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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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Al Khalloufi K, Laiyemo AO. Management of rectal varices in portal hypertension. World J Hepatol 2015; 7:2992-2998. [PMID: 26730278 PMCID: PMC4691702 DOI: 10.4254/wjh.v7.i30.2992] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 10/13/2015] [Accepted: 12/11/2015] [Indexed: 02/06/2023] Open
Abstract
Rectal varices are portosystemic collaterals that form as a complication of portal hypertension, their prevalence has been reported as high as 94% in patients with extrahepatic portal vein obstruction. The diagnosis is typically based on lower endoscopy (colonoscopy or sigmoidoscopy). However, endoscopic ultrasonography has been shown to be superior to endoscopy in diagnosing rectal varices. Color Doppler ultrasonography is a better method because it allows the calculation of the velocity of blood flow in the varices and can be used to predict the bleeding risk in the varices. Although rare, bleeding from rectal varices can be life threatening. The management of patients with rectal variceal bleeding is not well established. It is important to ensure hemodynamic stability with blood transfusion and to correct any coagulopathy prior to treating the bleeding varices. Endoscopic injection sclerotherapy has been reported to be more effective in the management of active bleeding from rectal varices with less rebleeding rate as compared to endoscopic band ligation. Transjugular intrahepatic portsystemic shunt alone or in combination with embolization is another method used successfully in control of bleeding. Balloon-occluded retrograde transvenous obliteration is an emerging procedure for management of gastric varices that has also been successfully used to treat bleeding rectal varices. Surgical procedures including suture ligation and porto-caval shunts are considered when other methods have failed.
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Sakib SMN, Kobayashi K, Jawed M. Potential Pitfalls in Transjugular Portosystemic Shunt Placement for Bleeding Rectal Varices. Case Rep Gastroenterol 2015; 9:296-301. [PMID: 26464566 PMCID: PMC4592510 DOI: 10.1159/000439164] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
In patients with portal hypertension, bleeding from rectal varices is rare. However, it can be life-threatening. We report a case of massive bleeding from large rectal varices in a 59-year-old man with alcoholic cirrhosis. Emergent transjugular intrahepatic portosystemic shunt (TIPS) placement was performed following failed local endoscopic therapy. Despite normalization of the portosystemic pressure gradient, the patient had another episode of massive bleeding on the following day. Embolization of the rectal varices via TIPS successfully stopped the bleeding. After the procedure, rapid decompensation of the cirrhosis led to severe encephalopathy, and death was observed. Although TIPSs have been reported to be useful in controlling bleeding from rectal varices, our case illustrates the potential pitfalls in using this technique in the treatment of rectal variceal bleeding. TIPSs may not be always successful in controlling massive bleeding from large rectal varices, even after normalization of portal hypertension. TIPSs can also be associated with life-threatening complications that may lead to early mortality.
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Affiliation(s)
- S M Nazmus Sakib
- Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, N.Y., USA
| | - Katsuhiro Kobayashi
- Department of Radiology, SUNY Upstate Medical University, Syracuse, N.Y., USA
| | - Mohammed Jawed
- Department of Radiology, SUNY Upstate Medical University, Syracuse, N.Y., USA
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Maslekar S, Toh EW, Adair R, Bate JP, Botterill I. Systematic review of anorectal varices. Colorectal Dis 2013; 15:e702-10. [PMID: 24020839 DOI: 10.1111/codi.12417] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 06/18/2013] [Indexed: 12/13/2022]
Abstract
AIM Anorectal varices are an uncommon, but significant, source of bleeding in patients with portal hypertension. The aim of this article was to review systematically the available literature on the aetiology, clinical presentation and management of anorectal varices, and to suggest a simple treatment algorithm based on available evidence and local expertise. METHOD A systematic literature search was carried out to identify articles on anorectal varices, and the search strategy identified 57 relevant references. The inclusion criteria included a consecutive cohort of patients having treatment for anorectal varices with details of success rates and the number of different techniques used. Exclusion criteria included papers published in languages other than English with no English version and results not reported separately for anorectal varices. RESULTS Anorectal varices can occur in up to 89% of patients with portal hypertension, although the overall incidence in the general population is low. Diagnosis is best achieved with anoscopy or flexible sigmoidoscopy. The current evidence supports the use of local procedures, such as endoscopic band ligation, to arrest bleeding where feasible, with radiological or surgical procedures used in the event of failure. CONCLUSION As there are no large series on this pathology, we present a systematic approach for the patient with anorectal varices.
