Rescue therapy of a refractory rectal variceal bleeding in a cirrhotic patient by Linton-Nachlas tube and TIPS implantation in combination with variceal embolization

Abstract

Background Transjugular intrahepatic portosystemic shunt (TIPS) is considered the gold standard for treatment of gastrointestinal variceal bleeding refractory to endoscopic therapy in patients with portal hypertension. Clinically relevant hemorrhage from rectal varices is less frequent than from other sources, and the therapeutic role of TIPS is still ambiguous.

Case report A 57-year-old female patient was referred to us in December 2015 with severe signs of decompensated alcohol-induced liver cirrhosis. During hospitalization, she presented with recurrent hematochezia from rectal varices following electrosurgical snare removal of a rectal adenoma. Endoscopic treatment with hemoclips, epinephrine and fibrin glue injections, and thermocoagulation failed to permanently stop the bleeding. Recurrent hemorrhage led to a further deterioration of liver function and clinical status of the patient. After a total of 3 endoscopic treatment attempts, hemostasis was achieved by transanal placement of a Linton-Nachlas balloon tube. Additionally, TIPS implantation with embolization of the rectal varices was performed successfully 24 hours after tube insertion, resulting in reduction of the portosystemic pressure gradient from 24 to 12 mmHg. Subsequently, the patient recovered clinically, hemopressin and catecholamine treatment was discontinued, and liver function test as well as serum hemoglobin levels improved. No further blood transfusions were required.

Conclusion In this patient, rescue therapy with balloon compression and TIPS implantation in combination with variceal embolization in a cirrhotic patient with refractory rectal variceal bleeding was effective. To our knowledge, it is the first description of this specific therapeutic approach.

Zusammenfassung

Hintergrund Der transjuguläre intrahepatische portosystemische Shunt (TIPS) ist der Goldstandard in der Behandlung endoskopisch nicht beherrschbarer gastrointestinaler Blutungen bei Patienten mit portaler Hypertension. Klinisch relevante Blutungen aus rektalen Varizen sind seltener als obere gastrointestinale Blutungen und die therapeutische Bedeutung des TIPS unklar.

Fallbericht Eine 57-jährige Patientin wurde uns im Dezember 2015 mit massiv dekompensierter äthyltoxischer Leberzirrhose zugewiesen. Während des stationären Aufenthaltes kam zu wiederholten peranalen Blutabgängen aus Rektalvarizen nach vorangegangener Schlingenabtragung eines rektalen Adenoms. Endoskopische Behandlungen in Form von Hämoclip-Applikation, Suprarenin- und Fibrinkleberunterspritzungen sowie Thermokoagulation führten zu keiner dauerhaften Blutstillung. Die wiederholten Blutungen führten zu einer zunehmenden Verschlechterung von Leberfunktion und Allgemeinzustand der Patientin. Nach insgesamt 3 endoskopischen Behandlungsversuchen konnte eine Blutstillung mittels transanaler Einlage einer Linton-Nachlas-Sonde erreicht werden. 24 Stunden nach Sondeneinlage erfolgte die TIPS-Implantation mit Varizenembolisation, wodurch der portosystemische Druckgradient von 24 auf 12 mmHg gesenkt werden konnte. Daraufhin verbesserte sich der klinische Zustand der Patientin, Hämopressin- und Katecholamintherapie konnten ausgeschlichen werden und Leberfunktion sowie Bilirubinwerte verbesserten sich. Keine weiteren Bluttransfusionen waren erforderlich.

Schlussfolgerung Eine „Rescue“-Therapie in Form Ballonkompression und TIPS-Anlage in Kombination mit Varizenembolisation war effektiv bei einer Patientin mit Leberzirrhose und therapierefraktärer Rektalvarizenblutung. Nach unserem Kenntnisstand ist dies die erste Beschreibung dieses spezifischen Therapieversuchs.

Schlüsselwörter

gastrointestinale Blutung - untere gastrointestinale Blutung - Leber

Key words

gastrointestinal bleeding - lower gastrointestinal bleeding - liver

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