When the Critical Illness Dominoes Fall, Unforeseen Events Post BRTO
Recommended Citation
Allen B, Millard M, Ashburn N, Snavely A, Nowak RM, Mumma B, Madsen T, Wilkerson RG, Christenson R, Stopyra J, Mahler S. When the Critical Illness Dominoes Fall, Unforeseen Events Post BRTO. Am J Respir Crit Care Med 2024; 209.
Document Type
Conference Proceeding
Publication Date
5-20-2024
Publication Title
Am J Respir Crit Care Med
Abstract
Introduction: Gastric variceal bleeding is a complication of cirrhosis with portal hypertension (PHT) associated with significant morbidity and mortality. Management of suspected variceal bleeding includes resuscitation, medical therapy, endoscopic intervention and early consideration for advanced procedures such as TIPS, BRTO, surgery or liver transplant. Herein, we describe a rare adverse event following BRTO. Case: A 39 year old male with alcoholic cirrhosis and PHT, gastric varices (GV) and Gastroesophageal varices (GOV), presented to emergency department (ED) with hematemesis. He was intubated and transfused per massive transfusion protocol for large volume hematemesis. A Minnesota tube was placed emergently. Medical therapy was initiated including IV pantoprazole, octreotide, ceftriaxone. An endoscopy within 24 hours revealed a large GOV without stigmata of recent bleeding and GV with stigmata of recent bleeding. The GOV were banded and the GV identified as the source of hematemesis. To address the GV, he was taken to Interventional radiology (IR) for a Balloon-occluded Retrograde Transvenous Obliteration (BRTO) procedure. 12 hours later the patient developed abdominal distension, lactic acidosis and sudden rise in norepinephrine requirements refractory to fluid resuscitation. CT abdomen with contrast showed diffuse hypo enhancement and thickening of the bowel favored to be related to mesenteric ischemia secondary to mesenteric venous hypertension (MVH). As a solution, a TIPS procedure was performed to reduce MVH. MICU course was complicated by ARDS, Renal failure required SLED, multiple transfusion of blood products for correction of coagulopathy. Discussion: A BRTO is an advanced procedure for intervention of GV as the source For GV as the source of the variceal bleeding in decompensated liver cirrhosis, advanced options such as BRTO are available as secondary prevention for further bleeding. This case highlights an adverse event associated with BRTO that has not been commonly reported. Intensivists, while not performing advanced procedures for these patients, must have heightened awareness of all complications and adverse events related to BRTO, because early recognition can result in expedited care to decrease severity of morbidity or mortality.
Volume
209
