Question

Discuss any two such procedures in detail, including its indications, contraindications, procedural details, and complications.

Hint:

BRTO is an excellent procedure for controlling bleeding gastric varices, particularly when other methods are unsuccessful. However, it requires careful monitoring for complications like portal vein thrombosis.

Answer 1

Step 1: Transjugular Intrahepatic Portosystemic Shunt (TIPS).
1. Indications:
- Refractory variceal bleeding: TIPS is indicated when bleeding from varices cannot be controlled by endoscopic treatment.
- Refractory ascites: TIPS can help in reducing the portal pressure and improving ascitic fluid reabsorption.
- Hepatorenal syndrome: A potential indication to improve renal function by reducing portal pressure.
2. Contraindications:
- Severe liver dysfunction (Child-Pugh Class C).
- Severe heart failure.
- Hepatic encephalopathy.
- Portal vein thrombosis with a poor collateral circulation.
3. Procedural Details:
- TIPS is performed through a transjugular approach, where a needle is inserted into the jugular vein, and a catheter is advanced into the hepatic vein.
- A tract is created between the portal and hepatic veins using a balloon, and a stent is placed to maintain the shunt.
- The procedure is guided by fluoroscopy and ultrasound.
4. Complications:
- Hepatic encephalopathy: A potential complication due to the diversion of blood from the liver, causing toxins to bypass the detoxifying effect of the liver.
- Stent thrombosis: This can occur, necessitating stent revision or revascularization.
- Bleeding: Due to the invasive nature of the procedure, bleeding is a risk, though rare.
- Infection: As with any invasive procedure, there is a risk of infection.
Step 2: Balloon-occluded Retrograde Transvenous Obliteration (BRTO).
1. Indications:
- Bleeding gastric varices: BRTO is primarily used to manage bleeding gastric varices, a complication of portal hypertension.
- Large or isolated varices that cannot be controlled by other treatments like TIPS or endoscopic interventions.
2. Contraindications:
- Severe liver dysfunction: In cases of liver cirrhosis or decompensated liver disease, BRTO may not be suitable.
- Non-bleeding varices: BRTO is not indicated for non-bleeding gastric varices or as a prophylactic treatment.
3. Procedural Details:
- A catheter is inserted into the femoral vein, and contrast injection is used to visualize the varices.
- A balloon is then inserted to occlude the varices, and a sclerosing agent is injected to obliterate the varices.
- The balloon is inflated to stop the blood flow and prevent further bleeding.
- The procedure is minimally invasive, performed under local anesthesia with fluoroscopic guidance.
4. Complications:
- Portal vein thrombosis: As the procedure involves occlusion of the veins, there is a risk of thrombosis in the portal circulation.
- Gastric mucosal injury: If the balloon is not correctly positioned, it can lead to damage to the gastric wall.
- Infection: Infection from the catheter insertion or from the use of sclerosing agents is a potential complication.