Early variceal rebleeding after successful distal splenorenal shunt

Of 77 patients with repeated variceal hemorrhage who underwent distal splenorenal shunt, five (6.5%) developed rebleeding despite a patent splenorenal anastomosis. Three of the five patients died. Early variceal rebleeding usually indicates shunt thrombosis but may occur with a patent anastomosis. Anatomic or functional left renal vein and/or splenic vein hypertension producing incomplete variceal decompression is generally the cause. Ineffective separation of the main portal vein from the gastrosplenic venous plexus may coexist and further intensify variceal congestion. Urgent angiographic studies and direct shunt catheterization with measurement of splenic vein, left renal vein, and inferior vena cava pressures should be performed to plan appropriate therapy. A significant gradient between the splenic and renal veins is evidence of an unsatisfactory anastomosis and should be managed by balloon angioplasty or reoperation. High splenic and left renal vein pressures with a gradient of more than 10 mm Hg between the renal vein and the inferior vena cava indicate renal vein hypertension. Initial therapy should include serial injection sclerotherapy, as renal vein hypertension will usually resolve over time as additional collaterals develop. However, persistent or recurrent variceal hemorrhage may require total portal decompression to bypass the restrictive left renal vein segment.