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Zorluk: OrtaSurgical and Procedural Interventions

A 55-year-old woman is evaluated in the intensive care unit for refractory hematemesis. She has a history of decompensated cirrhosis secondary to nonalcoholic steatohepatitis. Two hours ago, she was admitted with large-volume hematemesis, hypotension, and tachycardia. She was promptly intubated for airway protection, started on intravenous octreotide and ceftriaxone, and resuscitated with packed red blood cells, fresh frozen plasma, and platelets using a massive transfusion protocol. An emergent upper endoscopy was performed, revealing actively bleeding esophageal varices. The gastroenterologist deployed multiple bands, but brisk, spurting hemorrhage continues from a defect that cannot be controlled endoscopically. The patient's current blood pressure is 70/40 mmHg, and her heart rate is 135/min. Which of the following is the most appropriate next step in the management of this patient?

  1. Placement of a balloon tamponade deviceCevap
  2. B
    Transjugular intrahepatic portosystemic shunt creation
  3. C
    Emergent open portosystemic shunt surgery
  4. D
    Computed tomography angiography of the abdomen
  5. E
    Administration of recombinant activated factor VII

Cevap

Placement of a balloon tamponade device
The correct answer is placement of a balloon tamponade device (e.g., Sengstaken-Blakemore tube). The management of acute variceal hemorrhage begins with hemodynamic resuscitation, prophylactic antibiotics, and vasoactive drugs (such as octreotide), followed by emergent endoscopy for band ligation or sclerotherapy. In approximately 10-20% of cases, bleeding cannot be adequately controlled endoscopically. If the patient is hemodynamically unstable and actively exsanguinating, immediate bedside mechanical compression with balloon tamponade is indicated. This procedure provides rapid hemostasis to stabilize the patient, serving as a critical, temporary 'bridge' (usually for a maximum of 24 hours) until a definitive decompression procedure, such as a transjugular intrahepatic portosystemic shunt (TIPS), can be performed.

Adım Adım Çözüm

1
Assess the patient's hemodynamic status and identify the source of bleeding.
The patient is in hemorrhagic shock due to actively bleeding esophageal varices that persist despite attempted endoscopic band ligation.
Accurate assessment of stability and etiology dictates the urgency and type of the required intervention.
2
Identify the immediate therapeutic priority.
Immediate mechanical hemostasis is required to prevent death from exsanguination.
Initial pharmacologic and endoscopic therapies have failed, and the patient is too unstable to wait for complex definitive procedures.
3
Select the most appropriate bridging procedure.
A balloon tamponade device (e.g., Sengstaken-Blakemore tube) is selected.
It can be deployed immediately at the bedside to temporarily compress the bleeding varices and stabilize the patient while arrangements are made for definitive shunt placement.

Anahtar Kavram

In patients with acute variceal hemorrhage who fail endoscopic therapy and remain hemodynamically unstable, immediate placement of a balloon tamponade device serves as a life-saving bridge to definitive therapy such as a transjugular intrahepatic portosystemic shunt (TIPS).
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Surgical and Procedural Interventions

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