Media Release
Udupi, Jul 27: Recently, a 60-year-old gentleman was brought to Kasturba Hospital, Manipal, vomiting blood. The bleeding was brought under control within hours by the gastroenterology team, and its underlying blood vessel shunt was closed by the interventional radiology team, working from inside the blood vessels. He was discharged within 48 hours of the procedure and continues to do well on outpatient review. At no stage did he need an operation.
The patient had gastrointestinal bleeding due to a fundal varix, which was caused by chronic liver disease and portal hypertension. Bleeding due to liver disorders has a high mortality rate if not treated on time. With new medical advancements, gastrointestinal bleeding is now being managed by endoscopy, thereby avoiding surgery.
An urgent upper gastrointestinal endoscopy by Dr Shiran Shetty, gastroenterologist at Kasturba Hospital, Manipal, showed large fundal varices in the upper part of the stomach, one of which was bleeding actively. After the patient was resuscitated, the gastric varix was treated using EUS/endoscopy-guided therapy to stop the ongoing bleed. Further, newer endo-ultrasound technology was used to detect the vein and shunt responsible for the bleeding.
"Endoscopy today is not merely for making a diagnosis. The ultrasound at the tip of the scope let us pick out the exact vessel that had given way and treat it precisely, at a moment when the patient was critically unwell. Getting the bleeding under control quickly is what gives us the room to plan a lasting solution, instead of moving from one crisis to the next," said Dr Shiran Shetty, gastroenterologist, Kasturba Hospital, Manipal.
A large abnormal channel had opened between the portal circulation and the left kidney vein, forming a gastrorenal shunt, and it was continuously feeding the gastric varices. Sealing the bleeding vessel alone would not have held. So long as that shunt stayed open, the bleeding was very likely to return. The case was therefore taken up for a joint discussion between gastroenterology and interventional radiology. Interventional radiology is the speciality that treats diseases from inside the blood vessels, using live imaging in place of an incision, and it has steadily changed the way complications of portal hypertension are managed the world over. The team at Kasturba Hospital, Manipal, led by Dr Harshith K, took up the case for a procedure known as plug-assisted retrograde transvenous obliteration, or PARTO.
Working through a single puncture in a vein, Dr Harshith K and his team navigated a catheter all the way up to the shunt, following its path on an X-ray as they went. A specially designed vascular plug was positioned at the mouth of the shunt and deployed, closing it from within and cutting off the supply that kept refilling the varices in the stomach. A CT scan taken afterwards confirmed that the plug was correctly placed and the shunt was completely sealed. A patient who, not many years ago, would have been facing major surgery and weeks of recovery was treated instead through a puncture no bigger than a pinprick, with not a single incision on his body. He had no further episodes of bleeding and went home within 48 hours. A follow-up endoscopy by Dr Shiran Shetty showed that the varices had been obliterated with no evidence of active bleeding, and he has remained well since.
"A case like this is exactly what we have been building towards at Kasturba Hospital. Advanced endoscopy, interventional radiology, and critical care are all available here under one roof, and, more importantly, these teams are in the habit of sitting together to arrive at a single plan for the patient. That is what a centre of excellence really means. It allows a patient from any part of this region to walk in here and receive care of the same standard he would have travelled to a metro city for," said Dr Sudhakar Kantipudi, chief operating officer, MAHE Teaching Hospitals.