A Case of Acute Liver Failure of Unknown Cause Following PTFE-Coated TIPS Stent Insertion for Prevention of Esophageal Variceal Rebleed

Abstract

Purpose: Case report: A 58 year old man with alcohol/HCV cirrhosis was evaluated for iron deficiency anemia. He had been abstinent for 10 months with stable liver function, and denied overt bleeding. Physical examination revealed caput medusa and splenomegaly without ascites or peripheral edema. His colonoscopy was normal. PHG and grade IV esophageal varices were identified on gastroscopy. Band ligation of esophageal varices resulted in massive hemorrhage with application of the first band, controlled with subsequent banding. He returned 7 months later for repeat banding and the same scenario ensued. He was started on nadolol but was unable to tolerate side effects. He was referred for TIPS to prevent further variceal bleeding. His MELD score was 11. A 6 cm PTFE covered stent was inserted through his middle hepatic vein into his portal vein, and reduced his porto-caval pressure gradient from 20 mmHg to 6 mmHg. A routine Doppler ultrasound one week post TIPS demonstrated flow within the right and left hepatic veins and confirmed patency of the stent. He presented to ER the following day with the only complaint of increasing jaundice. He denied no infections symptoms or ingestion of any medications. His blood work revealed markedly elevated bilirubin of 607 umol/L, mild rises in transaminases (AST= 158 and ALT= 196) and INR of 1.4. Unfortunately, he quickly decompensated, with steadily rising bilirubin. His MELD score rose from 11 to 42. The stent was evaluated and was in good position. All causes of acute liver failure had been excluded. Despite occlusion of TIPS, his liver function continued to decline and eventually required liver transplantation 1 month after TIPS. The liver explant showed end stage liver cirrhosis with features consistent with HCV and steatohepatitis without evidence of hepatic ischemia. Discussion: A recent randomized controlled trial demonstrated greater efficacy and lower mortality of early TIPS in preventing variceal rebleeding in cirrhotic patients hospitalized for acute bleed compared to pharmacologic plus band ligation therapy. Rare cases of liver failure caused by segmental liver ischemia following TIPS have been reported, thought to be due to a “partial Budd-Chiari syndrome” caused by obstruction of the hepatic vein in which the stent was implanted. In these cases, hepatic failure resolved either with supportive care or with occlusion of TIPS. Our patient developed acute liver failure of unknown cause following TIPS, necessitating liver transplantation. Careful selection of patients must be considered before embarking on early TIPS for prevention of variceal rebleed.