Kawthar Mohamed, MD University of Minnesota, Minneapolis, MN
Introduction: Chronic obstruction of portal venous blood flow secondary to portal venous thrombosis(PVT) results in cavernous transformation of the PV and development of clinical sequele of portal hypertension. In NCPH secondary to chronic PVT, acute variceal hemorrhage is often the most serious and common clinical presentation.
Case Description/Methods: 37-year-old male with history of Evans syndrome, AIH, and ITP requiring splenectomy presents for further work-up of incidental finding of rectal varices seen on diagnostic colonoscopy done for chronic diarrhea and abdominal discomfort. Labs notable for Hgb 7.4 g/dL and Plt 80,000/mm3. CT A/P revealed chronic appearing extensive PVT with cavernous transformation of PV and poorly visualized portal vein along with esophageal and gastric varices; no ascites seen. EGD demonstrated large EV as well prominent gastroesophageal varices (GOV1/2). Liver biopsy without features suggestive of cirrhosis or portal hypertension. Following development of melena , attempt made EUS-guided coil embolization and glue injection of known varices, however extensive nature of varices made it difficult to identify target lesion. VCE also performed that demonstrated numerous ectopic varices. Given ongoing melena and persistent transfusion dependent anemia, decision made to proceed with PV recanalization and TIPS creation. Cavernous transformation made standard transjugular PV access difficult and a laparoscopic-assisted transmesenteric PV recanalization, thrombectomy and TIPS was performed. Post-TIPS portal pressure successfully reduced at 10mmgHg and Hgb as well as Plt Ct have since normalized.
Discussion: Chronic PVT with cavernous transformation makes standard transjugular approach to PV recanalization challenging. Minimally invasive surgical techniques in combination with established percutaneous methods for PV access is a feasible alternative to management of portal hypertensive bleeding in NCPVT with cavernous transformation.
Figure: Figure 1 Large Esophageal and Gastric Varices with near obstruction of esophageal lumen.
Disclosures:
Kawthar Mohamed indicated no relevant financial relationships.
Kawthar Mohamed, MD. P1085 - Laparoscopic-Assisted Transmesenteric Portal Vein Recanalization and TIPS: An Effective Approach to Management of Variceal Bleeding in NCPH, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.
