Dhiraj Tripathi

Bleeding ectopic varices in cirrhosis: the role of transjugular intrahepatic portosystemic stent shunts

Aliment Pharmacol Theru200228, 294–303

Haemodynamic effects of acute and chronic administration of low‐dose carvedilol, a vasodilating β‐blocker, in patients with cirrhosis and portal hypertension

Carvedilol is a non‐selective vasodilating β‐blocker with weak α1 receptor antagonism. Recent studies have demonstrated its potential as a portal hypotensive agent.

Good clinical outcomes following transjugular intrahepatic portosystemic stent-shunts in Budd-Chiari syndrome.

There have been encouraging reports on transjugular intrahepatic portosystemic stent‐shunt (TIPSS) for Budd–Chiari syndrome (BCS). Long‐term data are lacking.

Review article: recent advances in the management of bleeding gastric varices

Gastric variceal bleeding can be challenging to the clinician. Tissue adhesives can control acute bleeding in over 80%, with rebleeding rates of 20–30%, and should be first‐line therapy where available. Endoscopic ultrasound can assist in better eradication of varices. The potential risks of damage to equipment and embolic phenomena can be minimized with careful attention to technique.

The management of acute variceal bleeding

Variceal haemorrhage is a common medical emergency with a high mortality (30–50%). Adequate resuscitation is vital, and once stabilised the patient should be moved to a high‐dependency area. Antibiotics reduce mortality, and the vasoactive drug terlipressin should be administered if early endoscopy is unavailable. Early endoscopy is essential both to make the diagnosis and to allow therapeutic measures to be performed. The evidence suggests that variceal band ligation is the most effective therapy for oesophageal varices. If gastric varices are found at the index endoscopy the evidence at present is inadequate to be certain which is the best treatment, but both endoscopic therapy with cyanoacrylate or thrombin and transjugular intrahepatic portosystemic stent shunt (TIPSS) have been reported to be of benefit. When initial treatments fail, rescue therapy should be initiated. Most authorities agree that TIPSS is the rescue therapy of choice. Many questions remain concerning the treatment of acute variceal bleeding, particularly the ideal therapy for gastric varices and the role of combination vasoactive and endoscopic therapy. Randomised controlled trials are required to answer these important issues.

An update on the diagnosis and management of Budd-Chiari syndrome.

Budd–Chiari syndrome is a rare disorder caused by hepatic venous outflow obstruction and resulting hepatic dysfunction. Despite a lack of prospective randomized trials, much progress has been made in its management over the last 20 years. The main goals of treatment are to ameliorate hepatic congestion and prevent further thrombosis. The selective use of anticoagulation, vascular stents, transjugular intrahepatic portosystemic stent-shunt and liver transplant has resulted in a significant increase in survival. The diagnosis, initial management and long-term follow-up of patients with Budd–Chiari syndrome is reviewed. The concept of individualization of treatment and a stepwise approach to invasive procedures is also discussed.

Portal vein thrombosis in cirrhosis: Controversies and latest developments

Portal vein thrombosis (PVT) is encountered in liver cirrhosis, particularly in advanced disease. It has been a feared complication of cirrhosis, attributed to significant worsening of liver disease, poorer clinical outcomes and potential inoperability at liver transplantation; also catastrophic events such as acute intestinal ischaemia. Optimal management of PVT has not yet been addressed in any consensus publication. We review current literature on PVT in cirrhosis; its prevalence, pathophysiology, diagnosis, impact on the natural history of cirrhosis and liver transplantation, and management. Studies were identified by a search strategy using MEDLINE and Google Scholar. The incidence of PVT increases with increasing severity of liver disease: less than 1% in well-compensated cirrhosis, 7.4%-16% in advanced cirrhosis. Prevalence in patients undergoing liver transplantation is 5%-16%. PVT frequently regresses instead of uniform thrombus progression. PVT is not associated with increased risk of mortality. Optimal management has not been addressed in any consensus publication. We propose areas for future research to address unresolved clinical questions.

A case‐controlled study of the safety and efficacy of transjugular intrahepatic portosystemic shunts after liver transplantation

The role of transjugular intrahepatic portosystemic shunt (TIPS) insertion in managing the complications of portal hypertension is well established, but its utility in patients who have previously undergone liver transplantation is not well documented. Twenty‐two orthotopic liver transplantation (OLT) patients and 44 nontransplant patients (matched controls) who underwent TIPS were analyzed. In the OLT patients, the TIPS procedure was performed at a median of 44.8 months (range = 0.3‐143 months) after transplantation. Eight (36.4%) had variceal bleeding, and 14 (63.6%) had refractory ascites. The underlying liver disease was cholestatic in 10 (45.4%) and viral in 4 (18.2%). The mean pre‐TIPS Model for End‐Stage Liver Disease (MELD) score was 13.4 ± 5.1. There were no significant differences in age, sex, indication, etiology, or MELD score with respect to the control group. The mean initial portal pressure gradients (PPGs) were similar in the 2 groups (21.0 versus 22.4 mm Hg for the OLT patients and controls, respectively), but the final PPG was lower in the control group (9.9 versus 6.9 mm Hg, P < 0.05). The rates of both technical success and clinical success were higher in the control group versus the OLT group [95.5% versus 68.2% (P < 0.05) and 93.2% versus 77.2% (P < 0.05), respectively]. The rates of complications and post‐TIPS encephalopathy were similar in the 2 groups, and there was a trend toward increased rates of shunt insufficiency in the OLT group. The mortality rate of the patients with a pre‐TIPS MELD score > 15 was significantly higher in the OLT group [hazard ratio (HR) = 4.32, 95% confidence interval (CI) = 1.45‐12.88, P < 0.05], but the mortality rates of the patients with a pre‐TIPS MELD score < 15 were similar in the 2 groups. In the OLT group, the predictors of increased mortality were the pre‐TIPS MELD score (HR = 1.161, 95% CI = 1.036‐1.305, P < 0.05) and pre‐TIPS MELD scores > 15 (HR = 5.846, 95% CI = 1.754‐19.485, P < 0.05). In conclusion, TIPS insertion is feasible in transplant recipients, although its efficacy is lower in these patients versus control patients. Outcomes are poor for OLT recipients with a pre‐TIPS MELD score > 15. Liver Transpl 17:771‐778, 2011.

Embolization of Bleeding Stomal Varices by Direct Percutaneous Approach

Stomal varices can occur in patients with stoma in the presence of portal hypertension. Suture ligation, sclerotherapy, angiographic embolization, stoma revision, beta blockade, portosystemic shunt, and liver transplantation have been described as therapeutic options for bleeding stomal varices. We report the case of a 21-year-old patient with primary sclerosing cholangitis and colectomy with ileostomy for ulcerative colitis, where stomal variceal bleeding was successfully treated by direct percutaneous embolization. We consider percutaneous embolization to be an effective way of treating acute stomal bleeding in decompensated patients while awaiting decisions regarding shunt procedures or liver transplantation.

Long-term outcomes following percutaneous hepatic vein recanalization for Budd–Chiari syndrome

A proportion of patients with Budd–Chiari Syndrome (BCS) associated with stenosis or short occlusion of the hepatic vein (HV) or upper inferior vena cava (IVC) can be treated with recanalization by percutaneous venoplasty ± HV stent insertion. We studied the long‐term outcomes of this approach.