A Case of Acute Liver Failure of Unknown Cause Following PTFE-Coated TIPS Stent Insertion for Prevention of Esophageal Variceal Rebleed
Bibliographic record
Abstract
Purpose: Case report: A 58 year old man with alcohol/HCV cirrhosis was evaluated for iron deficiency anemia. He had been abstinent for 10 months with stable liver function, and denied overt bleeding. Physical examination revealed caput medusa and splenomegaly without ascites or peripheral edema. His colonoscopy was normal. PHG and grade IV esophageal varices were identified on gastroscopy. Band ligation of esophageal varices resulted in massive hemorrhage with application of the first band, controlled with subsequent banding. He returned 7 months later for repeat banding and the same scenario ensued. He was started on nadolol but was unable to tolerate side effects. He was referred for TIPS to prevent further variceal bleeding. His MELD score was 11. A 6 cm PTFE covered stent was inserted through his middle hepatic vein into his portal vein, and reduced his porto-caval pressure gradient from 20 mmHg to 6 mmHg. A routine Doppler ultrasound one week post TIPS demonstrated flow within the right and left hepatic veins and confirmed patency of the stent. He presented to ER the following day with the only complaint of increasing jaundice. He denied no infections symptoms or ingestion of any medications. His blood work revealed markedly elevated bilirubin of 607 umol/L, mild rises in transaminases (AST= 158 and ALT= 196) and INR of 1.4. Unfortunately, he quickly decompensated, with steadily rising bilirubin. His MELD score rose from 11 to 42. The stent was evaluated and was in good position. All causes of acute liver failure had been excluded. Despite occlusion of TIPS, his liver function continued to decline and eventually required liver transplantation 1 month after TIPS. The liver explant showed end stage liver cirrhosis with features consistent with HCV and steatohepatitis without evidence of hepatic ischemia. Discussion: A recent randomized controlled trial demonstrated greater efficacy and lower mortality of early TIPS in preventing variceal rebleeding in cirrhotic patients hospitalized for acute bleed compared to pharmacologic plus band ligation therapy. Rare cases of liver failure caused by segmental liver ischemia following TIPS have been reported, thought to be due to a “partial Budd-Chiari syndrome” caused by obstruction of the hepatic vein in which the stent was implanted. In these cases, hepatic failure resolved either with supportive care or with occlusion of TIPS. Our patient developed acute liver failure of unknown cause following TIPS, necessitating liver transplantation. Careful selection of patients must be considered before embarking on early TIPS for prevention of variceal rebleed.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.003 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.002 | 0.001 |
| Science and technology studies | 0.003 | 0.001 |
| Scholarly communication | 0.002 | 0.002 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.004 | 0.003 |
| Insufficient payload (model declined to judge) | 0.004 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".