gi grand rounds usc gastrointestinal and liver diseases february 10 th, 2006 presented by yoshi...

GI Grand RoundsGI Grand Rounds USC Gastrointestinal and Liver DiseasesUSC Gastrointestinal and Liver Diseases

February 10February 10thth, 2006, 2006

Presented byPresented by

Yoshi Makino, M.D.Yoshi Makino, M.D.

Moderated byModerated by

Dr. Andrew StolzDr. Andrew Stolz

Case PresentationCase Presentation

• Patient W.L. is a 57 year old Chinese Patient W.L. is a 57 year old Chinese male, with PMH sig for chronic Hep B, male, with PMH sig for chronic Hep B, cirrhosis and HCC diagnosed in 10/2005, cirrhosis and HCC diagnosed in 10/2005, presenting with hematemesis and melena presenting with hematemesis and melena x 1 day. Pt denies prior history of UGI x 1 day. Pt denies prior history of UGI bleed.bleed.


• PMH:PMH:– Hepatitis B cirrhosis (dx 2004)– HCC (dx 10/2005)– DM, hyperlipidemaa– Otherwise per HPI

• PSH:PSH:– L inguinal hernia repair

• SH:SH:– Denies EtOH/tobacco/illicit drug use– Born in mainland China, then lived in Venezuela for 24

years, before moving to United States 15 years ago• FH:FH:

– Non-contributory: Hep B status unknown


• Allergies: Allergies: NKDANKDA• MedicationsMedications

– Epivir 100 mg PO daily– Hepsera 10 mg PO daily– Aldactone 50 mg PO daily– Experimental Chemo Agent

• GW572016: EGFR1/EGFR2/HER-2 inhibitor

– Megace/MVI/Folate

• ROS:ROS:– Non-contributory

Physical ExamPhysical Exam

• Vital: Vital: – T 97.8 / P 121 / R 20 / BP 120/64– Orthostatics (+)

• Gen:Gen: thin, cachectic male, A+O x 4 in NAD thin, cachectic male, A+O x 4 in NAD• HEENT:HEENT: temporal wasting, no conjuctival pallor temporal wasting, no conjuctival pallor• Cardiac:Cardiac: sinus tachy sinus tachy• Lungs:Lungs: CTA(B) CTA(B)• Abdomen:Abdomen:

– Mod firm, distended, with shifting dullness– Non tender, (+)BS

• Ext:Ext: 2+ pitting edema to BLE 2+ pitting edema to BLE• Rectal:Rectal: normal tone, (+)melena, OB(+) normal tone, (+)melena, OB(+)• Skin:Skin: No spider angiomas seen No spider angiomas seen• Neuro:Neuro: No asterixis, no focal deficits No asterixis, no focal deficits

Laboratories (1/24/06)Laboratories (1/24/06)

133133 9999 4040

5.95.9 2323 1.11.1171171

9.69.6 27927910.110.1

30.930.9

MCVMCV 84.984.9 Alk PAlk P 317317 ASTAST 309309RDWRDW 19.219.2 TProtTProt 6.56.5 ALTALT 208208PTPT 18.318.3 AlbAlb 2.72.7 INRINR 1.521.52 TBiliTBili 2.12.1PTTPTT 30.930.9 DBiliDBili 0.90.9 PTT ratPTT rat

6.86.8 2142148.68.6

26.826.8

EGD Images (1/25/06)EGD Images (1/25/06)

EGD Results (1/25/06)EGD Results (1/25/06)

• 4 columns of Grade 1 Esophageal Varices 4 columns of Grade 1 Esophageal Varices with no stigmata of recent bleedingwith no stigmata of recent bleeding

• Large, grape-like, plump gastric varices, Large, grape-like, plump gastric varices, with one large varix with a “white nipple” with one large varix with a “white nipple” signsign

• No active bleeding nor oozing notedNo active bleeding nor oozing noted

• Mild portal hypertensive gastropathyMild portal hypertensive gastropathy

• Normal duodenal bulbNormal duodenal bulb

CT ImagesCT Images

• Insert magical slide show here…Insert magical slide show here…

CT Results (1/3/2006)CT Results (1/3/2006)

• Compared with 11/1/2005 studyCompared with 11/1/2005 study• Large heterogeneous enhancing lobulated liver Large heterogeneous enhancing lobulated liver

mass occupying the entire R lobe of the liver, mass occupying the entire R lobe of the liver, and medial segment of L lobe of the liver: and medial segment of L lobe of the liver: increased in size by 50%increased in size by 50%

• Tumor invasion of right and main portal veinsTumor invasion of right and main portal veins• Cirrhosis with multiple collaterals, Portal HTNCirrhosis with multiple collaterals, Portal HTN• R inguinal hernia, fluid filledR inguinal hernia, fluid filled

Hospital CourseHospital Course

• Pt was subsequently transferred to USC Pt was subsequently transferred to USC University Hospital on 1/26/2006University Hospital on 1/26/2006

• TIPS considered for decompression of TIPS considered for decompression of gastric varices, but not advised due to gastric varices, but not advised due to large tumor burden, portal vein invasion, large tumor burden, portal vein invasion, and overall poor prognosisand overall poor prognosis

• Hospice care discussed with patient, and Hospice care discussed with patient, and patient discharged on 2/2/2006patient discharged on 2/2/2006

Gastric VaricesGastric Varices

OutlineOutline

• Overview of Gastric VaricesOverview of Gastric Varices• Vascular AnatomyVascular Anatomy• ClassificationClassification• Diagnostic ModalitiesDiagnostic Modalities

