is warranted to refine strategies and improve patient outcomes.

Diagnosis and management of ectopic varices in portal hypertension

Ectopic variceal bleeding is a rare cause of gastrointestinal bleeding that can occur in settings of cirrhotic and non-cirrhotic portal hypertension and is characterised by its development at locations remote from the oesophagus and stomach. Ectopic varices can be difficult to identify and access, and, although a relatively uncommon cause of portal hypertensive bleeding, can represent a difficult diagnostic and therapeutic challenge associated with considerable mortality. Low incidence and variance in variceal anatomy preclude large randomised controlled trials, and clinical practice is based on experience from case reports, case series, and specialist centre expertise. Optimisation of survival outcomes relies on understanding a patient's portal venous anatomy and functional hepatic reserve to guide timely and targeted endoscopic and endovascular interventions to facilitate the rapid control of ectopic variceal bleeding.

Technical and clinical outcomes following EUS-guided thrombin injection and coil implantation for parastomal varices

BACKGROUND AND AIMS

Bleeding from parastomal varices causes significant morbidity and mortality. Treatment options are limited, particularly in high-risk patients with significant underlying liver disease and other comorbidities. The use of EUS-guided embolisation coils combined with thrombin injection in gastric varices has been shown to be safe and effective. Our institution has applied the same technique to the treatment of parastomal varices.

METHODS

A retrospective review was performed of 37 procedures on 24 patients to assess efficacy and safety of EUS-guided injection of thrombin, with or without embolisation coils for treatment of bleeding parastomal varices. All patients had been discussed in a multidisciplinary team meeting, and correction of portal hypertension was deemed to be contraindicated. Rebleeding was defined as stomal bleeding that required hospital admission or transfusion.

RESULTS

All patients had significant parastomal bleeding at the time of referral. 100% technical success rate was achieved. 70.8% of patients had no further significant bleeding in the follow-up period (median 26.2 months) following one procedure. 1-year rebleed-free survival was 80.8% following first procedure. 7 patients (29.1%) had repeat procedures. There was no significant difference in rebleed-free survival following repeat procedures. Higher age was associated with higher risk of rebleeding. No major procedure-related complications were identified.

CONCLUSIONS

EUS-guided thrombin injection, with or without embolisation coils, is a safe and effective technique for the treatment of bleeding parastomal varices, particularly for patients for whom correction of portal venous hypertension is contraindicated.

Endoscopic Cyanoacrylate Glue Injection for Duodenal Varices—A Single-Center Study

Aim/Objectives Duodenal varices (DVs), although rare, can present with massive, potentially fatal upper gastrointestinal bleeding; however, there are no randomized trials regarding management of this relatively uncommon presentation. We aim to report our experience with endoscopic cyanoacrylate glue injection in patients with DVs.

Materials and Methods We retrospectively evaluated the medical records of all patients with portal hypertension at our center between January 2010 and December 2021. Demographic characteristics along with the etiology, location, and effectiveness of cyanoacrylate glue injection for bleeding DVs were collected and analyzed.

Results A total of 5,892 patients with portal hypertension underwent endoscopy during the study period, of whom 41 patients (M:F = 29:12) with mean age of 38 years were noted to have DVs. While extrahepatic portal vein obstruction was the commonest etiology (n = 26), the most common site of DVs was the duodenal bulb (n = 21). Twenty-one (51%) out of these 41 patients presented primarily with DV bleeding and underwent endoscopic cyanoacrylate glue injection with successful hemostasis achieved of the index bleed; however, four of these 21 patients had rebleeding between 2 weeks and 12 months of follow-up requiring repeat endotherapy.. While three patients underwent successful repeat glue injections, one patient had recurrent massive bleedings, not amenable to endotherapy and was subjected to duodenal resection with surgical shunt procedure.

Conclusion While the prevalence of DVs in portal hypertension patients was 0.7% (41/5892), DVs accounted for 0.42% (21/4889) of portal hypertension-related bleedings. Endotherapy with cyanoacrylate glue appears to be a safe and cost-effective treatment for acute DV bleeding in a resource-limited setting.

