CASE PRESENTATIONGS intern 장규호

Chief complaint

Nausea

Patient ID : 0328635 Sex /Age : F/44

Present illness

44 세 여환 HCV LC 로 현재 본원 GI f/u 중인 자 .

본원 내원 전 E.varix bleeding 으로 수 차례 타병원에서 EVL 시행한 병력 있으며 올해 3 월 본원 GI 입원하여 E. varix, s/p EVL 한 차례 더 시행한 병력 있음 .

퇴원 이후 특이 소견 없이 지내다가 7/29 nu-asea 심해 울산병원 내원하여 DFS 시행하였고 Esophageal varix, Cardiac varix 확인되어 7/30 EVL 시행후 OP 위해입원함 .

Past medical history

HTN/DM/Hep/Tb : +/+/+(HCV)/- Esophageal varix s/p EVL #10 Cardicac varices s/p EVL #2

Social Hx Smoking : (-) Alcohol : (-)

Surgical Hx : Cholecystectomy(07’)

Review of systemGeneral Fever(-), chilling(-), poor oral intake(-), general weakness(-)

Respiratory Cough/sputum/rhinorrhea(-/-/-), dyspnea(-), cyanosis(-)

Cardiovascular Chest pain(-), chest discomfort(-)

Gastrointestinal Abdominal pain(-), RUQ pain(-), diarrhea/constipation(-/-)

Musculoskeletal Myalgia(-), arthralgia(-), paresthesia(-)

Genitourinary Dysuria/frequency/urgency/voiding difficulty (-/-/-/-)

Physical ExamVital sign BP: 115/77mmHg- HR 59 회 / 분 - RR 20 회 / 분 -BT 36.0℃

Mental state: Alert

General appearance Not so ill looking

Body measurements Height : 150.4cm, weight : 45.6kg, BMI : 20.1

HEENT Anemic conjunctiva/Anicteric sclera(-/-)

Chest Symmetric chest wall movement without deformity Clear breathing sounds without crackle Regular heart beat without murmur

Abdomen Soft and distended abdomen(-)Hypoactive bowel sound(-) Tenderness(Murphy sign)/rebound tenderness(-/-), Hepatomegaly/splenomegaly(-/-) Palpable mass(-)

Back/Extremities CVA tenderness(-/-) Pretibial pitting edema(-/-)Joint swelling/tenderness/heating/redness(-/-/-/-) Varicose vein(-), dermopathy(-)

Skin Jaundice(-)

Initial Lab

CBC WBC 17490, Hgb 8.1, PLT 210K, ANC 13030

Chemistry AST/ALT: 40/33 IU/L total/direct bilirubin: 0.2/0.1 mg/dl BUN/Cr.: 12.8/0.73 mg/dl total protein/albumin: 5.5/3.2 g/dl

Electrolyte Na/K/Cl: 139/4.8/108

Cardiac varixEVL(140729)

CT(140731)

Initial Problem list

#1.esophageal varix #2.HCV-LC #3.HTN #4.DM

ADMISSION NOTE

HD 1

#1.esophageal varix S : n-s O : V/S - BP: 115/77mmHg- HR 59

회 / 분 - RR 20 회 / 분 -BT 36.0℃

A : esophageal varix P : Kobayashi OP

Operation(141015) Preoperation diagnosis

Hepatic sclerosis Postoperation diagnosis

HCV/LC Operation(Kobayashi OP)

Paraesophago-gastirc devascularization/ Esopageal R&A/ TV /Pyloroplasty

OP findings liver macronodularity Ascites - mild splenomegaly

POD 1

S : 수술부위 통증 O : V/S - BP: 142/96mmHg- HR 78

회 / 분 - RR 20 회 / 분 -BT 36.4℃ A : esophageal varix P : ICU care, NPO, pain control

POD 3

S : 수술부위 통증 O : V/S - BP: 138/87mmHg- HR 81 회 / 분 - RR 20 회 / 분 -BT 36.3℃ Hgb – 8.1 A : esophageal varix P : transfusion, NPO, pain control

