A Sticky Situation Upper GI bleed in a young female Jehovahs - - PowerPoint PPT Presentation

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A Sticky Situation Upper GI bleed in a young female Jehovahs - - PowerPoint PPT Presentation

Jan 11, 2024 18 likes •213 views

A Sticky Situation Upper GI bleed in a young female Jehovahs Witness Dr. Leigh Minuk , PGY2 General Internal Medicine, University of Toronto Co-authors: Dr. Deb Chakraborty (Western University), Dr. Amir Rumman (University of Toronto), Dr.

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A Sticky Situation

Upper GI bleed in a young female Jehovah’s Witness

  • Dr. Leigh Minuk, PGY2 General Internal Medicine,

University of Toronto Co-authors: Dr. Deb Chakraborty (Western University), Dr. Amir Rumman (University of Toronto), Dr. Gary May (University of Toronto, Department of Gastroenterology)

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SLIDE 2

Conflicts of Interest

  • None
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SLIDE 3

Learning Objectives

After reading this clinical vignette, the practitioner should be able to: 1. Understand the state of current therapeutic options for variceal bleed 2. Recognize the complications of cyanoacrylate glue 3. Develop an approach to the patient with non-cirrhotic portal hypertension

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SLIDE 4

25 year old female with two episodes of black, tarry stool

Past medical history

  • Long history of

“functional” abdominal pain.

  • Splenectomy for presumed ITP
  • Cholecystectomy for gallstones

Family History: FAP gene (She is negative) Social History: Non-smoker, no alcohol, no drug use. Jehovah's Witness.

  • Caucasian. No consanguinity.
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SLIDE 5

Initial Exam and Labs

Examination Initial Laboratory Investigations Appears well, no pallor, no distress Vitals HR 100, BP 112/76, RR 18, O2 98% on RA Abdo: bowel sounds present, no tenderness, no hepatomegaly, digital rectal exam negative for melena stools. CV/Resp: normal Hgb 121, WBC 15.6, Plt 262 PT 12.5, INR 1.13 Normal electrolytes, extended electrolytes, creatinine AST 33, ALT 23, ALP 47 LD 329, Alb 30, TBili 7

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SLIDE 6

Initial Exam and Labs

Examination Initial Laboratory Investigations Appears well, no pallor, no distress Vitals HR 100, BP 112/76, RR 18, O2 98% on RA Abdo: bowel sounds present, no tenderness, no hepatomegaly, digital rectal exam negative for melena stools. CV/Resp: normal Hgb 121, WBC 15.6, Plt 262 PT 12.5, INR 1.13 Normal electrolytes, extended electrolytes, creatinine AST 33, ALT 23, ALP 47 LD 329, Alb 30, TBili 7

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SLIDE 7

Repeat Hemoglobin

121  77

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SLIDE 8

Unexpected Endoscopy

Rapidly bleeding gastroesophageal varices

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SLIDE 9

Options for Management

Medical Therapy

  • Splanchnic Vasoconstriction

(i.e., Octreotide) Endoscopic Therapy

  • Endoscopic Variceal Ligation
  • Endoscopic Injection

Sclerotherapy

  • Endoscopic variceal obturation

Trans-jugular Intrahepatic Portal Shunt

https://www.gastrointestinalatlas.com/e nglish/variceal_banding_iv.html

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SLIDE 10

2 Minutes after injection…

Loss of Consciousness Code Blue Seizure

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SLIDE 11

MR Brain

Axial images from T2 FLAIR sequences demonstrating small scattered bilateral hyperintensities (black arrows) correlating with small subacute infarcts post glue embolization

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SLIDE 12

Complications of Cyanoacrylate Glue

  • Rebleeding
  • Sepsis
  • Splenic Emboli
  • Pulmonary Emboli
  • Cerebral Emboli
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SLIDE 13

Thoracoabdominal CTA

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SLIDE 14
  • CT scan/MR – No intraabdominal or

intrathoracic AVMs, no blood vessel

  • bstruction
  • Portal venous doppler x 2 – no portal VTE
  • No hepatomegaly or cirrhosis on CT/MRI/US
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SLIDE 15