– Endoscopic– CT/MRI

• Therapeutic optionsTherapeutic options– Endoscopic– Interventional Radiology– Surgery

Overview of Gastric VaricesOverview of Gastric Varices

• Gastric varices (GV) are a well known Gastric varices (GV) are a well known complication of both non-cirrhotic and complication of both non-cirrhotic and cirrhotic portal hypertensioncirrhotic portal hypertension

• In general, gastric varices bleed less In general, gastric varices bleed less frequently than esophageal varicesfrequently than esophageal varices

• However, when they bleed, bleeding is However, when they bleed, bleeding is usually severeusually severe

EpidemiologyEpidemiology

• Gastric varices can be found in 15-20% of Gastric varices can be found in 15-20% of patients with portal hypertensionpatients with portal hypertension

• Lifetime bleeding rate of roughly 25%Lifetime bleeding rate of roughly 25%• Overall mortality rate of 30-52%Overall mortality rate of 30-52%

Kim T et al. Hepatology 1997.Kim T et al. Hepatology 1997.

• In a prospective study of 568 patients with In a prospective study of 568 patients with portal hypertension, Sarin et al found that GVs portal hypertension, Sarin et al found that GVs formed at an annual incidence rate of 9%formed at an annual incidence rate of 9%

Sarin SK et al. Hepatology 1992.Sarin SK et al. Hepatology 1992.

Risk Factors for BleedingRisk Factors for Bleeding

• Risk factors for bleeding may includeRisk factors for bleeding may include– Specific caliber and lengthSpecific caliber and length– Source of venous collaterals involvedSource of venous collaterals involved– Advanced liver diseaseAdvanced liver disease

Kim et al. Hepatology 1997.Kim et al. Hepatology 1997.

• Degree of portal hypertension appears to Degree of portal hypertension appears to be less of a factor, with GVs often be less of a factor, with GVs often bleeding at portal pressure gradients of bleeding at portal pressure gradients of <12 mmHg<12 mmHg

Tripathi et al. Gut 2002.Tripathi et al. Gut 2002.

Vasculature InvolvedVasculature Involved

• Afferent VeinsAfferent Veins– Left gastric vein (LGV)– Posterior gastric vein (PGV)– Short gastric vein (SGV)

• Efferent VeinsEfferent Veins– Esophageal veins (EV)– Gastrorenal shunt (GRS: 85% of IGV)– Left inferior phrenic vein (LIPV: 10% of IGV)– Left pericardiacophrenic vein (LPCPV: 5% of IGV)

Chikamori et al. Abdominal Imaging 2005.

Formation of Varices in Portal HTNFormation of Varices in Portal HTN

• LGV to EV to azygous v.LGV to EV to azygous v.– Traditional model for

esophageal varices, can also result in the formation of gastric varices

• SV to GRS to LRV to IVCSV to GRS to LRV to IVC– Significant portal HTN can

also lead to reversal of flow in the splenic vein, resulting in transgastric shunts (usually GRS) Willmann et all. BMJ 2003.

Splenic Vein ThrombosisSplenic Vein Thrombosis

• Sinistral (left-sided) portal HTN due to splenic Sinistral (left-sided) portal HTN due to splenic vein thrombsis (SVT) is an often cited but less vein thrombsis (SVT) is an often cited but less common cause of gastric varicescommon cause of gastric varices

• Incidence of gastric varices in patients with Incidence of gastric varices in patients with isolated SVT ranges from 17% to 55%isolated SVT ranges from 17% to 55%

• SVT should be suspected in patients withSVT should be suspected in patients with– History of pancreatitis with newly diagnosed GI bleeding– splenomegaly in the absence of cirrhosis– Isolated gastric varices

Weber and Rikkers. Word J. Surg. 2003.


• Risk factors for SVT includeRisk factors for SVT include– Chronic pancreatitis (48-65%)– Pancreatic carcinoma (9-29%)– Other causes: adenopathy from metastatic carcinoma,

lymphoma and iatrogenic (following surgery such as splenectomy and gastrectomy)

• PathophysiologyPathophysiology– The splenic vein is posterior to and in direct contact with

the pancreas– Pancreatic inflammation is believed to trigger clot

formation in the splenic veinWeber and Rikkers. Word J. Surg. 2003.


• Prevalence of SVTPrevalence of SVT– In patient with chronic pancreatitis, the prevalence of

SVT by ultrasonography ranges from 4% to 45%

• Incidence of SVTIncidence of SVT– In a prospective study of 266 patients with chronic

pancreatitis, Bernard et al found the overall incidence rate of major splanchnic vein thrombosis to be 13%

• Splenic vein 8%

• Portal vein 4%

• Superior mesenteric vein 1%

Bernades et al. Dig Dis Sci. 1992.

Formation of Varices in SVTFormation of Varices in SVT

Weber et al. World J Surg 2003.

Histologic FindingsHistologic Findings

• Fundamentally, GVs differ from EVs by locationFundamentally, GVs differ from EVs by location– EVs form in both the lamina propria and submucosa– In contrast, GVs form in the submucosa

• This difference make rupture of GVs less frequent than This difference make rupture of GVs less frequent than EVsEVs

• However, when do GVs rupture, they penetrate the However, when do GVs rupture, they penetrate the muscularis mucosa and lamina propria, leading to more muscularis mucosa and lamina propria, leading to more massive bleedingmassive bleeding

Hashizume M. JGH 2004.

Willmann et all. BMJ 2003.