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Affiliation(s)
- S Maslekar
- The John Goligher Colorectal Unit, St James's University Hospital, Leeds, UK
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Moore JS, Seah AS, Hyman N. Management of hemorrhoids in unusual circumstances. SEMINARS IN COLON AND RECTAL SURGERY 2013. [DOI: 10.1053/j.scrs.2013.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Watanabe N, Toyonaga A, Kojima S, Takashimizu S, Oho K, Kokubu S, Nakamura K, Hasumi A, Murashima N, Tajiri T. Current status of ectopic varices in Japan: Results of a survey by the Japan Society for Portal Hypertension. Hepatol Res 2010; 40:763-76. [PMID: 20649816 DOI: 10.1111/j.1872-034x.2010.00690.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM The Clinical Research Committee of the Japan Society for Portal Hypertension has conducted a nationwide questionnaire survey to clarify the current status of ectopic varices in Japan. METHODS A total of 173 cases of ectopic varices were collected. RESULTS Duodenal varices were found in 57 cases, and most of them were located in the descending to transverse parts. There were 11 cases of small intestinal varices and 6 cases of colonic varices, whereas 77 patients had rectal varices, accounting for the greatest proportion (44.5%). Other sites of varices were the biliary tract, anastomotic sites, the stoma, and the diaphragm. Liver cirrhosis was the most frequent diseases (80.3%) underlying ectopic varices. It was noted that patients with rectal varices frequently had a history of esophageal varices (94.8%) and received endoscopic treatment (87.0%). The treatments for ectopic varices were as an emergency in 46.5%, elective in 35.4% and prophylactic in 18.2%. In emergency cases, endoscopic therapy was most frequent (67.4%), followed by interventional radiology (IVR; 15.2%), and endoscopy-IVR combination (6.5%). Elective treatment was performed by endoscopy in 34.3%, IVR in 28.6%, combined endoscopy-IVR in 5.7%, and surgical operation in 25.7%. The prophylactic treatment was endoscopic in 50.0%, IVR in 33.3%, combined treatments in 11.1%, and prophylactic surgery in none. The change of ectopic varices after treatment was disappearance in 54.9%, remnant in 35.4% and recurrence in 9.7%. The rate of disappearance was significantly lower in rectal varices (40.8%) than in duodenal varices (73.4%). The patient outcome did not differ among the various sites of the lesion. Conslusions: Current status of ectopic varices in Japan has been clarified by a nationwide questionnaire survey. The authors expect that the pathophysiology of ectopic varices will be further elucidated, and that improved diagnostic modalities and treatment methods are established in the future.
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Affiliation(s)
- Norihito Watanabe
- Department of Internal Medicine, Tokai University School of Medicine, Isehara, Japan
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Martel G, Boushey RP. The Treatment of Hemorrhoids in Unusual Situations and Difficult Circumstances. SEMINARS IN COLON AND RECTAL SURGERY 2007. [DOI: 10.1053/j.scrs.2007.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Okazaki H, Higuchi K, Shiba M, Nakamura S, Wada T, Yamamori K, Machida A, Kadouchi K, Tamori A, Tominaga K, Watanabe T, Fujiwara Y, Nakamura K, Arakawa T. Successful treatment of giant rectal varices by modified percutaneous transhepatic obliteration with sclerosant: Report of a case. World J Gastroenterol 2006; 12:5408-11. [PMID: 16981280 PMCID: PMC4088217 DOI: 10.3748/wjg.v12.i33.5408] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2006] [Revised: 04/28/2006] [Accepted: 05/22/2006] [Indexed: 02/06/2023] Open
Abstract
We present a female patient with continuous melena, diagnosed with rectal variceal bleeding. She had a history of esophageal varices, which were treated with endoscopic therapy. Five years after the treatment of esophageal varices, continuous melena occurred. Since colonoscopy showed that the melena was caused by giant rectal varices, we thought that they were not suitable to receive endoscopic treatment. We chose the modified percutaneous transhepatic obliteration with sclerosant, which is one of the interventional radiology techniques but a new clinical procedure for rectal varices. After the patient received this therapy, her condition of rectal varices was markedly improved.
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Affiliation(s)
- Hirotoshi Okazaki
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, 1-4-3, Asahimachi, Abeno-ku, Osaka, Japan
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Boursier J, Oberti F, Reaud S, Person B, Maurin A, Cales P. [Bleeding from rectal varices in a patient with severe decompensated cirrhosis: success of endoscopic band ligation. A case report and review of the literature]. ACTA ACUST UNITED AC 2006; 30:783-5. [PMID: 16801904 DOI: 10.1016/s0399-8320(06)73315-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
In patients with cirrhosis, portal hypertension can be complicated by bleeding rectal varices. Treatment of bleeding rectal varices is not well established because clinical therapeutic trials are scarce in the literature and there are only a few case reports. In most cases, first line treatment is endoscopic (band ligation or sclerotherapy) and in case of failure or rebleeding, portosystemic shunts are the second line treatment. The indication of endoscopic treatment is not always easy in patients with cirrhosis and impaired liver function as well as major haemostatic problems. We report the case of a patient with severe decompensated cirrhosis and bleeding rectal varices who was successfully treated by endoscopic band ligation.
