Multimodal therapy of recurrent and refractory bleeding from esophageal varices – case report and review of the literature

Abstract

Bleeding from esophageal varices is a major cause of mortality in patients with advanced liver disease. Although standard treatment and secondary prophylaxis are effective, in some patients sustained hemostasis cannot be achieved.

We report the case of a woman with alcoholic liver disease in whom pharmacological, endoscopic, and intravascular therapies failed to control variceal bleeding. Only a combination of (repeated) band ligation, insertion of a self-expanding metal stent, TIPS implantation and redilatation, transjugular variceal embolization, and finally implantation of a portocaval shunt proved to be successful. We discuss the stepwise approach to this situation and the challenges encountered in the process.

Zusammenfassung

Ösophagusvarizenblutungen sind eine häufige Todesursache von Patienten mit fortgeschrittener Lebererkrankung. Auch endoskopische Standardbehandlungsmethoden und eine medikamentöse Sekundärprophlyaxe können nicht in allen Fällen eine refraktäre oder rezidivierte Blutung verhindern.

Wir berichten den Fall einer Patientin mit alkoholischer Lebererkrankung, bei der pharmakologische, endoskopische und intravaskuläre Therapiemodalitäten nicht zur Blutstillung führten. Erst eine Kombination aus wiederholten Gummibandligaturen, Einlage eines selbst expandierenden Metallstents (SEMS), Implantation eines transjugulären intrahepatischen portosystemischen Shunts (TIPS), retrograder Varizenembolisation und schließlich chirurgischer Anlage eines portosystemischen Shunts führten zur dauerhaften Hämostase. Wir diskutieren das schrittweise Vorgehen und die Herausforderungen bei der Behandlung.

Schlüsselwörter

Portale Hypertension - Gastrointestinale Blutung - Ösophagusvarizen - TIPS - Selbst expandierende Metallstents (SEMS)

Key words

portal hypertension - gastrointestinal bleeding - esophageal varices - TIPS - self-expanding covered metal stents (SEMS)

