Large paraesophageal varices causing recurrent hepatic encephalopathy.

CASE PRESENTATION P araesophageal varices connect the coronary vein with the azygos and hemiazygos veins and the vertebral plexus. On computed tomographic scans, the prevalence of paraesophageal varices is 10% to 22% in cirrhotic patients with portal hypertension. Large paraesophageal varices appear to be associated with a higher risk of developing recurrent varices and rebleeding. However, little information was provided regarding the relationship between hepatic encephalopathy and large paraesophageal varices. In this report, a rare case of large paraesophageal varices after transjugular intrahepatic portosystemic shunt (TIPS) insertion causing recurrent hepatic encephalopathy is reported. A 49-year-old man presented with massive hematemesis and melena at our department. He had no history of nonsteroidal antiinflammatory drug use, viral hepatitis, or liver cirrhosis. On physical examination, the patient was pale with a mild hypotension of 95/69 mm Hg, a respiratory rate of 18 breaths per minute, and a heart rate of 78 beats per minute. Laboratory tests showed a low hemoglobin concentration of 111 g/L (normal range, 131–172 g/L), a low white blood count of 1.37 3 109/L (normal range, 3.97–9.15 3 109/L), a low platelets count of 44 3 109/L (normal range, 85–303 3 109/ L), a high total bilirubin level of 42.5 mmol/L (normal range, 3.4– 20.5 mmol/L), a normal albumin level of 35.8 g/L (normal range, 35–55 g/L), and a prolonged prothrombin time of 19.5 seconds (normal range, 11.0–15.0 seconds). Additionally, the test for HBsAg was positive. No ascites was found on color Doppler ultrasound. On emergency upper gastrointestinal endoscopy, active variceal bleeding at the middle of esophagus was found. Intravenous infusion of octreotide was administered. Contrast-enhanced computed tomography demonstrated large paraesophageal varices (white arrowhead) outside the relatively smooth esophageal walls (white arrow), splenomegaly (asterisk), and remarkable signs of liver cirrhosis (triangle) (Figure 1). Given Child-Pugh class B score and active variceal bleeding, an emergency TIPS insertion with a covered stent was performed. Portosystemic pressure gradient was decreased from 31 cm H2O to 9 cm H2O. No variceal bleeding recurred after TIPS. TIPS shunt was noted to be patent during his follow-up by color Doppler ultrasound. However, repeated episodes of grade I or grade II hepatic encephalopathy occurred 14 days, 33 days, and 90 days after TIPS, and it was controlled by medical treatment at his local hospital. Thus, a direct portography by means of a transjugular approach was performed, showing that excessive blood directly returned to the inferior vena cava (black arrows) through large paraesophageal varices (black arrowheads), but little blood returned through the patent TIPS shunt (white arrows) (Figure 2). Given such a large diameter of paraesophageal varices, an Amplatzer Vascular Plug (Xianjian Lifetech Limited Company, Shenzhen, Guangdong Province, China) was used to embolize these large varices. After that, no episode of hepatic encephalopathy recurred.