Complex Portal Hypertension in Rural Kenya

I had a patient with clinically significant portal hypertension, who presented with an acute upper GI bleed, secondary to oesophageal varices. After initial management with emergency endoscopy and banding, the cause of portal hypertension was determined to be extra-hepatic portal vein occlusion, secondary to Schistosomiasis.

The challenges

The patient lives in a rural area, with poor access to healthcare and emergency medical services. Repeat banding to eradicate the varices was also not possible, due to the difficulty to travel back and forth for this. In view of the extra hepatic obstruction, TIPSS was also not an option. Furthermore, despite having interventional radiology support, TIPSS is currently not being widely performed in Kenya, even if it was feasible.

A shared surgical plan

Bearing in mind these challenges and the need to come up with a definitive plan to prevent further bleeding, this was discussed on HPBridge and a decision was made to perform a splenectomy and Oesophageal devascularization procedure, as opposed to a surgical porto-systemic shunt. Both of these options had been considered and the HPBridge helped me arrive at the correct decision about what procedure to perform for this patient.

While awaiting the HPBridge meeting and decision, we had time to medically control the portal pressures and vaccinate the patient in anticipation of splenectomy. The surgery went well, with minimal blood loss and the spleen was squeezed after ligation of the artery, to return most of the blood into the circulation before ligating the vein and completing the splenectomy.

The outcome

Subsequently, the patient did extremely well and made a quick recovery, being discharged on the 4th post-operative day. He has been on phone follow-up and had not experienced another episode of bleeding since July 2024.