Overview
Definition:
Bleeding gastric varices are dilated submucosal veins in the stomach, typically arising from portal hypertension, that can rupture and cause life-threatening hemorrhage
Surgical shunts are procedures designed to decompress the portal venous system by creating an artificial pathway for blood flow, thereby reducing portal pressure and the risk of varix rupture.
Epidemiology:
Gastric varices occur in approximately 20-40% of patients with portal hypertension, with higher prevalence in East Asian populations and those with advanced liver disease
Bleeding from gastric varices accounts for 5-10% of all variceal bleeding episodes and is associated with higher mortality rates compared to esophageal varices.
Clinical Significance:
Uncontrolled bleeding from gastric varices presents a significant surgical challenge due to their location and the compromised hemodynamic status of the underlying liver disease
Surgical shunt procedures aim to permanently reduce portal pressure, offering a definitive solution for recurrent or refractory bleeding, and are crucial for improving patient outcomes in selected individuals
Understanding these procedures is vital for surgical residents preparing for DNB and NEET SS examinations.
Diagnostic Approach
History Taking:
Key history includes symptoms of portal hypertension (ascites, encephalopathy, splenomegaly), previous variceal bleeding, history of liver disease (hepatitis B/C, alcohol abuse, NASH), and anticoagulant use
Look for red flags like hematemesis, melena, syncope, and signs of hypovolemic shock.
Physical Examination:
Examination may reveal stigmata of chronic liver disease (jaundice, palmar erythema, spider angiomata, hepatomegaly/splenomegaly, ascites)
Assess for hemodynamic instability (tachycardia, hypotension)
Abdominal examination may reveal a palpable spleen or pulsatile liver.
Investigations:
Endoscopy (EGD) is the gold standard for diagnosis, classifying varices by size and Redness (F-1, F-2, F-3)
Ultrasound with Doppler can assess portal vein patency and flow
CT or MRI angiography provides detailed anatomical information about venous collaterals
Liver function tests (LFTs), coagulation profile, and platelet count are essential
Viral serologies and autoantibodies help determine the etiology of liver disease.
Differential Diagnosis:
Other causes of upper gastrointestinal bleeding must be considered, including peptic ulcers, erosive gastritis, Mallory-Weiss tears, Dieulafoy lesions, and gastric neoplasms
Gastric varices are typically distinguished by their endoscopic appearance and association with portal hypertension.
Management
Initial Management:
Immediate resuscitation with intravenous fluids, blood products (packed red blood cells, fresh frozen plasma, platelets), and correction of coagulopathy
Pharmacological management includes vasoactive agents like octreotide or terlipressin to reduce splanchnic blood flow and portal pressure
Antibiotic prophylaxis (e.g., norfloxacin, ciprofloxacin) is crucial to prevent spontaneous bacterial peritonitis.
Endoscopic Management:
Endoscopic variceal ligation (EVL) or endoscopic injection sclerotherapy (EIS) are the first-line treatments for actively bleeding varices
However, gastric varices are often more challenging to manage endoscopically due to their location and size, with higher recurrence rates
Balloon tamponade may be a temporizing measure.
Interventional Radiology:
Transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive procedure that creates a shunt between the portal vein and hepatic vein, decompressing the portal system
It is highly effective for controlling acute variceal bleeding and preventing rebleeding, but carries risks of hepatic encephalopathy and shunt stenosis.
Surgical Management:
Surgical shunt procedures are considered for patients with refractory bleeding despite endoscopic and radiological interventions, or those who are not candidates for TIPS
Indications include Child-Pugh C cirrhosis or decompensated cirrhosis with bleeding gastric varices refractory to other therapies
The goal is to reduce portal pressure by diverting portal blood flow away from the varices
Types of shunts include:
1
**Distal Splenorenal Shunt (Warren Shunt):** Connects the splenic vein to the left renal vein
This selective shunt preserves portal flow to the liver while decompressing varices, theoretically reducing hepatic encephalopathy
It requires an intact spleen
2
**Proximal Splenorenal Shunt (Warren-Warren Shunt):** Connects the splenic vein to the left renal vein, but with ligation of the splenic vein at its origin
Less commonly performed
3
**Mesocaval Shunt:** Connects the superior mesenteric vein to the inferior vena cava
This is a non-selective shunt, diverting all portal blood flow away from the liver, increasing the risk of encephalopathy and ascites
4
**Portacaval Shunt:** Connects the portal vein directly to the inferior vena cava
Also a non-selective shunt with significant risks
5
**H-graft Shunts:** Synthetic grafts are used to create portocaval or mesocaval shunts when native vessels are unsuitable
6
**Gastric Devacularization Procedures:** In cases where shunting is not feasible or desirable, procedures like the Sugiura procedure (ligation of gastric and esophageal varices, transection of the esophagus, and splenectomy) may be considered, though they are less common now.