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Affiliation(s)
- Jérôme Boursier
- Service d'Hépato-Gastroentérologie, Centre Hospitalier Universitaire, Angers
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Parvaiz A, Azeem S, Singh RK, Lamparelli M. Stapled hemorrhoidopexy: an alternative technique for the treatment of bleeding anorectal varices. Report of a case. Dis Colon Rectum 2006; 49:411-2. [PMID: 16322963 DOI: 10.1007/s10350-005-0255-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Amjad Parvaiz
- Department of Surgery, Dorset County Hospital, Williams Avenue, Dorchester, DTI 2JY, United Kingdom
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Saravanan R, Nayar M, Gilmore IT, Smart H, McWilliams RG, Rowlands PC, Evans J, Murphy M, Gould D, Taylor S, Sutton R, Lombard MG. Transjugular intrahepatic portosystemic stent shunt: 11 years' experience at a regional referral centre. Eur J Gastroenterol Hepatol 2005; 17:1165-71. [PMID: 16215427 DOI: 10.1097/00042737-200511000-00003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Transjugular intrahepatic portosystemic stent shunt (TIPSS) is now widely used in the treatment of uncontrolled and recurrent variceal haemorrhage. This study reports the outcome and long-term follow-up of 125 patients who were referred to a single centre for TIPSS. METHODS One hundred and twenty-five patients were referred to undergo TIPSS. All but 10 had variceal haemorrhage. The 10 patients referred with refractory ascites were excluded from the analysis. Our follow-up protocol was to assess shunt patency only if bleeding recurred or there was a clinical indication. The mean age was 51.5 years (range 18-87 years) and 64 patients (56%) were male. The commonest aetiology for chronic liver disease was alcohol (80%). At referral, 19 patients (16%) were Child-Pugh class A, 26 patients (23%) were Child-Pugh class B and 70 patients (61%) were Child-Pugh class C. The mean follow-up period was 20.4 months (range 0-95 months). RESULTS TIPSS was successfully placed in 108 of 115 patients (94%). The thirty-day mortality was 30%. One-year and 2-year overall cumulative survival was 52% (survival ratio, 0.525; 95% confidence interval, 0.432-0.619) and 43% (survival ratio, 0.436; 95% confidence interval, 0.340-0.532), respectively. CONCLUSION TIPSS is effective in the treatment of uncontrolled or recurrent variceal bleeding. In comparison with previously published studies, our study suggests no value in regular or routine shunt surveillance to reduce rebleeding episodes or mortality, but this needs to be further assessed in prospective randomized studies.
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Affiliation(s)
- Ramasamy Saravanan
- Department of Gastroenterology, Royal Liverpool & Broadgreen University Hospitals, UK
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Vangeli M, Patch D, Terreni N, Tibballs J, Watkinson A, Davies N, Burroughs AK. Bleeding ectopic varices--treatment with transjugular intrahepatic porto-systemic shunt (TIPS) and embolisation. J Hepatol 2004; 41:560-6. [PMID: 15464235 DOI: 10.1016/j.jhep.2004.06.024] [Citation(s) in RCA: 144] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2004] [Revised: 05/30/2004] [Accepted: 06/25/2004] [Indexed: 12/12/2022]
Abstract
BACKGROUND/AIMS Bleeding ectopic varices due to cirrhosis can be difficult to manage. We report our experience of uncontrolled bleeding from ectopic varices treated with transjugular intrahepatic porto-systemic shunt (TIPS). METHODS We selected the 21 cirrhotics who underwent TIPS for bleeding ectopic varices from our database: Child-Pugh grade A (2), B (11) and C (8). Site of bleeding was rectal (11), colonic (2), ileal 1, jejunal 1, duodenal 1, and stomal (5). RESULTS TIPS was performed successfully in 19/21 (90%) patients. All except 1 had either a reduction in portosystemic pressure gradient < or = 12 mmHg (n=12) or reduction by 25-50% of baseline (n=6). TIPS alone was used in 12/19: 7 of these 12 had no further bleeding; 5 (42%) rebled within 48 h, and had embolisation, 4 without further bleeding. In 7 of 19, TIPS and embolisation were performed together: 2 patients (28%) rebled; further embolisation stopped the bleeding. CONCLUSIONS Ectopic varices do rebleed despite a reduction of porto-systemic pressure gradient < or = 12 mmHg or by 25-50% of baseline, following TIPS. Embolisation stopped bleeding in all but 1 patient. We recommend performing embolisation at the time of the initial TIPS to control bleeding from ectopic varices.