Isolated sigmoid varicose vein rupture and hemorrhage: A case report

RATIONALE

Ectopic varices are the collateral circulation of portal vein located anywhere in the gastrointestinal tract other than the esophageal and gastric regions. Rupture of these varices often results in life-threatening hemorrhage. Management guidelines for ectopic variceal bleeds are not yet standardized because cases are rare and treatment approaches described in the literature vary considerably.

PATIENT CONCERNS

A 53-year-old woman with a 20-year history of chronic hepatitis C cirrhosis came to our hospital for treatment due to intermittent black stools for 4 days. After admission, the patient developed hemorrhagic shock, with hemodynamic instability.

DIAGNOSIS

Postoperative histological examination confirmed the diagnosis of sigmoid varicose veins.

INTERVENTION

Emergency colonoscopy showed that a varicose vein mass in the sigmoid colon wall 30 cm from the anus was ruptured and bleeding. Percutaneous transhepatic inferior mesenteric venography revealed the presence of a varicose mass of sigmoid colon veins. After embolization of the sigmoid varicose veins with spring coils, angiography showed that the hemorheology of the distal varicose vein mass was slow but not completely blocked. Three days after embolization, the patient had hematochezia again. Splenectomy and sigmoid colon resection were performed immediately.

OUTCOMES

Follow-up computed tomography showed no residual varices were observed after sigmoid colon resection.

LESSONS

Ectopic varices, which are rare sequelae of portal hypertension, need to be taken seriously because bleeding from these varices can be catastrophic. We report a case of isolated sigmoid variceal rupture and hemorrhage due to portal hypertension in cirrhosis. The patient experienced failure of endoscopic hemostasis and sigmoid colon venous coil embolization. She was eventually successfully brought to hemostasis by surgery.

Embolization of parastomal and small bowel ectopic varices utilizing a transhepatic antegrade approach: A case series

Background

The ideal approach to managing parastomal and small bowel ectopic varices (EVs) is yet to be established.

Purpose

To evaluate outcomes following percutaneous antegrade transhepatic venous obliteration (PATVO) in patients presenting with bleeding from parastomal or small bowel EVs.

Material and Methods

A case series of 12 patients presenting with active or recurrent bleeding from parastomal or small bowel EVs who underwent 17 PATVO interventions at our tertiary care institution was performed. Data extraction from electronic medical records included baseline characteristics and procedural details. Endpoints included technical success, early clinical success, and re-bleeding.

Results

Technical success was 100% ( n = 17), and early clinical success was 82.3% ( n = 14). No patient experienced any intra- or post-operative complications. Rebleed rates after initial PATVO in patients who achieved early clinical success was as follows: 3-month, 0% ( n = 0); 6-month, 20% ( n = 2); 12-month, 20% ( n = 2). Rebleed rates after all PATVO procedures (including patients undergoing repeat procedures) that achieved early clinical success were as follows: 3-month, 0% ( n = 0); 6-month, 14% ( n = 2; 12-month, 14% ( n = 2). All patients with re-bleeding required reintervention with either PATVO, transjugular intrahepatic portosystemic shunt (TIPS) or both.

Conclusion

PATVO can be safely performed to treat bleeding from parastomal and small bowel EVs. In patients who present with recurrent bleeding despite PATVO, TIPS with/without embolization of bleeding varices remains a valid option as described by the literature.

