LETTERS TO THE EDITOR

 

Portal vein thrombosis following endoscopic treatment for gastric varices with N-butyl-2-cyanoacrylate: Management with TIPS

Trombosis portal tras terapia endoscópica de varices gástricas con N-butil-2-cianocrilato: tratamiento con TIPS

 

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Key words: Portal vein thrombosis. N-butyl-2-cyanoacrylate. Gastric varices. TIPS.

Palabras clave: Trombosis venosa portal. N-butil-2-cianocrilato. Varices gástricas. TIPS.

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Dear Editor,

Gastric varices (GV) are present in approximately 20% (1) of patients with portal hypertension; the management of GV-related bleeding remains a challenge (2): Prognosis is worse (3) as compared to esophageal varices (EV), with rebleeding and/or mortality rates of up to 30%.

 

Case report

We report the case of a 71-year-old woman with histologically unconfirmed cryptogenic liver cirrhosis (MELD 6; Child-Pugh A6) who had several variceal bleeding events during the previous 2 years, which were attributed to EV with typical subcardial prolongations. A previous endoscopy managed to eradicate varices by sequentially combining band ligation and sclerosis using N-butyl-2-cyanoacrylate (NBC). Under optimized medical treatment a hepatic venous pressure gradient of 15 mmHg was measured. The splenoportal axis remained always patent on Doppler sonograms every 6 months.

She developed an additional hemorrhagic event, now secondary to the rupture of a previously undescribed GV, which received emergency treatment with NBC (2 cc) prior to delayed transjugular intrahepatic portosystemic shunt (TIPS) insertion (Fig. 1). During the procedure a radiopaque partial portal vein thrombosis (PVT) was identified both with the radioscopy and in indirect splenoportography, which was then confirmed with direct portography; TIPS allowed to resolve this PVT and the pressure gradient dropped to 8 mmHg. With regular US follow-up the average flow velocity in the portal vein (40 cm/sec) and inside the TIPS (100 cm/sec) remained normal after 12 months.

 

 

Discussion

The endoscopic (subjective) differentiation between the two varieties of "cardiofundal" varices in Sarin's classification (1), which may occassionally coincide, is challenging; this differentiation is not arbitrary but results from anatomic peculiarities with therapeutic implications. GV development after intermittent endoscopic treatment for EV -and vice versa- is well documented (4), particularly in the setting of suboptimal drug prophylaxis, as in our case.

NBC is the endoscopic treatment of choice (5), with a success rate nearing 90%, but may result in severe, fortunately rare complications (6); it also is a potential cause of PVT, particularly following repeated injections (7). Complications decrease when technical recommendations are strictly complied with (8). The recommended amount of NBC (with lipiodol on a 1:1 basis) is 1 cc per action and varix. TIPS is an alternative for refractory bleeding (9) and the rescue therapy after conventional secondary prophylaxis failure (10).

The development of PVT in our patient is highly peculiar: Unusual, incidental, direct endothelial injury with an unequivocal temporal relationship with a prior NBC treatment. Lipiodol, a radiopaque compound, fully delineated the complete splenoportal axis, maybe because an amount greater than recommended was used. TIPS, as usual when "running out" of endoscopic options, induced in monotherapy a complete, instantaneous response with thrombosis resolution, a fact to our knowledge not previously described in the medical literature.

 

Cristina Márquez-Galisteo¹, Álvaro Giráldez-Gallego¹,
Verónica Nacarino-Mejías², Adalberto Rincón-Gatica³
and Teófilo López-Ruiz^3
1Unit for Medical Management of Digestive Diseases.
Section of Hepatology.
²Department of Radiology. Section of Vascular and
Interventional Radiology.
³Unit for Medical Management of Digestive Diseases.
Section of Digestive Endoscopy.
Hospitales Universitarios Virgen del Rocío. Sevilla, Spain

 

References

1. Sarin SK, Lahoti D, Saxena SP, et al. Prevalence, classification and natural history of gastric varices: A long-term follow-up study in 568 portal hypertension patients. Hepatology 1992;16:1343-9.         [ Links ]

2. de Franchis R, Baveno V, Faculty. Revising consensus in portal hypertension: Report of the Baveno V Consensus Workshop on Methodology of Diagnosis and Therapy in Portal Hypertension. J Hepatol 2010;53:762-8.         [ Links ]

3. Escorsell A, Abraldes JG, Pipa-Muñiz M, et al. Prognosis of acute bleeding from isolated fundal varices in patients with cirrhosis: A European cohort. Hepatology 2012;56(Supl.):748A.         [ Links ]

4. Turon F, Casu S, Hernández-Gea V, et al. Variceal and other portal hypertension related bleeding. Best Pract Res Clin Gastroenterol 2013; 27:649-64.         [ Links ]

5. Caldwell SH, Hespenheide EE, Greenwald BD, et al. Enbucrilate for gastric varices: Extended experience in 92 patients. Aliment Pharmacol Ther 2007;26:49-59.         [ Links ]

6. Cheng LF, Wang ZQ, Li CZ, et al. Low incidence of complications from endoscopic gastric variceal obturation with butyl cyanoacrylate. Clin Gastroenterol Hepatol 2010;8:760-6.         [ Links ]

7. Liu C-H, Tsai F-C, Liang P-C, et al. Splenic vein thrombosis and Klebsiella pneumonia septicemia after endoscopic gastric variceal obturationtherapy with N-butyl-2-cyanoacrylate. Gastrointest Endosc 2006;63:336-8.         [ Links ]

8. Seewald S, Ang TL, Imazu H, et al. A standardized injection technique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices. Gastrointest Endosc 2008;68:447-54.         [ Links ]

9. Mahadeva S, Bellamy MC, Kessel D, et al. Costeffectiveness of N-butyl-2-cyanoacrylate (histoacryl) glue injections versus transjugular intrahepatic portosystemic shunt in the management of acute gastric variceal bleeding. Am J Gastroenterol 2003;98:2688-93.         [ Links ]

10. Procaccini NJ, Al-Osaimi AM, Northup P, et al. Endoscopic cyanoacrylate versus transjugular intrahepatic portosystemic shunt for gastric variceal bleeding: A single-center U.S. analysis. Gastrointest Endosc 2009;70:881-7.         [ Links ]