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Affiliation(s)
- Marcello Vangeli
- Liver Transplantation and Hepatobiliary Unit, Royal Free Hospital and NHS Hampstead Trust, London, UK
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Oberti F. Comment prévenir et traiter les hémorragies par varices gastriques, ou ectopiques ou par gastropathie congestive. ACTA ACUST UNITED AC 2004; 28 Spec No 2:B53-72. [PMID: 15150498 DOI: 10.1016/s0399-8320(04)95241-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Frédéric Oberti
- Service d'Hépato-Gastroentérologie, Centre Hospitalo-Universitaire Angers, 49100 Angers
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Ory G, Spahr L, Megevand JM, Becker C, Hadengue A. The long-term efficacy of the intrahepatic portosystemic shunt (TIPS) for the treatment of bleeding anorectal varices in cirrhosis. A case report and review of the literature. Digestion 2002; 64:261-4. [PMID: 11842284 DOI: 10.1159/000048871] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND In patients with portal hypertension and variceal hemorrhage, the transjugular intrahepatic portosystemic shunt (TIPS) is indicated when drug therapy or endoscopic treatment fails to control bleeding. Ruptured esophageal or gastric varices are the most frequent causes of portal hypertension-related hemorrhage, but anorectal varices may also bleed. Although several case reports have proposed TIPS in this situation, the long-term results of this procedure have not been described. METHODS We report here the case of a 68-year-old patient with decompensated cirrhosis who presented with recurrent hematochezia due to anorectal varices. RESULTS A successful control of bleeding could be obtained after placement of TIPS. After 3 years of follow-up, rectal bleeding did not recur, the shunt remained primarily patent, and the patient did not present overt hepatic encephalopathy. CONCLUSION TIPS procedure should be considered as an effective treatment of recurrent bleeding from anorectal varices in patients with decompensated cirrhosis.
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Affiliation(s)
- G Ory
- Gastroenterology and Hepatology, University Hospital, Geneva, Switzerland
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Hidajat N, Stobbe H, Hosten N, Schroeder RJ, Fauth M, Vogl T, Felix R. Transjugular intrahepatic portosystemic shunt and transjugular embolization of bleeding rectal varices in portal hypertension. AJR Am J Roentgenol 2002; 178:362-3. [PMID: 11804893 DOI: 10.2214/ajr.178.2.1780362] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Nico Hidajat
- Department of Radiology, Charité, Virchow Clinic of the Humboldt University, Augustenburger Platz 1,13353 Berlin, Germany
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Ikeda K, Konishi Y, Nakamura T, Nabeshima M, Yamamoto S, Migihashi R, Chiba T. Rectal varices successfully treated by endoscopic injection sclerotherapy after careful hemodynamic evaluation: a case report. Gastrointest Endosc 2001; 54:788-91. [PMID: 11726865 DOI: 10.1067/mge.2001.119258] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- K Ikeda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Postgraduate School Of Medicine Kyoto University, Kyoto, Japan
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Patch D, Dagher L. Acute variceal bleeding: general management. World J Gastroenterol 2001; 7:466-75. [PMID: 11819812 PMCID: PMC4688656 DOI: 10.3748/wjg.v7.i4.466] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2001] [Revised: 04/08/2001] [Accepted: 04/15/2001] [Indexed: 02/06/2023] Open
Affiliation(s)
- D Patch
- Liver Transplantation and Hepatobiliary Medicine, 9th Floor-Department of Surgery, Royal Free Hospital NHS Trust, Pond Street-Hampstead, London NW3 2QG, UK
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Abstract
Since the introduction of transjugular intrahepatic portosystemic shunt (TIPS) 10 years ago, it has been used increasingly in the management of portal hypertension and its complications. TIPS is now considered the procedure of choice for management of refractory variceal bleeding. Its role in the management of refractory ascites, hepatic hydrothorax, hepatorenal syndrome, and hepatopulmonary syndrome still awaits further prospective studies. The two main complications of TIPS are hepatic encephalopathy and shunt malfunction. Generally, TIPS stenosis or occlusion is a major drawback requiring routine surveillance of TIPS with doppler ultrasound. Venography with balloon dilation of the stent or placement of serial or parallel stents may be required in some cases. Promising modalities of preventing TIPS malfunction (e.g., brachy-therapy, covered stents, or anti-platelet derived growth factor) are currently being investigated.
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Affiliation(s)
- J P Ong
- Department of Gastroenterology, Cleveland Clinic Foundation, Ohio 44195, USA
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