When Banding Breaks, New Paths Awaken: The BRTO Revelation
Leema Rebakkal Rosy1, Kasthuri. G2
1ANS Kauvery Hospital, Tennur, Trichy
2Nursing Incharge, Kauvery Hospital, Tennur, Trichy
Correspondence: M: 9659333344; Email ID: jayamenon@kauveryhospital.com
Abstract
This case report details the management of a 43-year-old male with chronic liver disease, portal hypertension, and gastric varices who presented with multiple episodes of hematemesis. Initial endoscopic interventions, glutherapy, and endoscopic variceal ligation (EVL) banding, were unsuccessful. The patient subsequently underwent Balloon-Occluded Retrograde Transvenous Obliteration (BRTO), leading to gradual clinical improvement. This case highlights the challenges of managing gastric variceal bleeding in patients with portal hypertension and the efficacy of BRTO as a salvage therapy.
Introduction
Gastric variceal bleeding is a life-threatening complication in patients with portal hypertension and chronic liver disease. While endoscopic intervention is typically the first line of treatment, they may fail in cases of refractory varices, necessitating alternative therapeutic approaches. BRTO is less commonly utilized but effective procedure in such scenarios. This report presents a case where BRTO was successfully employed after initial endoscopic therapies failed.
Case Presentation
A 43-year-old male known to have chronic liver disease, portal hypertension, type 2 diabetes mellitus. He presented with four episodes of hematemesis over 24 hr.
Clinical Findings on admission
Physical Examination: Tachycardia (HR: 110 bpm), hypotension (BP: 90/60 mmHg), and pallor. Lab Results: Haemoglobin: 6.5 g/dL, Platelets: 1,01,000 /μL, INR: 2.5
| 15.07.2024 - CBC | |||
|---|---|---|---|
| Investigation | Patient Value | Normal Value | Remarks |
| Haemoglobin | 6.6 | 13-17 g/dl | Decreased |
| PCV | 20.1 | 40-54 % | Decreased |
| WBC Count | 13,500 | 4000-10,000 cells / | Increased |
| Platelet count | 1,01,000 | 140000-4000000 | Decreased |
| 15.07.2024 - Liver Function Test | |||
| Total Bilirubin | 1.03 | 0.2 -1.0 mg/dl | Normal |
| Direct Bilirubin | 0.54 | 0-0.3 mg/dl | Increased |
| Indirect Bilirubin | 0.49 | 0.2- 0.7 mg /dl | Increased |
| Albumin, Serum | 2.2 | 3.5 – 5 g/l | Decreased |
Imaging
| Date | Investigations | Impression |
|---|---|---|
| 15.07.2024 | USG Abdomen Scan | F/S/O Parenchymal liver disease. Oedematous gall bladder |
| 15.07.2024 | Endoscopy | Bleeding Fundal varix. oesophagus Plan: Glue therapy (or) BRTO |
| 15.07.2024 | Multi Slice Abdomen & Pelvis Angiogram | Parenchymal liver disease with multiple Gastric varices and Gastro renal shunt with gross Ascites. |
Multi Slice Abdomen and Pelvis Angiogram
Medical Interventions
Initial Management
UGI Scopy and Glutherapy: Attempted but unsuccessful in controlling the bleeding.
EVL Banding: Could not be performed due to technical difficulties and risk of exacerbating the bleeding.
Definitive Treatment
BRTO Procedure: Performed under general anaesthesia. A balloon catheter was introduced via the femoral vein, and the procedure was successful in obliterating the varices.
Outcome
Post-BRTO, the patient showed gradual improvement. He was weaned off ventilator support within 48 hr, inotropes were discontinued by day 5, and he was transferred to the general ward on day 7. The patient was discharged home in stable condition on day 14.
Discussion
Gastric varices are associated with a high risk of bleeding in patients with portal hypertension, and their management can be particularly challenging. This case underscores the importance of considering BRTO as a salvage therapy in patients where conventional endoscopic interventions fail. BRTO offers a less invasive option compared to surgical shunting, with a favourable risk profile and effective outcomes in controlling variceal bleeding.
Patients with gastric variceal bleeding require a upper gastrointestinal endoscopy as it is the first-line diagnostic and management tool for bleeding gastric varices.
When endoscopy fails to control gastric variceal bleeding, a trans jugular intrahepatic portosystemic shunt (TIPS) is traditionally performed.