• References

• 1 Sharara AI, Rockey DC. Gastroesophageal variceal hemorrhage. N Engl J Med 2001; 345: 669-681
• 2 Bosch J, Abraldes JG, Berzigotti A et al. Portal hypertension and gastrointestinal bleeding. Semin Liver Dis 2008; 28: 3-25
• 3 Garcia-Pagán JC, Di Pascoli M, Caca K et al. Use of early-TIPS for high-risk variceal bleeding: results of a post-RCT surveillance study. J Hepatol 2013; 58: 45-50
• 4 Ferguson JW, Tripathi D, Hayes PC. Review article: the management of acute variceal bleeding. Aliment Pharmacol Ther 2003; 18: 253-262
• 5 McAvoy NC, Hayes PC. The use of transjugular intrahepatic portosystemic stent shunt in the management of acute oesophageal variceal haemorrhage. Eur J Gastroenterol Hepatol 2006; 18: 1135-1141
• 6 de Franchis R. Baveno VI Faculty. Expanding consensus in portal hypertension: report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63: 743-752
• 7 García-Pagán JC, Caca K, Bureau C et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med 2010; 362: 2370-2379
• 8 Lakhoo J, Bui JT, Zivin SP et al. Root cause analysis of rebleeding events following transjugular intrahepatic portosystemic shunt creation for variceal hemorrhage. J Vasc Interv Radiol 2015; 26: 1444-1453
• 9 Lo GH. Prevention of esophageal variceal rebleeding. J Chin Med Assoc 2006; 69: 553-560
• 10 Paquet KJ. Prophylactic endoscopic sclerosing treatment of the esophageal wall in varices -- a prospective controlled randomized trial. Endoscopy 1982; 14: 4-5
• 11 Carbonell N, Pauwels A, Serfaty L et al. Improved survival after variceal bleeding in patients with cirrhosis over the past two decades. Hepatology 2004; 40: 652-659
• 12 Stokkeland K, Brandt L, Ekbom A et al. Improved prognosis for patients hospitalized with esophageal varices in Sweden 1969–2002. Hepatology 2006; 43: 500-505
• 13 Liu CL, Wu CK, Shi HY et al. Medical expenses in treating acute esophageal variceal bleeding: A 15-year nationwide population-based cohort study. Medicine (Baltimore) 2016; 95: e4215
• 14 Hung TH, Tsai CC, Tseng CW et al. No difference in mortality between terlipressin and somatostatin treatments in cirrhotic patients with esophageal variceal bleeding and renal functional impairment. Eur J Gastroenterol Hepatol 2016; 11: 1275-1279
• 15 Graham DY, Smith JL. The course of patients after variceal hemorrhage. Gastroenterology 1981; 80: 800-809
• 16 Cho H, Nagata N, Shimbo T et al. Recurrence and prognosis of patients emergently hospitalized for acute esophageal variceal bleeding: a long-term cohort study. Hepatol Res 2016; [Epub ahead of print]
• 17 Gournay J, Masliah C, Martin T et al. Isosorbide mononitrate and propranolol compared with propranolol alone for the prevention of variceal rebleeding. Hepatology 2000; 31: 1239-1245
• 18 Li T, Ke W, Sun P et al. Carvedilol for portal hypertension in cirrhosis: systematic review with meta-analysis. BMJ Open 2016; 6: e010902
• 19 Abid S, Ali S, Baig MA et al. Is it time to replace propranolol with carvedilol for portal hypertension?. World J Gastrointest Endosc 2015; 7: 532-539
• 20 Tripathi D, Hayes PC. Beta-blockers in portal hypertension: new developments and controversies. Liver Int 2014; 34: 655-667
• 21 Lo GH. Endoscopic therapy plus beta blocker is still the first choice for prevention of variceal rebleeding?. Hepatology 2016; [Epub ahead of print]
• 22 Garcia-Tsao G, Sanyal AJ, Grace ND et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol 2007; 102: 2086-2102
• 23 Bhutta AQ, Garcia-Tsao G. The role of medical therapy for variceal bleeding. Gastrointest Endosc Clin N Am 2015; 25: 479-490
• 24 Biecker E. Portal hypertension and gastrointestinal bleeding: diagnosis, prevention and management. World J Gastroenterol 2013; 19: 5035-5050
• 25 Kapoor A, Dharel N, Sanyal AJ. Endoscopic diagnosis and therapy in gastroesophageal variceal bleeding. Gastrointest Endosc Clin N Am 2015; 25: 491-507
• 26 Dai C, Liu WX, Jiang M et al. Endoscopic variceal ligation compared with endoscopic injection sclerotherapy for treatment of esophageal variceal hemorrhage: a meta-analysis. World J Gastroenterol 2015; 21: 2534-2541
• 27 Sauerbruch T, Mengel M, Dollinger M et al. Prevention of rebleeding from esophageal varices in patients with cirrhosis receiving small-diameter stents versus hemodynamically controlled medical therapy. Gastroenterology 2015; 149: 660-668
• 28 Holster IL, Tjwa ETTL, Moelker A et al. Covered transjugular intrahepatic portosystemic shunt versus endoscopic therapy + β-blocker for prevention of variceal rebleeding. Hepatology 2016; 63: 581-589
• 29 Papatheodoridis GV, Goulis J, Leandro G et al. Transjugular intrahepatic portosystemic shunt compared with endoscopic treatment for prevention of variceal rebleeding: a meta-analysis. Hepatology 1999; 30: 612-622