Posthepatic

  • Budd Chiari
  • Right sided heart

failure

  • IVC obstruction

Hepatic Sinusoidal

  • Alcoholic Cirrhosis
  • Viral Hepatitis
  • NASH
  • Drug induced
  • Infiltrative (incl. amyloid)
  • Gaucher’s

Post Sinusoidal Sinusoidal obstruction syndrome

Prehepatic Portal Vein thrombosis Splenic vein thrombosis

Presinusoidal

  • Idiopathic non-

cirrhotic Portal Hypertension

  • Biliary diseases
  • Sarcoidosis
  • Congenital hepatic

cirrhosis

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SLIDE 16

Next Steps

  • Definitive control of variceal bleed
  • Liver biopsy
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SLIDE 17

References

  • 1. Krynytska I, Marushchak M, Mikolenko A, et al. Differential diagnosis of hepatopulmonary syndrome (HPS): Portopulmonary

hypertension (PPH) and hereditary hemorrhagic telangiectasia (HHT). Bosn J Basic Med Sci. 2017;17(4):276-285. doi:10.17305/bjbms.2017.2020

  • 2. Kudo M, Zheng RQ, Kim SR, et al. Diagnostic accuracy of imaging for liver cirrhosis compared to histologically proven liver
  • cirrhosis. Intervirology. 2008;51(SUPPL. 1):17-26. doi:10.1159/000122595
  • 3. Schouten JNL, Verheij J, Seijo S. Idiopathic non-cirrhotic portal hypertension: A review. Orphanet J Rare Dis. 2015;10(1):1-8.

doi:10.1186/s13023-015-0288-8

  • 4. Gioia S, Riggio O, Pentassuglio I, Nicoletti V, Valente M, d’Amati G. Idiopathic noncirrhotic portal hypertension: current
  • perspectives. Hepatic Med Evid Res. 2016;Volume 8:81-88. doi:10.2147/HMER.S85544
  • 5. Gallet B, Zemour G, Saudemont JP, Renard P, Hillion ML, Hiltgen M. Echocardiographic demonstration of intracardiac glue after

endoscopic obturation of gastroesophageal varices. J Am Soc Echocardiogr. 1995;8. 759-761. doi:10.1016/S0894-7317(05)80396- 7

  • 6. N. U, P.S. K. Hepatopulmonary syndrome and portopulmonary hypertension. Hepatol Res. 2009;39(10):1020-1022.

doi:10.1111/j.1872-034X.2009.00552.x

  • 7. Christensen RD, Baer VL, MacQueen BC, O’Brien EA, Ilstrup SJ. ABO hemolytic disease of the fetus and newborn: Thirteen years
  • f data after implementing a universal bilirubin screening and management program. J Perinatol. 2018;38(5):517-525.

doi:10.1038/s41372-018-0048-4

  • 8. Dandana A, Ben Khelifa S, Chahed H, Miled A, Ferchichi S. Gaucher Disease: Clinical, Biological and Therapeutic Aspects.
  • Pathobiology. 2016;83(1):13-23. doi:10.1159/000440865
  • 9. Chew Dr JRY, Balan A, Griffiths W, Herre J. Delayed onset pulmonary glue emboli in a ventilated patient: A rare complication

following endoscopic cyanoacrylate injection for gastric variceal haemorrhage. BMJ Case Rep. 2014;2014:1-4. doi:10.1136/bcr- 2014-206461

  • 10. Burke MP, O’Donnell C, Baber Y. Death from pulmonary embolism of cyanoacrylate glue following gastric varix endoscopic
  • injection. Forensic Sci Med Pathol. 2017;13(1):82-85. doi:10.1007/s12024-016-9835-4
  • 11. Cheng LF, Wang ZQ, Li CZ, Lin W, Yeo AET, Jin B. Low incidence of complications from endoscopic gastric variceal obturation

with butyl cyanoacrylate. Clin Gastroenterol Hepatol. 2010;8(9):760-766. doi:10.1016/j.cgh.2010.05.019

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SLIDE 18

Thank you!

  • Dr. Gary May
  • Dr. Deb Chakraborty, and Dr. Amir Rumman
  • Dr. Stephen Power, Radiology for assistance

with the imaging

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SLIDE 19

Contrast-enhanced Abdominal CT

1 2

(1) coronal and (2) axial contrast enhanced CT demonstrating thrombus within the portal vein (solid white arrows) post trans-portal embolization procedure