LL

Classification of Gastric VaricesClassification of Gastric Varices

• Gastro-oesophageal varices (GOV)Gastro-oesophageal varices (GOV)– Usually develop from the left gastric vein– GOV1: extend from esophageal varices across the

gastroesophageal junction, extending 5 cm or less– GOV2: extend from esophageal varices into the fundus

• Fundic varices (IGV)Fundic varices (IGV)– Usually develop from the short gastric and posterior gastric veins or

via direct anastomoses with retroperitoneal veins– IGV1: varices found only in the fundus– IGV2: isolated non-fundic varices

• GOV1 represents 75% of gastric varicesGOV1 represents 75% of gastric varices• IGV1 result in the most serious bleedingIGV1 result in the most serious bleeding

Sarin SK et al. Hepatology 1992.Sarin SK et al. Hepatology 1992.

Diagnostic ModalitiesDiagnostic Modalities

• EndoscopyEndoscopy– Gastric varices can appear as “grape-like” clusters

or “serpiginous” varices that resemble gastric folds– The bluish color that is characteristic of esophageal

varices is usually absent– However, conventional endoscopy frequently misses

submucosal lesions• gastric varices: sensitivity of 48% and a specificity of 50%• esophageal varices: sensitivity of 94% and a

specificity of 17%• (in a series of 23 patients, using EUS as a gold standard)

Liu JB et al. Radiology 1993.

Non-invasive ImagingNon-invasive Imaging

• Multi-detector row CT (MDCT) is an emerging Multi-detector row CT (MDCT) is an emerging minimally invasive technique for detective GVsminimally invasive technique for detective GVs

• Allows for visualization of small visceral Allows for visualization of small visceral vessels by offering faster acquisition times with vessels by offering faster acquisition times with less motion artifactless motion artifact

• In a series of 22 patients by Willmann et all, In a series of 22 patients by Willmann et all, MDCT was compared against the present old MDCT was compared against the present old standard of EUS with comprable detection ratesstandard of EUS with comprable detection rates

Willmann et all. Gut 2003

MDCT 3D ReconstructionMDCT 3D Reconstruction

Willmann et all. Gut 2003

Treatment OptionsTreatment Options

• Endoscopic TherapyEndoscopic Therapy

• TIPSTIPS

• B-TROB-TRO

• SurgerySurgery

• Plan BPlan B

Endoscopic TherapyEndoscopic Therapy

• Endoscopic therapeutic options for Endoscopic therapeutic options for gastric varices remains limited in the gastric varices remains limited in the United StatesUnited States

• While band ligation is moderately While band ligation is moderately effective in GOV1, rebleeding rates still effective in GOV1, rebleeding rates still approach 50%approach 50%

• Endoscopic injection sclerotherapy (EIS) Endoscopic injection sclerotherapy (EIS) is largely ineffective, as the high flow is largely ineffective, as the high flow rates in gastric varices “wash-out” the rates in gastric varices “wash-out” the sclerosantsclerosant

Sarin SK. Gastro Endo 1997.Sarin SK. Gastro Endo 1997.

Does Treating EVs worsen GVs?Does Treating EVs worsen GVs?

• Theoretically, obliteration of esophageal varices should Theoretically, obliteration of esophageal varices should lead to increased pressure elsewhere in the portal lead to increased pressure elsewhere in the portal systemsystem

• Indeed, sclerotherapy of EVs has been shown to Indeed, sclerotherapy of EVs has been shown to transiently worsentransiently worsen portal hypertensive gastropathy portal hypertensive gastropathy (PHG)(PHG)

Sarin et al. Am J Gastroenterol 2000.

• Furthermore, secondary GV’s following both EVL/EIS Furthermore, secondary GV’s following both EVL/EIS appeared at a rate of 8.8%appeared at a rate of 8.8%

• However, overall sclerotherapy of EVs However, overall sclerotherapy of EVs improvesimproves GVs GVs– post EVL: resolution of GOV1 in 50%– post EIS: resolution of GOV1 in 61.5%

Sarin et al. J Hepatol 1997.

Endoscopic SclerosantsEndoscopic Sclerosants

• Ethanolamine OleateEthanolamine Oleate– Agglutinating platelets– Destroying the endothelial cells of shunts and varices– Promotes clot formation

• N-butyl-2-cyanoacrylate (Histoacryl) N-butyl-2-cyanoacrylate (Histoacryl) – Adhesive similar to super glue (which is made of ethyl-2-

cyanoacrylate)– Polymerize on contact with basic substances such as

water or blood to form a strong bond– Histoacryl is typically mixed 1:1 with Lipiodol to prevent

premature solidification in the endoscope

SclerotherapySclerotherapy

• Sarin studied 71 patients with gastric variceal Sarin studied 71 patients with gastric variceal sclerotherapy over an 11 year periodsclerotherapy over an 11 year period

• OutcomesOutcomes– Primary hemostasis in acute bleeding: 66.7%– Variceal obliteration: 71.6% (with repeated elective sclerotherapy)– Variceal obliteration by GV type

• GOV1: 94.4% • GOV2: 70.4% • IGV1: 41%

– Rebleeding rates• GOV1: 5.5%• GOV2: 19%• IGV1: 53%

Sarin SK. Gastrointest Endosc 1997.

Combination EVL and EISCombination EVL and EIS

• In a study by Arakai et al, 56 patients with In a study by Arakai et al, 56 patients with gastric varices were treated with combination gastric varices were treated with combination band ligation and polidocanol injectionband ligation and polidocanol injection

• Extremely favorable results were obtainedExtremely favorable results were obtained– 100% control of acute bleeding– 12.5% variceal recurrence rate – 3.6% rebleeding rate

• However, most cases were GOV1, and However, most cases were GOV1, and applicability to all types of gastric varices applicability to all types of gastric varices remains questionableremains questionable

Arakai et al. Endoscopy 2003.

