encephalopathy by balloon - Hindawi

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RESUME : Le shunt lntrahepatique transjugulaire (SITJ) est une technique ... rates associated with shunt surgery re- ..... Long-term effects of distal splenorenal.
CLINIC AL HEP A T O LOGY

Successful reversal of chronic incapacitating post--TIPS encephalopathy by balloon occlusion of the stent DAPHNA FEN YVES Mn, M ICHEL P DUFRESNE MD, JEAN RAYMOND MD, MICI-IEL LAFORTUNE MD, BERNARD W ILLEMS MD, G ILLES POMIER-LAYRARGUES MD

D FENYVES, MP DUFRESNE, J RAYMOND, M LAFORTUNE, B WILLEMS, G POMIER-LAYRARGUES. Successful reversal of chronic incapacitating post-

TIPS encephalopathy by balloon occlusion of the stent. Can J Gastroenterol 1994;8(2):75-80. T ransjugula r lntrahepatic portosystemic shunt (TIPS) placement is a n ew technique allowing decompression of the portal system without the need for abdominal surgery or gene ral anesthetic. This promising procedure appears safe, and is being evalua ted in the context of life threatening uncon trollable variceal hemorrhage as well as ascites refractory to medical treatment. Following TlPS, portal flow diversion is associated with hepatic encephalop athy in up to 25% of patients. This is most often mild and treatable but may become uncontrollable, incapacitating an d even life threatening in up to 3 to 5% of cases. The authors present two patients in whom such life threatening enceph alopathy and stupor was reversed by transjugular balloon occlusion of the TIPS. Key Words: Ascites, Encephalopathy, Portal hypertension, T ransjugular intrahepatic shunt (TIPS)

Traitement d'une encephalopathie chronique invalidante apres shunt intrahepatique transjugulaire par occlusion de la prothese a l'aide d'un ballonnet

RESUME : Le shunt

lntrahepatique transjugulaire (SITJ) est une technique nouvelle qui permet de decomprimer le systeme porte sans qu'il soit necessaire d'avoir recours a la chirurgie et a une anesthesie generale. Cette technique promettcusc apparatt securitaire e t est actuelle ment evaluee dans le traitement des hemorragies par varices oesophagie n nes incontro la bles, ainsi que de l'ascite refractaire au rraiteme nt medical. Le shunt int rahepatique entra'in e un e diminucont/nued on next page

Li11er Unit and Department of Radiology. Hopiu1l Saint-Luc and Universite de Montreal , Monrreal, Quebec Correspondence: Dr Daphna Fenyves . Hopiral Saint-Luc, 264 , Rene-Levesque ea.st, Monrreal, Quebec H2X IP l Recei11ed for publication Seprember 3 , I99 3 . Accepted December 15, 1993 CAN J 0ASTROENTEROL VOL 8 No 2 MARCH/APRIL 1994

T

HE MAJOR COMPLICATION OF PORta l hyperten sion and primary cause of death in cirrhotics remains variceal rupture. It carries a h igh morbidity an d mortali ty ( 1), is often associa ted with deteriora ting liver function, and may thus make t he need fo r eventual organ replacement even more imminent in patients with chron ic li ver disease. Despite available h emostatic procedures, includ ing balloon tamponade and endoscopic sclerotherapy, the hemorrhage may be uncontrollable. A more definitive intervention is then requ ired. Unfortunately in cirrhotics with more advanced underlying liver disease, the morbid ity and morta lity rates associated with shunt surgery remain prohibitive. T hese poten tial candidates need a nothe r option to prevent th em fro m succumbing to hemorrhage and to provide a 'bridge' until organ replacement (2). Such a life-saving procedure is the transjugular intrahepatic portosystemic shun t (TIPS) . T he technique consists of transjugu lar placeme nt of an intravascular Stent into the liver parenchyma to con nect the portal and hepatic veins (3,4 ). T his c reates a shunt, thus decompressing the portal system without the

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FENYVES c!C

a/

t ion importante du debit portal qui peut etre compliquee d'une encephalopathie hepa t ique chez plus de 25 % des patients. Celle-ci est la pluparr du te mps moderee et facilement traitable, mais peut devenir incontrolable, incapacitan te, et meme mettre la vie du patient en danger clans 3 a 5 % des cas. Les auteurs presentent deux cas ch ez qui une te lle encephalopathie grav issime a pu etre traitee de fa~on efficace par l'occlusion du shunt a u moyen d'un ballonnet mis en p lace par voie tran sj ugu la ire.