Bleeding ectopic varices: clinical presentation, natural history, and outcomes

Bleeding complications from ectopic varices are often difficult to manage. We aimed to study the natural history and outcomes of bleeding ectopic varices to better understand appropriate clinical management. This retrospective cohort study included patients admitted to the hospital with bleeding ectopic or esophageal varices from 2010 through 2019. Study subjects were identified through searching the Medical University of South Carolina's electronic medical record, and complete demographic, clinical, and procedural data were abstracted. 25 patients with gastrointestinal bleeding from ectopic varices and a matched group of 50 patients with bleeding esophageal varices were identified. Bleeding ectopic varices were identified in the following locations: duodenum (n=5), jejunum/ileum (n=5), colon (n=2), rectum (n=6), and anastomotic sites (n=7). Model for End-Stage Liver Disease scores (patients with cirrhosis), need for intensive care unit admission, and administration of octreotide and antibiotics were significantly higher in patients with esophageal variceal bleeding than those with ectopic varices. All-cause 1-year mortality of patients with ectopic varices was significantly lower than those with bleeding esophageal varices (8% vs 35%, p<0.05). Patients with ectopic varices and cirrhosis bled at lower hepatic venous pressure gradients than patients with bleeding esophageal varices (17 mm Hg vs 24 mm Hg, p<0.01). Transjugular intrahepatic portosystemic shunts (TIPS) were performed in two-thirds of patients with ectopic varices and one patient rebled due to TIPS dysfunction. The clinical features of patients with ectopic varices and those with esophageal varices were similar, but patients with ectopic varices had significantly lower 1-year mortality after bleeding events.

Expanding Indications of TIPS in the Management of Portal Hypertension Complications

Transjugular intrahepatic portosystemic shunt (TIPS) is a nonsurgical intervention to reduce portal pressure by creating a low-resistance channel between the portal and systemic circulations. It is a well-accepted treatment for gastroesophageal varices and refractory ascites. This review aims to discuss the evidence-based applications of TIPS in other complications of portal hypertension beyond gastroesophageal varices and refractory ascites.

Imaging-guided interventions modulating portal venous flow: evidence and controversies

Portal hypertension is defined by an increase in the portosystemic venous gradient. In most cases, increased resistance to portal blood flow is the initial cause of elevated portal pressure. More than 90% of cases of portal hypertension are estimated to be due to advanced chronic liver disease or cirrhosis. Transjugular intrahepatic portosystemic shunts, a non-pharmacological treatment for portal hypertension, involve the placement of a stent between the portal vein and the hepatic vein or inferior vena cava which helps bypass hepatic resistance. Portal hypertension may also be a result of extrahepatic portal vein thrombosis or compression. In these cases, percutaneous portal vein recanalisation restores portal trunk patency, thus preventing portal hypertension-related complications. Any portal blood flow impairment leads to progressive parenchymal atrophy and triggers hepatic regeneration in preserved areas. This provides the rationale for using portal vein embolisation to modulate hepatic volume in preparation for extended hepatic resection. The aim of this paper is to provide a comprehensive evidence-based review of the rationale for, and outcomes associated with, the main imaging-guided interventions targeting the portal vein, as well as to discuss the main controversies around such approaches.

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

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.

Percutaneous Transhepatic Embolization of Ectopic Varices in a Patient With Portal Hypertension Presenting With Hemorrhagic Shock

Varices secondary to portal hypertension in the setting of liver cirrhosis typically occur in the gastroesophageal region. Management guidelines for bleeding gastroesophageal varices are well established in the literature. Ectopic varices that occur outside of this typical location are an uncommon complication of portal hypertension. Rarely, these varices can result in life-threatening hemorrhage. Management guidelines of ectopic variceal bleeds are not yet standardized as cases are rare and treatment approach in the literature has historically varied. We present an interesting case of a 37-year-old patient with alcoholic liver disease and cirrhosis who developed spontaneous hemorrhage and shock from bleeding ectopic varices. This report exemplifies how coil embolization via a percutaneous transhepatic approach can be used to manage ectopic variceal bleeds in the setting of hemorrhagic shock.