Combination EVL and EISCombination EVL and EIS

Movie not included due to Copyright.Movie may be viewed at:

Goff JS. VHJOE 2005. http://www.vhjoe.com/Volume4Issue1/4-1-4New.htm

Histoacryl InjectionsHistoacryl Injections

• Endoscopic tissue adhesive injection was first applied in the treatment of bleeding gastric varices by Gotlib and Zimmermann, and Ramond et al. in 1986.

• The rapid rate of activation of the adhesive appears to overcome the high flow rates within the large varices

• Overall, Histroacryl is effective in controlling bleeding– Primary hemostasis achieved in 94-97%– Rebleeding rates of roughly 20-30%– Long term survival is difficult to assess

Mahadeva et al. Am J of Gastro 2003.

Histoacryl: ComplicationsHistoacryl: Complications

• The most severe complication is the occurrence of systemic embolization

• Risk factors for systemic embolization– Large volume injection– Shunt between the portal system and the pulmonary vein

(rare)• Major complications include

– Cerebral infarct in 2 patients– Splenic infarction– Pulmonary embolism– Inflammatory tumor in pancreatic tail

See A. Gastroenterol Clin Biol 1986. / Yu et al. Gastro Endo 2005. / Witthoft et al. Z Gastroenterol 2004. / Sato et al. J Gastroenterol. 2004.

Ethanolamine and Gastric VaricesEthanolamine and Gastric Varices

• A novel approach has been proposed by Kojima et al., A novel approach has been proposed by Kojima et al., using Ethanolamine Oleate and Iopamidol (EOI) using Ethanolamine Oleate and Iopamidol (EOI) concurrently with vasopressinconcurrently with vasopressin

• Vasopressin is infused at 0.4 u/min continuously from Vasopressin is infused at 0.4 u/min continuously from 30 minutes before to 6 hours after sclerotherapy30 minutes before to 6 hours after sclerotherapy

• To counteract systemic vasoconstriction, a To counteract systemic vasoconstriction, a nitroglycerin patch is also applied to the patientnitroglycerin patch is also applied to the patient

• Under both endoscopic and fluroscopic guidance, using Under both endoscopic and fluroscopic guidance, using iopamidol as the contrast agent, EOI is injected to fill iopamidol as the contrast agent, EOI is injected to fill the varices (15 the varices (15 ± 10.5 mL)± 10.5 mL)

• As the injection needle is removed, the site is sprayed As the injection needle is removed, the site is sprayed with thrombin glue to seal the puncture sitewith thrombin glue to seal the puncture site

Kojima et al. J Gastro Hepato 2005.

Ethanolamine/Fibrin Dual NeedleEthanolamine/Fibrin Dual Needle


Ethanolamine: OutcomesEthanolamine: Outcomes

• Vasopressin presumably reduces portal pressure and Vasopressin presumably reduces portal pressure and blood flow, resulting in improved retention of the blood flow, resulting in improved retention of the sclerosant (EOI)sclerosant (EOI)

• In a series of 30 patients by Kojima et al., favorable In a series of 30 patients by Kojima et al., favorable results were obtainedresults were obtained– Primary hemostasis achieved in 28/30 patients (93.3%)– Cumulative rebleeding rate at 1, 3, and 5 years: 13%, 19%, 19%– Mortality at 1, 3, and 5 years: 31%, 54%, 59%– Average number of EIS sessions: 2.3 ± 1.1

• Side effects were minimalSide effects were minimal– 8 patients with mild fevers– 6 patients developed ulcerations at the injection site


Gastric Varices with EndoclipGastric Varices with Endoclip

Arantes and Albuquerque. Gastrointest Endosc 2005.

TIPSTIPS

• Transjugular Intrahepatic Portosystemic Shunt Transjugular Intrahepatic Portosystemic Shunt (TIPS) in a human was first created in Germany (TIPS) in a human was first created in Germany in 1988in 1988

• Since, TIPS has become the standard therapy Since, TIPS has become the standard therapy for secondary prevention of bleeding for secondary prevention of bleeding esophageal varicesesophageal varices

Boyer T. Gastro 2003.

• TIPS is also used to treat gastric varices in TIPS is also used to treat gastric varices in Europe and the United States, however the Europe and the United States, however the clinical utility of TIPS in this setting is debatableclinical utility of TIPS in this setting is debatable

TIPS: ContraindicationsTIPS: Contraindications

AbsoluteAbsolute•Primary prevention of variceal Primary prevention of variceal bleedingbleeding

•Congestive heart failureCongestive heart failure

•Multiple hepatic cystsMultiple hepatic cysts

•Uncontrolled systemic infection Uncontrolled systemic infection or sepsisor sepsis

•Unrelieved biliary obstructionUnrelieved biliary obstruction

•Severe pulmonary hypertensionSevere pulmonary hypertension

RelativeRelative•Hepatoma, especially if centralHepatoma, especially if central

•Obstruction of all hepatic veinsObstruction of all hepatic veins

•Portal vein thrombosisPortal vein thrombosis

•Severe coagulopathy Severe coagulopathy (INR >5)(INR >5)

•Thrombocytopenia of less than Thrombocytopenia of less than 20,000/cm20,000/cm33

•Moderate pulmonary Moderate pulmonary hypertensionhypertension

AASLD Guidelines 2005Boyer and Haskal. Hepatology. Vol. 41, No. 2, 2005.

