Editing Oesophageal/gastric varices (section)

== '''Procedures for patients with refractory varices''' ==

=== '''TIPS     (Transjugular Intrahepatic Portosystemic Shunt)''' ===

** ''See Portal      HTN page under HPB for full procedure info''
** Covered metal stent between      right hepatic and portal veins

=== '''Surgical     shunts''' ===

** Reserved for chronic or      recurrent variceal haemorrhage in patients in whom TIPS have thrombosed      repeatedly
** Can also be a salvage      procedure in the acute setting
** Classification
*** Selective - decompression       of portal/azygous system while preserving portal inflow into liver
**** Distal splenorenal shunt -        anastomosis of distal splenic vein to left renal vein and ligation of        collaterals, coronary vein and gastroepiploic veins. Liver still gets        perfused through SMV.
***** Contraindications -         intractable ascites - it can get worse.
***** Technically difficult         procedure
***** Pancreatic collaterals         sometimes develop
*** Nonselective - divert all       portal flow away from the liver
**** End-to-side portacaval        shunt - diverts all blood away from liver, so you get very high rates        of hepatic encephalopathy -> not done any more.
**** Side-to-side portacaval        shunt - discouraged if patient is a potential liver transplant        recipient as there is too much porta hepatis dissection
**** Interposition shunt
**** Conventional splenorenal        shunt
*** Rates of survival and       recurrent bleeding are similar between the two, but incidence of post-op       hepatic encephalopathy is obviously lower with selective.


[[Category:UGIS]]