An alcoholic patient presented with oral bleeding.Images of upper gastrointestinal endoscopy and barium swallow is shown .What should be the treatment of choice in this condition?
B. Liver transplantation.
C. TIPS (Transjugular intrahepatic portal shunt).
D. Endoscopic banding
Ans:D. Endoscopic banding.
The patient is suffering from Esophageal Varices.
- Important site for communication between the intra-abdominal splanchnic circulation and the systemic venous circulation is through the esophagus.
- The increased pressure in the esophageal plexus produces dilated tortuous vessels called varices. Persons with cirrhosis develop varices so that varices are present in approximately two-thirds of all cirrhotic patients
- Varices appear as tortuous dilated veins lying primarily within the submucosa of the distal esophagus and proximal stomach.
MANAGEMENT OF BLEEDING VARICES
- Blood volume should be replaced with colloids, plasma expanders and blood transfusions.
- Hypervolemia should be avoided since this may increase portal pressure and exacerbate the bleeding.
- Blood resuscitation should be performed carefully to reach a hemoglobin level of approximately 8 g/dL
- Vitamin K, FFP and platelet transfusion
- Use of recombinant factor Vila has not been shown to be more beneficial
- Treatment with a splanchnic vasoconstrictor should be started.
- Administration of a prophylactic antibiotic is recommended
- Gastric lavage with saline via NG tube is helpful to determine the extent of bleeding
- Room temperature saline is most physiologic; iced saline lavage is not more efficacious
- After haemodynamic stabilization an upper gastrointestinal endoscopy should be performed
- Inserted to provide temporary hemostasis (if the rate of blood loss prohibits endoscopic evaluation)
- Gastric balloon inflated with 300ml air and retracted to gastric fundus
- Oesophageal balloon inflated to a pressure of 40mmHg
- The balloons should be temporarily deflated after 12 hours to prevent pressure necrosis
- IV infusion of somatostatin analogue octreotide
- Glypressin (Terlipressin) has longer half-life and fewer side effects
- Propranolol/nadolol is not effective at acute bleeding. Used in prophylaxis
- Somatostatin analogues are more effective than vasopressin in acute bleedings
- Endoscopic banding (gold standard treatment)
- Endoscopic sclerotherapy
- Sclerosants: ethanolamine oleate, sodium morrhuate, sodium tetradecyl sulphate, polidocanol
- Chance of rebleeding is high compared to banding
- Complications: esophageal ulceration, perforation, pleural effusion, pulmonary edema, mediastinitis
- Standard treatment: vasoconstrictor + endoscopic therapy.
Transjugular intrahepatic portosystemic stent shunts (TIPSS)
- Inserted under LA, analgesia and sedation using fluoroscopic guidance and USG
- Stent placed between hepatic venule and portal venule
- For treatment of variceal haemorrhage that has not responded to drug treatment and endoscopic therapy
- The main early complication is perforation of liver capsule, which can be associated with fatal intraperitoneal hemorrhage
- Post-Shunt encephalopathy occurs in 40% patients
- The main contraindication to TIPSS is portal vein occlusion
- The main long term complication is stenosis of the shunt
- The main current indication is a patient with Child’s grade A (compensated) cirrhosis in whom the initial bleed has been controlled by sclerotherapy
- Effective methods of preventing rebleed
- Selective shunts have a lower incidence of Portal systemic encephalopathy (PSE)
Non selective shunts
- Porta-caval shunt
- Mesenterico-caval/renal shunt
- Proximal spleno-renal shunt (Linton’s shunt)
- Distal spleno-renal shunt (Warren’s shunt)
- Inokuchi shunt — shunt between IVC and left
- gastric vein