TIPS: TechniqueTIPS: Technique

• A needle catheter is introduced into the hepatic vein A needle catheter is introduced into the hepatic vein typically via the right transjugular veintypically via the right transjugular vein

• The catheter is thenwedged in a peripheral branch of The catheter is thenwedged in a peripheral branch of the right hepatic veinthe right hepatic vein

• Wedged hepatic venography is then performed with Wedged hepatic venography is then performed with carbon dioxide gas, demonstrating the location of the carbon dioxide gas, demonstrating the location of the main, left and right PVsmain, left and right PVs

• Colapinto needle is advanced through the wall of the Colapinto needle is advanced through the wall of the right hepatic vein and into the right PVright hepatic vein and into the right PV

• After an elevated pressure gradient is confirmed, After an elevated pressure gradient is confirmed, intrahepatic parenchymal tract is dilated with an 8- or intrahepatic parenchymal tract is dilated with an 8- or 10-mm high-pressure balloon.10-mm high-pressure balloon.

• Finally a self-expanding metallic stent, such as the Finally a self-expanding metallic stent, such as the Wallstent, is deployedWallstent, is deployed

Novelli et al. http://www.emedicine.com/radio/topic764.htm

TIPS: ProcedureTIPS: Procedure

From: http://ndovasc.rsmu.ru/ portal.htm

http://endovasc.rsmu.ru/portal.htm




TIPS: OutcomesTIPS: Outcomes

• TIPS has shown great success in achieving TIPS has shown great success in achieving immediate immediate short-term controlshort-term control of gastric variceal of gastric variceal bleeding, with hemostasis in 90-96% of casesbleeding, with hemostasis in 90-96% of cases

Barange. Hepatology 1999.

Chau et al. Gastro 1998.

• However, long term outcomes are poorHowever, long term outcomes are poor– Rebleeding in 31% after 1 year– Stenosis of TIPS in 95% after 2 years– Mortality rate of 41% after 1 year– Treatment may worsen encephalopathy

Barange. Hepatology 1999.Arai et al. J Gastroenterol 2005.

TIPS: The ProblemTIPS: The Problem

• Central to the problem is the fact that gastric Central to the problem is the fact that gastric varices can form at portal pressures of varices can form at portal pressures of <12 mmHg<12 mmHg

• TIPS must compete with large gastro-renal TIPS must compete with large gastro-renal shunts, reducing its efficacyshunts, reducing its efficacy

• Response can be predicted by the type of Response can be predicted by the type of gastric varixgastric varix– GOV1 respond more favorably (>80% hemostasis)– GOV2 respond less favorable (26% to 70% hemostasis) – IGV1 and IGV2 are usually associated with larger gastro-

renal shuntsBarange et al. Hepatology 1999.

TIPS: Competing with SR ShuntTIPS: Competing with SR ShuntL Gastric v. Gastric Varices

Splenorenal ShuntPost-TIPS, with persistant

L Gastric v. filling

From: Ford et al. Cadiovasc Intervent Radiol 2004.

IVC Filter + Coil EmbolizationIVC Filter + Coil Embolization

Simon Nitinol vena cava filter deployed in L gastric v.

Two 20 mm diameter coils deployed

Occlusion of L gastric v. confirmed

From: Ford et al. Cadiovasc Intervent Radiol 2004.

B-TROB-TRO

• Balloon-occluded Retrograde Transvenous Balloon-occluded Retrograde Transvenous Obliteration (B-TRO) is an interventional Obliteration (B-TRO) is an interventional radiolgy technique for embolizing gastric radiolgy technique for embolizing gastric varices through a gastrorenal shunt.varices through a gastrorenal shunt.

• First introduced by Kanagawa et al. in 1991, it is First introduced by Kanagawa et al. in 1991, it is increasingly used in Japan but has seen limited increasingly used in Japan but has seen limited use in Europe and the United Statesuse in Europe and the United States

B-TRO: TechniqueB-TRO: Technique

• B-TRO uses a 6.5 Fr occlusive balloon catheter B-TRO uses a 6.5 Fr occlusive balloon catheter placed through either the femoral or internal placed through either the femoral or internal jugular vein, to the left renal vein and into the jugular vein, to the left renal vein and into the gastro-renal shunt (GRS)gastro-renal shunt (GRS)

• The balloon is inflated, and contrast is injected The balloon is inflated, and contrast is injected retrograde into the GRSretrograde into the GRS

• Any collateral drainage (usually via the inferior Any collateral drainage (usually via the inferior phrenic vein) is embolizedphrenic vein) is embolized

• Patients also usually receive 4000 U of Patients also usually receive 4000 U of haptoglobin IV to reduce risk of hemolysis and haptoglobin IV to reduce risk of hemolysis and renal failurerenal failure

B-TRO: TechniqueB-TRO: Technique

• Once isolation of the shunt is confirmed, Once isolation of the shunt is confirmed, a 5-10% mixture of ethanolamine oleate with a 5-10% mixture of ethanolamine oleate with iopamidol (EOI) is injected to fill the GRS (up to iopamidol (EOI) is injected to fill the GRS (up to 50 cc may be required)50 cc may be required)

• The EOI and balloon are left in place for at least The EOI and balloon are left in place for at least 1 hour (even over-night in some protocols)1 hour (even over-night in some protocols)

• The balloon is deflated after cessation of blood The balloon is deflated after cessation of blood flow within the shunt is confirmed by flow within the shunt is confirmed by angiographyangiography

• A contrast-enhance CT is performed 1 week A contrast-enhance CT is performed 1 week after the procedure; if recanalization is seen, B-after the procedure; if recanalization is seen, B-TRO is repeatedTRO is repeated

B-TRO: DiagramB-TRO: Diagram

Adapted from Takuma et al. CGH 2005.

