Patients with Barrett’s esophagus (BE) and cirrhosis who develop high-grade dysplasia (HGD) or adenocarcinoma in the setting of esophageal varices present a unique therapeutic dilemma. There is limited literature regarding the optimal management of varices prior to invasive procedures or surgery involving the distal esophagus. We present a case of variceal decompression with a transjugular intrahepatic portosystemic shunt (TIPS) allowing for successful endoscopic mucosal resection (EMR) of BE with HGD overlying esophageal varices.
Patients with cirrhosis who need an invasive procedure present a challenge because of contraindications to perform the procedure or an increased risk of complications. A limited number of studies suggest that preoperative transjugular intrahepatic portosystemic shunt (TIPS) placement may be effective in reducing portal pressure prior to surgery, resulting in decreased perioperative complications.1–7 Endoscopic mucosal resection (EMR) is used for the staging and treatment of superficial neoplasms of the gastrointestinal tract,8 and bleeding is the most common complication.9
A 66-year-old white male with Child-Pugh class A hepatitis C (HCV) cirrhosis and esophageal varices was referred for management of Barrett’s esophagus (BE) with high-grade dysplasia (HGD). A surveillance esophagogastroduodenoscopy (EGD) showed large esophageal varices and BE with a nodule 38 cm from the incisors; biopsies demonstrated intestinal metaplasia with HGD. Repeat EGD with endoscopic ultrasound (EUS) was notable for 3 columns of large esophageal varices 20–36 cm from the incisors, and BE 30–36 cm from the incisors with 2 nodules at 36 cm. No abnormal lymph nodes were noted on EUS. There was thickening of the mucosal layer at 36 cm, which correlated with the nodules seen endoscopically, but no penetration into or beyond the submucosal layer. Band ligation for management of esophageal varices was not performed given concerns that scarring may affect the pathologic staging of the lesion and inhibit further EMR.
His initial exam was significant for several spider angiomata and trace lower extremity edema. Labs were significant for hemoglobin 10.7 g/dL, platelets 84 K/mm3, international normalized ratio (INR) 1.57, creatinine 0.67 mg/dL, total bilirubin 1.0 mg/dL, and albumin 3.9 g/dL, with a calculated MELD score of 11. An abdominal computed tomography (CT) showed splenomegaly and no enlarged lymph nodes. Given that his cirrhosis was well compensated with preserved liver function, we pursued treatment of the dysplastic Barrett’s esophagus. A TIPS was planned for decompression of esophageal varices prior to attempted endoscopic treatment of his BE with HGD.
Figure 1. TIPS procedure with reduction in the HVPG from 16 mm Hg to 6 mm Hg.
Figure 2. EGD showing no visible distal varices in the region of his BE.
The patient underwent a successful TIPS procedure with reduction in the hepatic venous pressure gradient (HVPG) from 16 mm Hg to 6 mm Hg (Figure 1). Six days later, an EGD established that there were no visible distal varices in the region of his Barrett’s esophagus (Figure 2). EMR was performed, and oozing from the margins of his EMR was treated with focal argon plasma coagulation therapy, with minimal estimated blood loss (Figure 3). Pathology confirmed HGD with negative margins. A repeat EGD at 2 months showed continued resolution of esophageal varices, scattered BE segments 35–41 cm from the incisors without nodules, and extensive re-epithelialization of the area of prior EMR (Figure 4). The residual BE was treated with radiofrequency ablation (RFA). The patient is doing well 15 months after EMR without dysphagia or odynophagia.
We report the first case of TIPS placement for reduction of portal pressure to facilitate EMR for BE with HGD. A literature search revealed a case report describing TIPS prior to successful EMR of a gastric adenocarcinoma in a cirrhotic with severe portal hypertensive gastropathy.10
Perioperative complications in patients with cirrhosis may be secondary to severe portal hypertension.2-7,11 Several studies have concluded that preoperative TIPS for portal decompression may be beneficial in patients with cirrhosis who have varices in or near the surgical field (Table 1). However, in a retrospective comparative study of patients with cirrhosis undergoing elective abdominal surgery, preoperative TIPS was not shown to reduce operative blood loss or improve survival at 1 month or 1 year, although the group undergoing TIPS had a statistically significant higher Child-Turcotte-Pugh score.11
In our case, TIPS was successful in decompressing the esophageal varices prior to effective EMR of BE with HGD, which not only ablated the neoplastic segment but also provided accurate staging. A previously reported alternative management strategy is the use of band ligation to eradicate dysplastic BE in the setting of esophageal varices, although in that setting, the accuracy of staging would be lost.12 Additional studies are needed to further delineate this potential role of TIPS and to optimize patient selection for this combined approach.
Author contributions: M. NeSmith is the primary author. All authors contributed to the manuscript. J. Ahn is the article guarantor.
Financial disclosure: None to report.
Informed consent was obtained for this case report.
Correspondence: Meghan NeSmith, MD, Department of Internal Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97219 (firstname.lastname@example.org).
Previous Presentation: This case was presented as a poster at the ACG 2013 Annual Meeting; October 14, 2013; San Diego, California.
Received: February 19, 2014; Accepted: May 9, 2014
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