Abstract
We report the case of a 27-year-old female patient with a history of cryptogenic cirrhosis who was admitted to the hospital due to multiple episodes of hematemesis secondary to bleeding esophageal varices. The varices were persistent and refractory to endoscopic intervention, so an emergent transjugular intrahepatic portosystemic shunt (TIPS) was performed by interventional radiology (IR). Months later, the patient returned to the hospital unresponsive with acute intermittent hepatic encephalopathy which required a TIPS reduction by IR. Once the TIPS reduction was performed, the patient’s hepatic encephalopathy declined, and her symptoms improved. Here, we present a unique method of TIPS reduction utilizing a single Viabahn VBX balloon-expandable stent (W. L. Gore & Associates, Inc; Flagstaff, AZ) to constrain the existing TIPS stent.
Highlights
Patients with a history of cirrhosis suffer a high risk of developing portal hypertension and resultant esophageal varices
Our patient initially presented to the emergency department (ED) with multiple episodes of hematemesis indicating an upper GI bleed caused by an acute rupture of her gastroesophageal varices as confirmed by endoscopy and CT angiography (Figures 1, 2)
hepatic encephalopathy (HE) is a common complication that arises in patients post-transjugular intrahepatic portosystemic shunt (TIPS) procedure
Summary
Patients with a history of cirrhosis suffer a high risk of developing portal hypertension and resultant esophageal varices. The patient had repeat active bleeding later that day, and a second endoscopy revealed red blood in the esophagus and large (>5 mm) bleeding esophageal varices (Figure 1C, 1D), which were banded. Delayed portal venous phase images from the hepatic angiogram (D) demonstrate patency of the portal vein (white arrowheads) and faintly opacified esophagogastric varices (perforated black oval), as well as presence of endoscopy clips (black triangle). The patient returned to the ED unresponsive and tachycardic with a Glasgow Coma Scale (GCS) of 6 Her family reported that she had been having mild intermittent hepatic encephalopathy (HE) since the TIPS procedure, which later acutely worsened and prompted the ED visit. The patient believes her HE symptoms have worsened after the TIPS reduction procedure, and so she remains on lactulose and rifaximin medications for medical management
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