B-TRO: ImagesB-TRO: ImagesPre-embolization: Collaterals Post-embolization: Isolation of GV

Ninoi et al. AJR Am J Roentgenol 2005.

B-TRO: ResultsB-TRO: Results

• Prophylactic B-TRO shows excellent Prophylactic B-TRO shows excellent resultsresults– 5-year recurrence rate of GVs: 2.7%– 5-year rebleeding rate from GVs: 1.5%

(78 patients with a median follow-up of 700 days)Ninoi et al. AJR 2005.

• Prophylactic B-TRO increases survivalProphylactic B-TRO increases survival– Cummulative survival at 1, 3 and 5 years

• B-RTO (17 patients): 94%, 85%, 39%• Control (17 patients): 71%, 41%, 22%

(p=0.04 34 patients, prospective, non-randomized study)Takuma et al. Clin Gastro Hepato 2005.

B-TRO: ResultsB-TRO: Results

• B-TRO has been applied in patients presenting B-TRO has been applied in patients presenting with acute bleedingwith acute bleeding– In a series of 11 patients by Arai et al, after either

spontaneous of endoscopic hemostasis was achieved, B-TRO was performed within 24 hours

– Obliteration of GVs was achieved in 10 out of 11 patients (90.9%)

Arai et al. J Gastroenterol 2005.

• Other benefits includeOther benefits include– Improvement in both Child-Pugh score, possibly due to

increased hepatic blood flow– Reduction of hepatic encephalopathy by occluding a

major shuntTakuma et al. Clin Gastro Hepato 2005.

B-TRO: B-TRO: Worsening VaricesWorsening Varices

• Obliteration of the gastro-renal shunt results in Obliteration of the gastro-renal shunt results in elevation of pressures elsewhere in the portal elevation of pressures elsewhere in the portal systemsystem

• Worsening of esophageal varices is seen in Worsening of esophageal varices is seen in roughly 50% of patients post-B-TROroughly 50% of patients post-B-TRO

• Presence of esophageal varices prior to B-TRO Presence of esophageal varices prior to B-TRO is a significant risk factoris a significant risk factor

• Post B-TRO Rates of EVs at 1, 2 and 3 yearsPost B-TRO Rates of EVs at 1, 2 and 3 years– Patients with prior EVs: 35%, 66% and 91%– Patients without EVs: 21%, 21% and 29%

(p < 0.01)Ninoi et al. AJR 2005.

Surgical ManagementSurgical Management

• IndicationsIndications– Failure of endoscopic therapy and salvage of for

TIPS– Noncirrhotic portal hypertension, in particular

with extrahepatic portal vein thrombosis

Surgical: Shunt ProceduresSurgical: Shunt Procedures

• Non-selectiveNon-selective– Decompresses the entire portal tree by diverting all flow

away from the portal system– i.e. Portacaval shunt

• Selective Selective – decompressed variceal system, but maintains sinusoidal

perfusion via a hypertensive superior mesenteric-portal compartment

– i.e. Distal splenorenal shunt (Warren)• PartialPartial

– Partial portocaval small diameter interposition shunt (Sarfeh)

Wolff M and Hirner Arch Surg 2003.

Surgical: ObliterationSurgical: Obliteration

• GastrectomyGastrectomy– IGV1 (Fundic): fundic portion of the stomach is

resected with mechanical stapling to eradicate intramural varices.

– IGV2 (Cardiac): proximal gastrectomy

• DevascularizationDevascularization– Gastric devascularization and splenectomy

(Hassab’s procedure)– Gastroesophageal devascularization and

splenectomy (Hassab-Paquet procedure)Hassab MA. Surgery 1967.

When All Else Fails… This Fails TooWhen All Else Fails… This Fails Too

• Primary hemostasis in 30 to 90 percentPrimary hemostasis in 30 to 90 percent

• ComplicationsComplications– Esophageal rupture– High risk of rebleeding following balloon deflation– Aspiration pneumonia secondary to inbaility to

clear oral secretionsChojkier and Conn. Dig Dis Sci 1980.

Hunt et al. Dig Dis Sci 1982.

Name the TubeName the Tube

Sengstaken-Blakemore Tube Minnesota Tube

Types of Tamponade BalloonsTypes of Tamponade Balloons

• Sengstaken-Blakemore tubeSengstaken-Blakemore tube– 250 cc gastric balloon and an esophageal

balloon – single gastric suction port

• Minnesota tubeMinnesota tube– 250 cc gastric balloon and an esophageal

balloon – esophageal suction port and gastric suction port

• Linton-Nachlas tube Linton-Nachlas tube – a single 600 cc gastric balloon

Questions… Comments?Questions… Comments?

Makino et al. observed high rates of hemostasis and lower overall mortality when balloon tamponade tubes were tied to USC football helmets vs. placebo (UCLA helmet)

Special Thanks:

Terri Wiksell of Centocor

Special Acknowledgement:

Bianca Harabour

This presentation is available at:This presentation is available at:http://www.doctoryoshi.comhttp://www.doctoryoshi.com

ReferencesReferences

• Arai et al. Emergency balloon-occluded retrograde transvenous obliteration for Arai et al. Emergency balloon-occluded retrograde transvenous obliteration for gastric varices. J Gastroenterol. 2005 Oct;40(10):964-71.gastric varices. J Gastroenterol. 2005 Oct;40(10):964-71.

