A Novel Indication for Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Abstract

A 64 yr/old male was transferred for management of gastrointestinal bleeding and ascites. The patient had been hospitalized twice in the past 11 days secondary to weakness, intermittent melena and profound anemia. He received a total of 9 units of RBCs. Concurrently, the patient was having difficulties with ascites refractory to diuretics requiring paracentesis. His past medical history included Laennec's cirrhosis and rectal adenocarcinoma stage IIIb. A rectosigmoid resection and colostomy was performed in 2004 followed by treatment with adjuvant chemotherapy and radiation. Esophagogastroduodenoscopy and colonoscopy revealed diverticulosis and duodenopathy without ulcerations or varices. A capsule endoscopy showed mucosal changes consisting of multiple areas of patchy erythematous and edematous small bowel mucosa and numerous telengectasias, petechiae and white varices. These findings were visualized from duodenum to terminal ileum and felt to represent extensive portal hypertension enteropathy. He was started on nadolol and discharged. The patient continued to have intermittent melena and required blood transfusions every 7–14 days in order to maintain his Hgb > 8.0 g/dL. He required paracentesis to manage his ascites. A TIPS was placed with reduction of his portosystemic gradient from 16 mmHg to 6 mmHg. The patient did well after TIPS placement with decreased transfusion requirements and resolution of ascites. He experienced one episode of encephalopathy which responded to lactulose. Three months post TIPS his hemoglobin was stable and he no longer required blood transfusions. A repeat capsule endoscopy noted significant improvement of his portal hypertensive enteropathy. The endoscopic findings of portal hypertension are well recognized in the esophagus, stomach and colon. The emergence of capsule endoscopy has allowed better visualization of the small bowel and characterization of portal hypertension enteropathy. The treatment and management of portal hypertension enteropathy has yet to be defined. A TIPS is a well recognized treatment of portal hypertension complications such as rescue therapy for variceal bleeding, refractory ascites, and hepatic hydrothorax. Indications are expanding and include Budd-Chiari syndrome, veno-occlusive disease, hepatorenal syndrome, and hepatopulmonary syndrome to name a few. Portal hypertension enteropathy represents an additional arena for a TIPS placement.