TABLE l Hepatic manometry pre- and post -transjugular intrahepatic shunt (TIPS) Ca se 1 Pre -TIPS Post-TIPS Infe rior vena c a va pressure (mmHg) Portal veno us pressure (mmHg ) Po rtohepatic gra die nt (mmHg)

need fo r a gene ral anesthetic or intraabdom inal surgery. The procedure, being evaluated m several centres, shows promise. lt seems effective in a rresting he morrhage from variceal rupture a nd, in experienced hands, appears relative ly safe (5-10). In light of good initial results, TIPS is also being evaluated for use in intracta ble ascites (11 - 14). Successful portal decompression by the c reation of a portosystemic shunt is accompanied, as is its surgical counte rpart, by the development of c h ron ic e ncephalopathy in up to a quarter of patients (1 5- 17). This can often be controlled with med ications; however, severe in tracta ble hepatic encephalopathy a nd/or progressive liver failure occur and present a serious problem. We descri be two patien ts in whom placemen t of TIPS for intractable ascites resulted in the developmen t of seve re, intractable hepat ic encephalopathy a nd coma, a nd in whom complete reversal was achi eved by permane ntly occluding t he intrahepa tic stent shunt.

CASE 1 PRESENTATION T he patien t was an 80-year-old male suffering fro m myelo id metaplasia, which has slowly evolved over the past 15 years. T he d isease was accompanied by portal hypertension and increasing ascites, with an associated umbilical hern ia and important periphe ral ede ma (treated with d iuretics since December 199 1). From March 1992, following variceal rupture, the patie nt underwent re-

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2

10 18

25

8

Case 2 Pre -TIPS Post-TIPS

14 37 23

11 20 9

peated mo nthly ethan olamine o leate injections and achi eved complete variceal eradicat ion by October 1992. The patien t was the n left with massive ascites resistan t to diuretic therapy and associated with ch ronic re nal insufficiency (c reati n ine approximately 185 to 190 µmol/L) , necessitating paracen tes is of 6 to 8 L every two to three weeks (as of March 1992). O n October 21, 1992, the patient was readmitted with massive ascites accompanied by a tense protuberant, excoriated um bilical hernia and massive leg edema. He was on a 'no added salt' d ie t, and his medication included aldactone 150 mg and furosemide 60 mg daily. The patient was alert and oriented, pale, cachectic, with absen ce of icterus or stigmata of chro nic liver disease and, in particular, no en cephalopathy. He was perfectly lucid with no flapping. In itial laboratory investigations revealed: hemoglobin 90 g/L; white blood cell count 12,100 cells~mm3 ; plate le t count 238,000 cells/mm ; prothrombin t ime/partial thromboplastin t ime n ormal; bilirubin 24 µmol/L; aspartate aminotransferase 22 IU/L; alanine aminotransferase 11 IU/L; alkaline phosphatase 546 IU/L; albumin 34 g/L; urea 25.8 mmol/L; c reatinine 254 µmol/L; sodium 134; potassium 5.3; c hloride 105; 24 h urin a ry sodiu m excretion 6 mmol; and creatinine clearance 0. 17 mL/s (n ormal 1.2 to 2.4). After in itial stabilization including fur ther paracen tesis, it was decided to provide more CAN

defini tive treatment due to fear of potent ial umbilical hernia rupture. O n October 29, under a nt ibiotic coverage and after mformed consent was obtained, a n intrahepatic portosyste mic stent shunt was placed via the transjugula r approach as previously described and without complications (6). Prior abdominal Doppler examination had shown a patent porto-splcno-mcsence ric ax is with heparopedal flow in all except the inferio r mesenteric vein (whe re flow was reversed ). T here was a sma ll patent para-umbil ical vein wi th hepa tofugal flow. T he coronary vei n was not visua lized. The baseline a nd post-TIPS hepatic manometric values arc summarized in T able l. Li ver biopsy done during the procedure revealed a large nu mber of megakaryocytes with in the sinusoids as well as discre te sinusoidal fibrosis, all compa tible with the underlying diagnosis of myelo id metaplasia. A bdominal Dopple r exami nation one week following TIPS placemen t confirmed a patent shunt between the right portal and hepatic veins. T he para-umbilical vei n was no longer patent and the inferior mesenteric vein h ad a reversed but slower flow. Bloodflow in the right portal radicals was h epatofuga l, and that in the left intrahepatic po rtal radicals was back a nd forth . Ascites were still present. The patie nt was well for the first week post-TIPS but then developed enceph alopathy. It was ini tially m ild and treatable (grade I to II) but became progressively more severe and more diffic ult to control (grade III ) despite persistent absence of any precipitating fac tors. The patient kept fl ucruating between a grade Il and lil encephalopathy over a period of two weeks despite progressive and addit ive use of lactulose up to 15 ml qid, metronidazole 250 mg bid a nd finall y sodium benzoate 3 g tid. O n November 25, t he patie nt's level of consciousness deteriorated further and he became comatose within the ensuing three days. It was decided to sec if occlusion of the intrahepatic shunt was feasible and could achieve restoration of portal perfusion a nd reversal of the hepatic coma. On Novemher 28, the prostheses

J 0ASTROENTEROL VOL 8 NO 2 MARCll/APRIL 1994

Balloon occlusion of TIPS

and portal vein were cannulated via the transjugular approach, demonstrating all portal venous flow to be