• Arantes and Albuquerque. Fundal variceal hemorrhage treated by endoscopic clip. Arantes and Albuquerque. Fundal variceal hemorrhage treated by endoscopic clip. Gastrointest Endosc. 2005 May;61(6):732.Gastrointest Endosc. 2005 May;61(6):732.

• Cakmak et al. Sinistral portal hypertension; imaging findings and endovascular Cakmak et al. Sinistral portal hypertension; imaging findings and endovascular therapy. Abdom Imaging. 2005 Mar-Apr;30(2):208-13. Epub 2005 Dec 30.therapy. Abdom Imaging. 2005 Mar-Apr;30(2):208-13. Epub 2005 Dec 30.

• Cheng et al. Sclerosant extravasation as a complication of sclerosing endotherapy Cheng et al. Sclerosant extravasation as a complication of sclerosing endotherapy for bleeding gastric varices. Endoscopy. 2004 Mar;36(3):239-41.for bleeding gastric varices. Endoscopy. 2004 Mar;36(3):239-41.

• Chikamori et al. Percutaneous transhepatic obliteration for isolated gastric varices Chikamori et al. Percutaneous transhepatic obliteration for isolated gastric varices with gastropericardiac shunt: case report. Abdom Imaging. 2005 Oct 21.with gastropericardiac shunt: case report. Abdom Imaging. 2005 Oct 21.

• Chojkier M, Conn HO. Esophageal tamponade in the treatment of bleeding varices. A Chojkier M, Conn HO. Esophageal tamponade in the treatment of bleeding varices. A decadel progress report. Dig Dis Sci 1980 Apr;25(4):267-72.decadel progress report. Dig Dis Sci 1980 Apr;25(4):267-72.

• Ferral and Patel. Selection criteria for patients undergoing transjugular intrahepatic Ferral and Patel. Selection criteria for patients undergoing transjugular intrahepatic portosystemic shunt procedures: current status. J Vasc Interv Radiol. 2005 portosystemic shunt procedures: current status. J Vasc Interv Radiol. 2005 Apr;16(4):449-55.Apr;16(4):449-55.

• Ford et al. Embolization of large gastric varices using vena cava filter and coils. Ford et al. Embolization of large gastric varices using vena cava filter and coils. Cardiovasc Intervent Radiol. 2004 Jul-Aug;27(4):366-9. Epub 2004 Jun 23.Cardiovasc Intervent Radiol. 2004 Jul-Aug;27(4):366-9. Epub 2004 Jun 23.

• Fukuda et al. Application of balloon-occluded retrograde transvenous obliteration to Fukuda et al. Application of balloon-occluded retrograde transvenous obliteration to gastric varices complicating refractory ascites. Cardiovasc Intervent Radiol. 2004 gastric varices complicating refractory ascites. Cardiovasc Intervent Radiol. 2004 Jan-Feb;27(1):64-7.Jan-Feb;27(1):64-7.


• Hassab MA. Gastroesophageal decongestion and splenectomy in the treatment of Hassab MA. Gastroesophageal decongestion and splenectomy in the treatment of esophageal varices in bilhazial cirrhosis; further studies with a report of 355 esophageal varices in bilhazial cirrhosis; further studies with a report of 355 operations. Surgery 16:169–176, 1967.operations. Surgery 16:169–176, 1967.

• Hsieh et al. Modified devascularization surgery for isolated gastric varices assessed Hsieh et al. Modified devascularization surgery for isolated gastric varices assessed by endoscopic ultrasonography. Surg Endosc. 2004 Apr;18(4):666-71. Epub 2004 by endoscopic ultrasonography. Surg Endosc. 2004 Apr;18(4):666-71. Epub 2004 Mar 19.Mar 19.

• JB Liu, LS Miller, RI Feld, CA Barbarevech, L Needleman and BB Goldberg. Gastric JB Liu, LS Miller, RI Feld, CA Barbarevech, L Needleman and BB Goldberg. Gastric and esophageal varices: 20-MHz transnasal endoluminal US. Radiology. 1993 and esophageal varices: 20-MHz transnasal endoluminal US. Radiology. 1993 May;187(2):363-6.May;187(2):363-6.

• Kakutani et al. Use of the curved linear-array echo endoscope to identify gastrorenal Kakutani et al. Use of the curved linear-array echo endoscope to identify gastrorenal shunts in patients with gastric fundal varices. Endoscopy. 2004 Aug;36(8):710-4.shunts in patients with gastric fundal varices. Endoscopy. 2004 Aug;36(8):710-4.

• Kim T, et al. Risk factors for hemorrhage from gastric fundal varices. Hepatology Kim T, et al. Risk factors for hemorrhage from gastric fundal varices. Hepatology 1997;25:307-12.1997;25:307-12.

• Kojima et al. Sclerotherapy for gastric fundal variceal bleeding: is complete Kojima et al. Sclerotherapy for gastric fundal variceal bleeding: is complete obliteration possible without cyanoacrylate? J Gastroenterol Hepatol. 2005 obliteration possible without cyanoacrylate? J Gastroenterol Hepatol. 2005 Nov;20(11):1701-6. Nov;20(11):1701-6.

• Komorizono et al. Successful balloon-occluded retrograde transvenous obliteration Komorizono et al. Successful balloon-occluded retrograde transvenous obliteration for ruptured gastric fundal varices in a patient with Child-Pugh C cirrhosis: case for ruptured gastric fundal varices in a patient with Child-Pugh C cirrhosis: case report and literature review. Dig Dis Sci. 2004 Feb;49(2):270-4.report and literature review. Dig Dis Sci. 2004 Feb;49(2):270-4.