Complications
Early Complications:
For surgical shunts, early complications include hemorrhage, thrombosis of the shunt, infection, abdominal compartment syndrome, pancreatitis (with splenectomy), and worsening ascites or encephalopathy
For TIPS, complications include bleeding, infection, hepatic artery pseudoaneurysm, pneumothorax, and arrhythmias
Endoscopic complications include perforation, bleeding, and esophageal injury.
Late Complications:
Late complications of surgical shunts include shunt stenosis or occlusion, chronic hepatic encephalopathy, progressive liver dysfunction, and development of new collateral channels
Late complications of TIPS include shunt stenosis or thrombosis, worsening hepatic encephalopathy, and development of Budd-Chiari syndrome
Recurrent bleeding can occur if the shunt fails or if other variceal sources are present.
Prevention Strategies:
Meticulous patient selection is paramount
For surgical shunts, careful pre-operative assessment of liver function and portal hemodynamics is crucial
Post-operative monitoring for shunt patency, liver function, and neurological status is essential
For TIPS, optimizing shunt caliber and placement, and judicious use of antiplatelet agents can help prevent stenosis
Endoscopic management should involve careful technique to minimize injury.
Prognosis
Factors Affecting Prognosis:
Prognosis is largely determined by the severity of underlying liver disease (Child-Pugh score, MELD score), the etiology of liver disease, the presence of other complications of portal hypertension (encephalopathy, ascites), and the success of the intervention in controlling bleeding and reducing portal pressure
Younger patients with less severe liver disease tend to have better outcomes.
Outcomes:
Surgical shunt procedures can achieve excellent hemostasis and reduce rebleeding rates significantly, but carry a high operative mortality, particularly in patients with advanced cirrhosis
TIPS offers a less invasive alternative with good control rates but a higher incidence of hepatic encephalopathy and shunt dysfunction
Non-shunt interventions (endoscopic therapy, devascularization) are associated with higher rebleeding rates but lower operative mortality.
Follow Up:
Patients require lifelong follow-up with regular liver function tests, monitoring for signs of hepatic encephalopathy, ascites, and recurrent bleeding
Doppler ultrasound or angiography is performed periodically to assess shunt patency (for surgical shunts and TIPS)
Regular endoscopic surveillance may be necessary depending on the initial management and risk of rebleeding.
Key Points
Exam Focus:
DNB and NEET SS exams will likely test the indications for surgical shunts in bleeding gastric varices, the specific types of shunts (distal splenorenal, mesocaval, portacaval), their technical aspects, and their respective advantages and disadvantages concerning portal decompression, hepatic blood flow, and complications like encephalopathy
Understanding the role of TIPS as an alternative is also crucial.
Clinical Pearls:
Gastric varices are often more challenging to manage than esophageal varices
Consider the patient's overall liver status meticulously when deciding between endoscopic, radiological, or surgical interventions
The Warren shunt (distal splenorenal) is preferred over non-selective shunts when possible due to its lower risk of encephalopathy
Always assess for patent portal vein and hepatic veins before considering shunt surgery.
Common Mistakes:
Misclassifying gastric varices as esophageal varices, delaying definitive management due to fear of intervention in cirrhotic patients, and not adequately considering the risk of hepatic encephalopathy with non-selective shunts are common errors
Inadequate pre-operative assessment of liver function and portal hemodynamics can lead to poor outcomes
Failure to monitor shunt patency post-operatively can result in rebleeding.