CONTROL OF RUPTURED PERISPLENIC INTRAPERITONEAL VARICEAL BLEEDING VIA PERCUTANEOUS TRANSHEPATIC OBLITERATION (PTO) APPROACH
Abstract
Ectopic varices (EV) are portal vein collaterals developing anywhere in the abdomen except Gastroesophageal Junction (GEJ). The bleeding from ectopic varices, notably, the intraperitoneal varix is a dreadful complication, resulting in high mortality. We report a case of a 50-year lady with Hepatitis C related chronic liver disease, Child Pugh score (CTP) was 7, Model of End-stage Liver Disease (MELD) score of 6, with no prior liver decompensation, presented in the emergency department with signs of shock, low hemoglobin, and gross ascites. A CT scan abdomen revealed high-density ascites with an area of high density in the left upper quadrant, suggestive of intraperitoneal hemorrhage secondary to perisplenic intraperitoneal varices. After two failed attempts at Balloon Retrograde Transvenous Obliteration (BRTO) due to tight narrowing at splenorenal shunt, the patient underwent successful embolization of bleeding ectopic varices using Percutaneous Transhepatic Obliteration (PTO) via left portal vein access. The patient discharged on 7th post-admission day in hemodynamically stable condition. The use of PTO in bleeding intraperitoneal varices has not been frequently reported in the literature. This case demonstrates the efficacy of PTO in controlling ectopic peritoneal variceal bleeding in technically difficult cases, which are un-amenable to BRTO.
References
Norton ID, Andrews JC, Kamath PS. Management of ectopic varices. Hepatology. 1998;28(4):1154-8.
Lebrec D. Ectopic varices in portal hypertension. Clin Gastroenterol. 1985;14:105-21.
Sarin SK, Kumar CKN. Ectopic varices. Clinical Liver Disease. 2012;1(5):167-72.
Khouqeer F, Morrow C, Jordan P. Duodenal varices as a cause of massive upper gastrointestinal bleeding. Surgery. 1987;102(3):548-52.
Watanabe N, Toyonaga A, Kojima S, Takashimizu S, Oho K, Kokubu S, et al. Current status of ectopic varices in Japan: Results of a survey by the Japan Society for Portal Hypertension. Hepatology research : the official journal of the Japan Society of Hepatology. 2010;40(8):763-76.
Ninoi T, Nakamura K, Kaminou T, Nishida N, Sakai Y, Kitayama T, et al. TIPS versus transcatheter sclerotherapy for gastric varices. AJR American journal of roentgenology. 2004;183(2):369-76.
Menu Y, Gayet B, Nahum H. Bleeding duodenal varices: diagnosis and treatment by percutaneous portography and transcatheter embolization. Gastrointest Radiol. 1987;12(2):111-3.
Okazaki H, Higuchi K, Shiba M, Nakamura S, Wada T, Yamamori K, et al. Successful treatment of giant rectal varices by modified percutaneous transhepatic obliteration with sclerosant: Report of a case. World journal of gastroenterology. 2006;12(33):5408-11.
Sakai M, Nakao A, Kaneko T, Takeda S, Inoue S, Yagi Y, et al. Transhepatic portal venous angioplasty with stenting for bleeding jejunal varices. Hepatogastroenterology. 2005;52(63):749-52.
Naidu SG, Castle EP, Kriegshauser JS, Huettl EA. Direct percutaneous embolization of bleeding stomal varices. Cardiovascular and interventional radiology. 2010;33(1):201-4.
Haq TU, AlQamari N, Sayani R, Hilal K. Successful percutaneous angioembolisation of bleeding jejunal varix by acrylate glue and coils. BMJ Case Reports. 2013;2013:bcr2013201874.
Kochar N, Tripathi D, McAvoy N, Ireland H, Redhead D, Hayes P. Bleeding ectopic varices in cirrhosis: the role of transjugular intrahepatic portosystemic stent shunts. Alimentary pharmacology & therapeutics. 2008;28(3):294-303.
D'Cruz AJ, Kamath PS, Ramachandra C, Jalihal A. Non-conventional portosystemic shunts in children with extrahepatic portal vein obstruction. Acta paediatrica Japonica : Overseas edition. 1995;37(1):17-20.