Mahadeva et al. Cost-effectiveness of N-butyl-2-cyanoacrylate (histoacryl) glue Mahadeva et al. Cost-effectiveness of N-butyl-2-cyanoacrylate (histoacryl) glue injections versus transjugular intrahepatic portosystemic shunt in the management injections versus transjugular intrahepatic portosystemic shunt in the management of acute gastric variceal bleeding. Am J Gastroenterol. 2003 Dec;98(12):2688-93.of acute gastric variceal bleeding. Am J Gastroenterol. 2003 Dec;98(12):2688-93.


• Matsumoto et al. Limitations of transjugular intrahepatic portosystemic shunt for Matsumoto et al. Limitations of transjugular intrahepatic portosystemic shunt for management of gastric varices. Gastroenterology. 2004 Jan;126(1):380-1.management of gastric varices. Gastroenterology. 2004 Jan;126(1):380-1.

• Ninoi et al. Balloon-occluded retrograde transvenous obliteration of gastric varices Ninoi et al. Balloon-occluded retrograde transvenous obliteration of gastric varices with gastrorenal shunt: long-term follow-up in 78 patients. AJR Am J Roentgenol. with gastrorenal shunt: long-term follow-up in 78 patients. AJR Am J Roentgenol. 2005 Apr;184(4):1340-6.2005 Apr;184(4):1340-6.

• Ninoi et al. TIPS versus transcatheter sclerotherapy for gastric varices. AJR Am J Ninoi et al. TIPS versus transcatheter sclerotherapy for gastric varices. AJR Am J Roentgenol. 2004 Aug;183(2):369-76.Roentgenol. 2004 Aug;183(2):369-76.

• Northup and Caldwell. Treatment of bleeding gastric varices. J Gastroenterol Northup and Caldwell. Treatment of bleeding gastric varices. J Gastroenterol Hepatol. 2005 Nov;20(11):1631-3.Hepatol. 2005 Nov;20(11):1631-3.

• Sarin SK, et al. Prevalence, classification and natural history of gastric varices: a Sarin SK, et al. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertensive patients. Hepatology long-term follow-up study in 568 portal hypertensive patients. Hepatology 1992;16:1343-9. 1992;16:1343-9.

• Sarin SK, Govil A, Jain AK, Guptan RC, Issar SK, Jain M, Murthy NS. Prospective Sarin SK, Govil A, Jain AK, Guptan RC, Issar SK, Jain M, Murthy NS. Prospective randomized trial of endoscopic sclerotherapy versus variceal band ligation for randomized trial of endoscopic sclerotherapy versus variceal band ligation for esophageal varices: influence on gastropathy, gastric varices and variceal esophageal varices: influence on gastropathy, gastric varices and variceal recurrence. J Hepatol. 1997 Apr;26(4):826-32. recurrence. J Hepatol. 1997 Apr;26(4):826-32.

• Sarin SK, Shahi HM, Jain M, Jain AK, Issar SK, Murthy NS. The natural history of Sarin SK, Shahi HM, Jain M, Jain AK, Issar SK, Murthy NS. The natural history of portal hypertensive gastropathy: influence of variceal eradication. Am J portal hypertensive gastropathy: influence of variceal eradication. Am J Gastroenterol. 2000 Oct;95(10):2888-93. Gastroenterol. 2000 Oct;95(10):2888-93.

• Sarin SK. Long-term follow-up of gastric variceal sclerotherapy: an eleven-year Sarin SK. Long-term follow-up of gastric variceal sclerotherapy: an eleven-year experience. Gastrointest Endosc. 1997 Jul;46(1):8-14. experience. Gastrointest Endosc. 1997 Jul;46(1):8-14.


• Takuma et al. Prophylactic balloon-occluded retrograde transvenous obliteration for Takuma et al. Prophylactic balloon-occluded retrograde transvenous obliteration for gastric varices in compensated cirrhosis. Clin Gastroenterol Hepatol. 2005 gastric varices in compensated cirrhosis. Clin Gastroenterol Hepatol. 2005 Dec;3(12):1245-52.Dec;3(12):1245-52.

• Taniai et al. The treatment of gastric fundal varices--endoscopic therapy versus Taniai et al. The treatment of gastric fundal varices--endoscopic therapy versus interventional radiology. Hepatogastroenterology. 2005 May-Jun;52(63):949-53.interventional radiology. Hepatogastroenterology. 2005 May-Jun;52(63):949-53.

• Weber and Rikkers. Splenic vein thrombosis and gastrointestinal bleeding in Weber and Rikkers. Splenic vein thrombosis and gastrointestinal bleeding in chronic pancreatitis. World J Surg. 2003 Nov;27(11):1271-4. Epub 2003 Oct 13. chronic pancreatitis. World J Surg. 2003 Nov;27(11):1271-4. Epub 2003 Oct 13.

• Wolff M, Hirner A. Current state of portosystemic shunt surgery. Langenbecks Arch Wolff M, Hirner A. Current state of portosystemic shunt surgery. Langenbecks Arch Surg. 2003 Jul;388(3):141-9.Surg. 2003 Jul;388(3):141-9.

• Yu et al. Splenic infarction complicated by splenic artery occlusion after N-butyl-2-Yu et al. Splenic infarction complicated by splenic artery occlusion after N-butyl-2-cyanoacrylate injection for gastric varices: case report. Gastrointest Endosc. 2005 cyanoacrylate injection for gastric varices: case report. Gastrointest Endosc. 2005 Feb;61(2):343-5. Feb;61(2):343-5.

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