VARIX TREATMENT

1.Endoscpic therapy

definitive treatment of choice for ac-tive variceal hemorrhage Endoscopic variceal ligation (EVL) 

it involves placing small elastic bands around varices 

Endoscopic sclerotherapy (ES)  injection of a sclerosant solution into the

varices

EVL and ES are initially successful in 70 to 100 percent of patients

Gastric varix

Bleeding from gastric varices is diffi-cult to control endoscopically

TIPS may be less effective than surgery Flow through collaterals that feed the

gastric varices often persists after TIPS

2. Management if endoscopic therapy fails 

definition of failed treatment for acute variceal hemorrhage Fresh hematemesis or nasogastric aspiration of

≥100 mL of fresh blood ≥2 hours after the start of a specific drug treatment or therapeutic endoscopy

Development of hypovolemic shock A 3-gm drop in hemoglobin (or a 9 percent drop in

hematocrit) within any 24-hour period if no transfu-sion is administered

rebleeding occurs a second time, more defini-tive therapy (TIPS placement or surgery) is re-quired. 

Transjugular intrahepatic por-tosystemic shunt

Absolute contraindications heart failure, severe pulmonary hypertension,

uncontrolled systemic infection or sepsis, se-vere tricuspid regurgitation.

Relative contraindications hepatocellular carcinoma, portal vein thrombo-

sis, and severe coagulopathy or thrombocy-topenia

Complications  portosystemic encephalopathy, technical com-

plications (eg, cardiac arrhythmias, traversal of the liver capsule), and TIPS stenosis

Surgery

The ideal patient for surgical therapy well-preserved liver function who fails

emergent endoscopic treatment  no complications from the bleeding or

endoscopy contraindication to TIPS placement

two basic types of operations shunt operations nonshunt operations

Shunt operations Nonselective (figure A)

decompress the entire portal tree and divert all flow away from the portal system, such as porta-caval shunts

Selective (figure B) compartmentalize the portal tree

into a decompressed variceal system while maintaining sinu-soidal perfusion via a hyperten-sive superior mesenteric-portal compartment, such as a distal splenorenal shunt

Partial Those that incompletely decom-

press the entire portal tree and thereby also maintain some he-patic perfusion

Non-shunt operations esophageal transection (in which the distal

esophagus is transected and then stapled back together after varices have been lig-ated)  bleeding can occur from the suture line, and

varices recur after a variable period of time because transection does not treat the portal hypertension.

devascularization of the gastroesophageal junction used in patients who are not candidates for a

shunt operation such as those with extensive portal vein thrombosis with extension into the splenic and superior mesenteric veins

Shunt OP vs non-shunt OP

Shunt OP 술후 간 혈류량 감소로 인한 간부전 간성뇌증

Non-shunt OP 문맥압 감압효과는 없지만 간혈류 유지 가능 술후 간부전이나 간성뇌증 유발하지 않음 재출혈의 위험성이 높음

Sugiura operation

단점 : 1 차 수술 4~6 주 후 2 차 수술이 필요함 1 차 수술의 시간이 오래걸리며 광범위한 devascularization으로 출혈 및 문합부 누출 발생

Kobayashi operation

1.Spleenectomy 2. 복부식도와 위근위부 devascularization & Truncal vagotomy3.EEA stappler 를 이용한 식도절단 및 문합술4.Pyloroplasty

식도정맥류에 대한 Kobayashi procedure

술후 식도정맥류 변화 술후 2~4 주후 식도조영술 시행 정맥류 완전소실 : 23 예중 12 예 현저한감소 : 9 예 약간의변화 : 2 예

원격 추적 조사 술후 3 개월 ~4 년 10 개월까지 추적조사한 21 예 중 2 예 (9.5%) 사망 - 술후 2 개월 - 간성혼수 - 술후 9 개월 - 재출혈 & 간성혼수

재출혈 2 예 (9.5%)- 고식적치료와 경화요법으로 지혈식도협착 -5 예 (23.8%)

식도정맥류의 Kobayashi 술식의 효과

Reference

Uptodate Methods to achieve hemostasis in pa-

tients with acute variceal hemorrhage 식도정맥류에 대한 Kobayashi procedure

외과학회지 vol30, No6, June, 1986 식도정맥류의 Kobayashi 술식의 효과

외과학회지 vol40, No2, February, 1991