However, TIPS has not shown the same effectiveness in controlling gastric variceal bleeding as that it has with esophageal variceal bleeding.
The difference between TIPS and BRTO;
| TIPS | BRTO |
|---|---|
| Decrease portal pressure by altering the dynamics of flow | Scleroses the gastric varices without altering the Portal pressure |
| Can’t done in patient with hepatic encephalopathy | Indication in patient with Hepatic encephalopathy |
| Technically difficult | Less invasive |
| Rebleed rate is high | Lower re bleed rate, Survival rate is high compared to tips |
Efficacy of BRTO
BRTO is designed to selectively occlude the feeding vessels of gastric varices, leading to effective obliteration of varices and subsequent reduction in bleeding risk. In our case, the transition to BRTO resulted in successful control of hemorrhage, highlighting its role as a rescue therapy. The procedure not only addressed the immediate threat of bleeding but also facilitated long-term resolution of the varices.
Safety Profile
While BRTO is a minimally invasive procedure, understanding its safety profile is crucial. Common complications may include transient abdominal pain, post-embolization syndrome, and, in rare cases, more severe adverse events such as liver dysfunction or portal vein thrombosis. However, in our patient, the procedure was well-tolerated, with no significant complications reported post-treatment. This underscores the importance of patient selection and careful procedural planning.
Nursing Diagnoses
- Risk for Bleeding related to portal hypertension and refractory gastric varices.
- Ineffective Breathing Pattern related to ventilator dependence post-BRTO.
- Risk for Infection due to invasive procedures and immunocompromised state.
- Altered Nutritional Status related to chronic liver disease and diabetes.
- Anxiety related to the severity of the condition and the need for multiple invasive procedures.
Nursing Interventions
- Bleeding Control: Monitored the vital signs and hemoglobin levels, administered of blood products as needed, and preparation for emergency interventions.
- Respiratory Support: Careful weaning from mechanical ventilation, monitored respiratory distress, and provided oxygen supplementation as required.
- Infection Prevention: Aseptic techniques followed during invasive procedures, monitored the signs of infection, and administered medication as per advice.
- Nutritional Support: Managed with enteral or parenteral nutrition, monitored glucose levels, and provided dietary advice post-discharge.
- Psychological Support: Offered reassurance, involving the patient in decision-making, and provided information about the disease and treatment plan to his attendant.
Team Discussion and Decision-Making
During the patient’s admission to the emergency room, the initial approach to control the bleeding from the gastric varices involved endoscopic interventions, including Upper gastrointestinal endoscopy and Endoscopic Variceal Ligation (EVL) banding. However, these attempts were unsuccessful due to the complexity and extent of the varices. The patient’s condition was deteriorating, with ongoing bleeding and increasing hemodynamic instability. Recognizing the gravity of the situation, a multidisciplinary team discussion was convened to determine the next course of action.
The gastroenterologist, expressed concern over the failure of the endoscopic interventions and the continuing risk posed by the untreated varices. He acknowledged the limitations of further endoscopic procedures and emphasized the need for an alternative approach to prevent further blood loss.
Interventional radiologist proposed Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) as the next step. He highlighted that BRTO is a minimally invasive procedure specifically designed to address gastric varices by occluding the shunt contributing to the bleeding.
Given the patient’s hemodynamic instability and chronic liver disease, BRTO was considered the most appropriate and least invasive option.
The intensivist, supported the recommendation for BRTO, pointing out that the patient’s critical condition made him a poor candidate for surgery. He stressed the need for an immediate and effective intervention to stabilize the patient and control the bleeding. The HOD of critical care also emphasized the importance of maintaining close hemodynamic monitoring throughout the procedure due to the patient’s dependency on a ventilator and inotropic support.
As critical care nurse, we played the crucial roles in preparing for the BRTO procedure. They ensured that all necessary equipment, blood products, and monitoring systems were ready for the patient’s transfer to the interventional radiology suite. They also coordinated the communication with the patient’s family, ensuring that they were informed about the change in the treatment plan and the rationale behind it.
Conclusion
This case illustrates the successful use of BRTO in managing gastric variceal bleeding in a patient with chronic liver disease and portal hypertension. The gradual but sustained improvement following the procedure underscores its potential as viable option in complex cases where endoscopic methods fail.
Ms. Leema Rebakkal Rosy
Assistant Nursing Superintendent
Ms. Kasthuri. G
Nursing Incharge
