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Gastric Varices with Gastrorenal Shunt: Combined Therapy Using Transjugular Retrograde Obliteration and Partial Splenic Embolization

Fumio Chikamori1, Nobutoshi Kuniyoshi2, Takahiko Kawashima3 and Yasuhiro Takase3

1 Department of Surgery, Kuniyoshi Hospital, 1-3-4 Kamimachi, Kochi, Japan 780-0901.
2 Department of Internal Medicine, Kuniyoshi Hospital, Kochi, Japan.
3 Department of Surgery, Tsukuba Soai Hospital, Ibaraki, Japan.


Figure 1
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  		Fig. 1A —40-year-old man with alcoholic cirrhosis was admitted for treatment of large gastric varices. Laboratory data on admission were as follows: WBC, 4,900/µL; hemoglobin, 13.3 g/dL; platelets, 8.6 x 104/µL; albumin, 2.6 g/dL; total bilirubin, 2.4 mg/dL; glutamic oxaloacetic transaminase, 59 U/L; glutamic pyruvic transaminase, 34 U/L; prothrombin time, 59.0%; hepaplastin test, 48%; total bile acid, 81.1 µmol/L; arterial ketone body ratio (AKBR), 0.3. Plasma ammonia level was 145 µg/dL, and indocyanine green retention rate at 15 min (ICG15) was 33%. Child-Pugh score was grade B. Antibodies to hepatitis B and C were negative. Patient was treated with partial splenic embolization and transjugular retrograde obliteration. Superior mesenteric arterial portography shows that gastric varices are supplied by left gastric vein and drained into gastrorenal shunt (arrow) and inferior phrenic vein.

 

Figure 2
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  		Fig. 1B —40-year-old man with alcoholic cirrhosis was admitted for treatment of large gastric varices. Laboratory data on admission were as follows: WBC, 4,900/µL; hemoglobin, 13.3 g/dL; platelets, 8.6 x 104/µL; albumin, 2.6 g/dL; total bilirubin, 2.4 mg/dL; glutamic oxaloacetic transaminase, 59 U/L; glutamic pyruvic transaminase, 34 U/L; prothrombin time, 59.0%; hepaplastin test, 48%; total bile acid, 81.1 µmol/L; arterial ketone body ratio (AKBR), 0.3. Plasma ammonia level was 145 µg/dL, and indocyanine green retention rate at 15 min (ICG15) was 33%. Child-Pugh score was grade B. Antibodies to hepatitis B and C were negative. Patient was treated with partial splenic embolization and transjugular retrograde obliteration. After microcoil obliteration of inferior phrenic vein, 10 mL of 5% ethanolamine oleate with iopamidol was injected into gastric varices (arrow), as shown on retrograde shunt venography.

 

Figure 3
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  		Fig. 1C —40-year-old man with alcoholic cirrhosis was admitted for treatment of large gastric varices. Laboratory data on admission were as follows: WBC, 4,900/µL; hemoglobin, 13.3 g/dL; platelets, 8.6 x 104/µL; albumin, 2.6 g/dL; total bilirubin, 2.4 mg/dL; glutamic oxaloacetic transaminase, 59 U/L; glutamic pyruvic transaminase, 34 U/L; prothrombin time, 59.0%; hepaplastin test, 48%; total bile acid, 81.1 µmol/L; arterial ketone body ratio (AKBR), 0.3. Plasma ammonia level was 145 µg/dL, and indocyanine green retention rate at 15 min (ICG15) was 33%. Child-Pugh score was grade B. Antibodies to hepatitis B and C were negative. Patient was treated with partial splenic embolization and transjugular retrograde obliteration. Retrograde shunt venography on day 1 after transjugular retrograde obliteration shows that thrombi have formed in gastric varices (arrow).

 

Figure 4
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  		Fig. 2 —Graph shows cumulative occurrence rate of esophageal varices after transjugular retrograde obliteration in groups 1 and 2. Lower line represents group 1, partial splenic embolization and transjugular retrograde obliteration; upper line, group 2, trans jugular retrograde obliteration only. Difference between the two groups was statistically significant (p < 0.05).

 

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