Effectiveness and safety of endoscopic treatment for duodenal variceal bleeding: a systematic review

Duodenal varix is a rare condition that involves massive bleeding, diagnostic difficulties, and a high rate of rebleeding and mortality. The purpose of this study was to systematically review endoscopic treatment for duodenal variceal bleeding to evaluate its effectiveness and safety. We searched PubMed, Embase, Web of Science, and the Cochrane Library up to 21 November 2019. Ninety-two studies containing 156 patients were finally included, and individual data from 101 patients (mean age: 52.67 ± 13.82 years, male: 64.4%) were collected and further analyzed. We used an analysis of variance and χ2 or Fisher's exact tests to analyze individual data from 101 patients. The cause of duodenal variceal bleeding was cirrhosis-related intrahepatic portal hypertension (IPH) in 76.2% of patients. The overall rates of initial hemostasis and treatment success of endoscopic treatment for duodenal variceal bleeding were 89.1 and 81.2%, respectively. The median duration of follow-up was 4.5 (1.0, 12.0) months. The overall rates of rebleeding and mortality were 8.9 and 13.9%, respectively. Among a variety of endoscopic treatments available, only the initial hemostasis rate was significantly different between the endoscopic injection sclerotherapy and endoscopic tissue adhesive (ETA) groups (72.7 vs. 94.7%, P = 0.023); differences in treatment success, rebleeding, mortality, and adverse events were not statistically significant among the four groups. Endoscopic intervention is a feasible, well tolerated, and effective modality for the treatment of duodenal variceal bleeding. Among the variety of endoscopic treatments available, ETA with cyanoacrylate may be preferable for duodenal variceal bleeding.

Ectopic variceal bleeding after hepatobiliary surgery: A case report

RATIONALE

Jejunal varices are rare in portal hypertension and are often difficult to diagnose and treat. Herein, we present a case of gastrointestinal bleeding due to jejunal varices after hepatobiliary surgery.

PATIENT CONCERNS

A 69-year-old man presented with recurrent massive gastrointestinal bleeding. He underwent partial right hepatectomy and cholangiojejunostomy 2 years prior to the first onset of bleeding. Two sessions of endoscopic vessel ligation for esophageal varices were performed afterwards, and hematemesis resolved completely, but massive melena still recurred during the following 5 years.

DIAGNOSIS

The patient was diagnosed with jejunal varices caused by portal venous stenosis after hepatobiliary surgery.

INTERVENTION

Portal venous angioplasty using balloon dilation and stent implantation was performed.

OUTCOMES

After the intervention procedure, the patient did not experience any onset of gastrointestinal bleeding during follow-up.

LESSONS

Hepatopancreatobiliary could lead to the formation of jejunal varices. The combined use of capsule endoscopy, contrast-enhanced computed tomography, and sometimes portal venography is a promising strategy to search for jejunal varices. Transcatheter angioplasty appears to be a safe and effective method for treatment of jejunal varices in certain appropriate cases.

Clinical characteristics and efficacy of endoscopic treatment of gastrointestinal ectopic varices: A single-center study

BACKGROUND

Ectopic varices (EcVs) may cause massive bleeding, which can be difficult to control, with a high rate of mortality. The purpose of this study was to analyze the clinical characteristics of EcVs and the efficacy of endoscopic treatment.

METHODS

From January 2008 to July 2017, the clinical data of 150 patients with EcVs in our center were retrospectively collected and analyzed.

RESULTS

One hundred and fifty patients with EcVs (male 74.7%), with a mean age of: 54.1 ± 14.6 years were included. The prevalence of EcVs was 0.92% in gastrointestinal varices. Cirrhosis was the most common cause of EcVs (67.0%). The rates of bleeding were 57.14%, 4.34%, 30.0%, 33.3%, and 100% in the duodenal varices rectal varices, colonic varices, anastomotic varices, and small bowel varices, respectively. An age under 55 years, varices in the duodenum, and erythema were considered risk factors for EcV bleeding. Endoscopic treatments were performed in 15 patients with EcV bleeding. The follow-up period of the patients who underwent endoscopic treatment ranged from 0.5 to 24 months. The overall rate of treatment success was 73.33% for endoscopic treatment of EcV bleeding. The overall rates of rebleeding and mortality during 2 years were as high as 53.3% and 26.7%, respectively.

