title: 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: BackgroundTransjugular 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 reportA 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.ConclusionIn 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.
authors.affiliation: Department of Gastroenterology and Hepatology, University Hospital Essen, Germany.
authors.forename: Matthias
authors.initials: M
authors.lastname: Buechter
authors.affiliation: Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Germany.
authors.forename: Jens M
authors.initials: JM
authors.lastname: Theysohn
authors.affiliation: Department of Gastroenterology and Hepatology, University Hospital Essen, Germany.
authors.forename: Alisan
authors.initials: A
authors.lastname: Kahraman
authors.affiliation: Department of Gastroenterology and Hepatology, University Hospital Essen, Germany.
authors.forename: Paul
authors.initials: P
authors.lastname: Manka
authors.affiliation: Department of Gastroenterology and Hepatology, University Hospital Essen, Germany.
authors.forename: Guido
authors.initials: G
authors.lastname: Gerken
authors.affiliation: Department of Gastroenterology and Hepatology, University Hospital Essen, Germany.
authors.forename: Ali
authors.initials: A
authors.lastname: Canbay
authors.affiliation: Department of Gastroenterology and Hepatology, University Hospital Essen, Germany.
authors.forename: Alexander
authors.initials: A
authors.lastname: Dechêne
mesh_terms: D021721:Balloon Occlusion / Q000379:methods*; D003131:Combined Modality Therapy / Q000295:instrumentation / Q000379:methods; D004621:Embolization, Therapeutic / Q000379:methods*; D005260:Female; D005355:Fibrosis / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D006471:Gastrointestinal Hemorrhage / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D006801:Humans; D008875:Middle Aged; D019168:Portasystemic Shunt, Transjugular Intrahepatic / Q000295:instrumentation* / Q000379:methods; D012007:Rectum / Q000098:blood supply* / Q000601:surgery; D016896:Treatment Outcome; D014648:Varicose Veins / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*