Jawaid Qaiser, Saeed Zahid A, Di Bisceglie Adrian M, Brunt Elizabeth M, Ramrakhiani Sanjay, Varma Chintalapati R, Solomon Harvey
Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, Saint Louis, MO, USA.
Am J Transplant. 2003 Dec;3(12):1604-7. doi: 10.1046/j.1600-6135.2003.00267.x.
A 50-year-old White man with noncirrhotic portal hypertension presented with bleeding from gastric varices. Bleeding was initially managed with band ligation and subsequent transjugular intrahepatic portosystemic shunt (TIPS). Over the next few months, the patient had recurrent episodes of anemia, jaundice, fever and polymicrobial bacteremia. Computed tomography (CT) of the abdomen and chest, upper and lower endoscopy, endoscopic retrograde cholangiopancreatography (ERCP), and echocardiography failed to explain the bacteremia and anemia. Follow-up CT scan and Doppler sonography 9 months after placement showed TIPS was occluded. Repeat ERCP showed a bile leak with free run-off of contrast from the left hepatic duct into a vascular structure. The patient's status was upgraded for liver transplantation with Regional Review Board agreement and subsequently received a liver transplant. Gross examination of the native liver demonstrated a fistula between the left bile duct and the middle hepatic vein. Pathologic evaluation confirmed focal necrosis of the left hepatic duct communicating with an occluded TIPS and nodular regenerative hyperplasia consistent with noncirrhotic portal hypertension. Infection is rarely reported in a totally occluded TIPS. Biliary fistulas in patent TIPS have been treated by endoluminal stent graft and endoscopic sphincterotomy with biliary stent placement. Liver transplantation may be the preferred treatment if TIPS becomes infected following its complete occlusion.
一名50岁的白人男性，患有非肝硬化性门静脉高压症，因胃静脉曲张出血就诊。出血最初通过套扎术治疗，随后进行了经颈静脉肝内门体分流术（TIPS）。在接下来的几个月里，患者反复出现贫血、黄疸、发热和多种微生物菌血症。腹部和胸部计算机断层扫描（CT）、上下消化道内镜检查、内镜逆行胰胆管造影（ERCP）和超声心动图均无法解释菌血症和贫血的原因。放置TIPS 9个月后的随访CT扫描和多普勒超声检查显示分流道闭塞。重复ERCP显示有胆汁漏，造影剂从左肝管自由流入一个血管结构。经地区审查委员会同意，患者的病情升级为肝移植，随后接受了肝移植。对原肝脏的大体检查显示左胆管与肝中静脉之间存在瘘管。病理评估证实左肝管局灶性坏死与闭塞的TIPS相通，以及符合非肝硬化性门静脉高压的结节性再生性增生。完全闭塞的TIPS很少有感染的报道。通畅的TIPS中的胆瘘已通过腔内支架植入和内镜括约肌切开术并放置胆管支架进行治疗。如果TIPS完全闭塞后发生感染，肝移植可能是首选的治疗方法。