CONCLUSION

Age, erythema, and the location of EcVs are considered risk factors for EcV bleeding, and the rate of bleeding is higher in patients with duodenal varices than in those with other EcVs. Endoscopic treatment is safe, effective, and feasible for controlling EcV bleeding.

Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.

Transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension

These guidelines on transjugular intrahepatic portosystemic stent-shunt (TIPSS) in the management of portal hypertension have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the Liver Section of the BSG. The guidelines are new and have been produced in collaboration with the British Society of Interventional Radiology (BSIR) and British Association of the Study of the Liver (BASL). The guidelines development group comprises elected members of the BSG Liver Section, representation from BASL, a nursing representative and two patient representatives. The quality of evidence and grading of recommendations was appraised using the GRADE system. These guidelines are aimed at healthcare professionals considering referring a patient for a TIPSS. They comprise the following subheadings: indications; patient selection; procedural details; complications; and research agenda. They are not designed to address: the management of the underlying liver disease; the role of TIPSS in children; or complex technical and procedural aspects of TIPSS.

Halting the haematochezia

An elderly gentleman with primary sclerosing cholangitis (PSC) was admitted with rectal bleeding, shown on flexible sigmoidoscopy to be arising from rectal varices, which bled despite endoscopic therapy with histoacryl glue. Therapeutic options were limited with surgery and transjugular intrahepatic portosystemic shunt deemed too high risk, and endovascular embolisation through interventional radiology was sought. Coil-assisted retrograde transvenous obliteration was used to good effect. This rare approach has advantages over balloon occlusion, avoiding long indwelling balloon time and risk of rupture or infection, as well as time efficiency.

Management options for rectal variceal bleeding in the setting of hepatic encephalopathy

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.

Hemoperitoneum in cirrhotic patients in the absence of abdominal trauma

Introduction: Hemoperitoneum can be a life-threating condition in cirrhotic patients who have a limited compensatory reserve during hemorrhagic shock. We aim to review the literature on the different etiologies associated with non-traumatic hemoperitoneum (NTH), summarizing the most relevant conditions associated with spontaneous and iatrogenic peritoneal and retroperitoneal bleeding that may occur in cirrhotic patients and to illustrate the most relevant diagnostic strategies and optimal management. Area covered: This review encompasses the current literature in hemoperitoneum in cirrhotic patients in the absence of abdominal trauma. Established diagnostic procedures, therapeutic interventions and potential novel targets are reported and discussed. Expert opinion: To ensure the optimal management regardless of the underlying etiology of NTH, the first goal for the clinician is to obtain immediate hemodynamic stabilization with supportive measures and to control the source of bleeding. The latter can be achieved with angiographic embolization, which is usually the first choice, or with open surgery. Other therapeutic options according to specific etiologies include transjugular intrahepatic portosystemic shunt (TIPS), balloon-occluded retrograde transvenous obliteration (BRTO), balloon-occluded anterograde transvenous obliteration (BATO) or intra operative radio frequency (RF).

Massive Cecal Variceal Hemorrhage Treated with Transjugular Intrahepatic Portosystemic Shunt with Right Colic Vein and Ileocolic Vein Embolization

A 40-year-old male suffering from hallucinations and bizarre behavior was brought to our emergency room (ER) by the police. His drug and alcohol screens were positive for amphetamines and a blood alcohol content of 0.029 mg/dL. His past medical history was significant for alcohol use disorder, end-stage liver disease, ascites, esophageal varices, portal hypertension, and hepatic encephalopathy. He was admitted in an encephalopathic state and developed worsening hematochezia and hemodynamic instability over the course of days. Multiple investigations including contrast enhanced computed tomography (CT), upper and lower endoscopy, and mesenteric angiography did not identify a clear cause of the bleeding. Eventually, his source of bleeding was found to be from cecal varices. A transjugular intrahepatic portosystemic shunt procedure and coil embolization of the right colic and ileocolic veins stabilized the patient and he was discharged home a few days later.