• 30 Pereira K, Carrion AF, Martin P et al. Current diagnosis and management of post-transjugular intrahepatic portosystemic shunt refractory hepatic encephalopathy. Liver Int 2015; 35: 2487-2494
• 31 Andring B, Kalva SP, Sutphin P et al. Effect of technical parameters on transjugular intrahepatic portosystemic shunts utilizing stent grafts. World J Gastroenterol 2015; 21: 8110-8117
• 32 Clark W, Golkar F, Luberice K et al. Uncovering the truth about covered stents: is there a difference between covered versus uncovered stents with transjugular intrahepatic portosystemic shunts?. Am J Surg 2011; 202: 561-564
• 33 Bureau C, Garcia-Pagan JC, Otal P et al. Improved clinical outcome using polytetrafluoroethylene-coated stents for TIPS: results of a randomized study. Gastroenterology 2004; 126: 469-475
• 34 Monescillo A, Martínez-Lagares F, Ruiz-del-Arbol L et al. Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology 2004; 40: 793-801
• 35 Rudler M, Cluzel P, Corvec TL et al. Early-TIPSS placement prevents rebleeding in high-risk patients with variceal bleeding, without improving survival. Aliment Pharmacol Ther 2014; 40: 1074-1080
• 36 Klasen-Sansone J, Bode J, Lanzman RS et al. TIPS geometry influences patency. Z Gastroenterol 2015; 53: 28-32
• 37 Tanaka T, Günther RW, Isfort P et al. Pull-through technique for recanalization of occluded portosystemic shunts (TIPS): technical note and review of the literature. Cardiovasc Intervent Radiol 2011; 34: 406-412
• 38 Rössle M. When endoscopic therapy or pharmacotherapy fails to control variceal bleeding: what should be done? Immediate control of bleeding by TIPS?. Langenbecks Arch Surg 2003; 388: 155-162
• 39 Rössle M. TIPS: 25 years later. J Hepatol 2013; 59: 1081-1093
• 40 Loffroy R, Favelier S, Pottecher P et al. Transjugular intrahepatic portosystemic shunt for acute variceal gastrointestinal bleeding: indications, techniques and outcomes. Diagn Interv Imaging 2015; 96: 745-755
• 41 Qi X, Liu L, Bai M et al. Transjugular intrahepatic portosystemic shunt in combination with or without variceal embolization for the prevention of variceal rebleeding: a meta-analysis. J Gastroenterol Hepatol 2014; 29: 688-696
• 42 Hubmann R, Bodlaj G, Czompo M et al. The use of self-expanding metal stents to treat acute esophageal variceal bleeding. Endoscopy 2006; 38: 896-901
• 43 Dai C, Zhao L, Liu L et al. Questions for esophageal stents treatment in acute refractory esophageal variceal bleeding. Hepatology 2016; [Epub ahead of print]
• 44 McCarty TR, Njei B. Self-expanding metal stents for acute refractory esophageal variceal bleeding: a systematic review and meta-analysis. Dig Endosc 2016; 28: 539-547
• 45 Hogan BJ, O’Beirne JP. Role of self-expanding metal stents in the management of variceal haemorrhage: Hype or hope?. World J Gastrointest Endosc 2016; 8: 23-29
• 46 Dechêne A, El Fouly AH, Bechmann LP et al. Acute management of refractory variceal bleeding in liver cirrhosis by self-expanding metal stents. Digestion 2012; 85: 185-191
• 47 Zehetner J, Shamiyeh A, Wayand W et al. Results of a new method to stop acute bleeding from esophageal varices: implantation of a self-expanding stent. Surg Endosc 2008; 22: 2149-2152
• 48 Wright G, Lewis H, Hogan B et al. A self-expanding metal stent for complicated variceal hemorrhage: experience at a single center. Gastrointest Endosc 2010; 71: 71-78
• 49 Glowka TR, Kalff JC, Schäfer N. Clinical management of chronic portal/mesenteric vein thrombosis: the surgeon's point of view. Viszeralmedizin 2014; 30: 409-415
• 50 Pedersen MR, Molloy P, Wood D et al. Direct intrahepatic portocaval shunt for treatment of portal thrombosis and Budd-Chiari syndrome. Ann Hepatol 2016; 15: 127-130
• 51 Henderson JM, Boyer TD, Kutner MH et al. Distal splenorenal shunt versus transjugular intrahepatic portal systematic shunt for variceal bleeding: a randomized trial. Gastroenterology 2006; 130: 1643-1651
• 52 Rosemurgy AS, Frohman HA, Teta AF et al. Prosthetic H-graft portacaval shunts vs transjugular intrahepatic portasystemic stent shunts: 18-year follow-up of a randomized trial. J Am Coll Surg 2012; 214: 445-453 ; discussion 453–455
• 53 Orloff MJ. Fifty-three years' experience with randomized clinical trials of emergency portacaval shunt for bleeding esophageal varices in Cirrhosis: 1958–2011. JAMA Surg 2014; 149: 155-169
• 54 Helmy A, Redhead DN, Stanley AJ et al. The natural history of parallel transjugular intrahepatic portosystemic stent shunts using uncovered stent: the role of host-related factors. Liver Int 2006; 26: 572-578
• 55 Larson M, Kirsch D, Kay D. Clinical images: parallel transjugular intrahepatic portosystemic shunt (TIPS) in the setting of TIPS occlusion. Ochsner J 2016; 16: 113-115