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What is portal hypertension and variceal bleeding?
Variceal bleeding is caused by portal hypertension. Portal
hypertension is an increase in the pressure within the portal vein (the vein
that carries blood from the digestive organs to the liver). This increase in
pressure is caused by a blockage in the blood flow throughout the liver.
Increased pressure in the portal vein causes large veins (varices) to develop
across the esophagus and stomach to bypass the blockage. The varices become
fragile and can bleed easily. Symptoms of portal hypertension include:
- Bleeding -- black stools and/or vomiting of blood due to the spontaneous
rupture and hemorrhage from varices
- Ascites -- an accumulation of fluid in the abdomen
- Encephalopathy -- confusion and forgetfulness caused by poor liver
function and the diversion of blood flow away from your liver
Endoscopy, X-ray studies, and lab work confirm that you have variceal
bleeding. Further treatment is necessary to reduce the risk of re-bleeding.
How is variceal bleeding treated?
Once
the bleeding episode has been stabilized, treatment options are prescribed based
on the severity of your symptoms and how well your liver is functioning.
First level of treatment
When you are first diagnosed with variceal bleeding, you might be
treated with endoscopic therapy and/or medicine. Endoscopic therapy consists
of either sclerotherapy or banding. Medicines such as beta blockers or
nitrates might be prescribed alone or in combination with endoscopic
therapy to reduce the pressure in your varices and further reduce the risk of
re-bleeding.
If the first level of treatment does not successfully control your variceal bleeding, you
will require decompression (reducing the pressure) of your varices.
Second level of treatment
Two procedures for decompression are:
- Transjugular intrahepatic porto-systemic shunt (TIPS) -- This is a radiological
procedure in which a stent (a tubular device) is placed in the middle of the
liver to reroute the blood flow.
- Distal splenorenal shunt (DSRS) -- This is a surgical procedure that connects the splenic vein to the left kidney vein.
Fig 1: Portal hypertension
before either the TIPS or DSRS procedure is performed.
Portal hypertension causes veins to enlarge, and varices to develop
across the esophagus and stomach from the destruction to portal vein blood
flow through the liver. This causes high pressure in the portal
vein. The backup of pressure also causes the spleen to become
enlarged.
By
decreasing the pressure (decompression) in your veins, either the TIPS or DSRS
procedure can provide control of your bleeding. There are advantages and
disadvantages of both procedures. Neither procedure has been proven to be a
better treatment for long-term control of bleeding or for the overall management
of patients with cirrhosis and portal hypertension.
What is the TIPS procedure?
During the
TIPS procedure, a radiologist makes a tunnel through the liver with a needle,
connecting the portal vein (the vein that carries blood from the digestive
organs to the liver) to one of the hepatic veins (the three veins that carry
blood from the liver). A metal stent is placed in this tunnel to keep the track
open.
The TIPS procedure re-routes blood flow in the liver and reduces pressure in
all abnormal veins, not only in the stomach and esophagus, but also in the bowel
and the liver. Figure 2 illustrates the TIPS procedure.
Fig 2: After the TIPS procedure is performed.
A radiologist makes a tunnel through the liver with a needle,
connecting the portal vein to one of the hepatic veins. A metal stent is placed in this tunnel to keep
the track open.
The shunt allows the blood to flow from the high pressure portal vein
through the stent, bypassing liver tissue, to the hepatic vein. This reduces portal hypertension, and allows the veins to shrink to normal
size, helping to stop variceal bleeding.
Figure 3
Fig 3: After the distal splenorenal shunt
surgery is performed.
The vein from the spleen is disconnected from the portal vein and
reconnected to the left renal vein. The left gastric vein is
disconnected from the portal vein and tied off. The blood flows from
the varices through the splenic vein to the left renal vein and empties
into the inferior vena cava. The blood flow to the liver is
maintained through the portal vein.
The TIPS procedure is not a surgical procedure. The radiologist
performs the procedure within the vessels in the X-ray room under X-ray
guidance. The procedure lasts one to three hours. You should expect to stay in the
hospital two to three days after the procedure.
The TIPS procedure controls bleeding immediately in more than 90 percent of patients, but
has a late re-bleeding rate of about 20 percent because the shunt might narrow.
What are the potential complications of the TIPS procedure?
- Shunt narrowing or occlusion (blockage) -- This could happen within the
first year after the procedure. Follow-up ultrasounds are performed
frequently after the TIPS procedure to detect these complications. The signs
of occlusion include increased ascites or re-bleeding. This condition can be
treated by a radiologist who re-expands the shunt with a balloon or repeats
the procedure to place a new stent.
- Encephalopathy -- This refers to mental changes caused by abnormal functioning of the
brain that occur with severe liver disease. Encephalopathy can be worse when
blood flow to the liver is reduced by TIPS, which might result in toxic
substances reaching the brain without being metabolized first by the liver.
This condition can be treated with medicine and diet, or by revising the
shunt.
What is the DSRS procedure?
The DSRS
is a surgical procedure. During the surgery, the vein from the spleen (called
the splenic vein) is detached from the portal vein and reattached to the left
kidney (renal) vein. This surgery selectively reduces the pressure in your
varices and controls the bleeding. Figure 3 illustrates the distal
splenorenal shunt procedure.
A general anesthetic is given to you before the surgery. The surgery lasts
about four hours. You should expect to stay in the hospital from seven to 10
days. DSRS controls bleeding in more than 90 percent of patients, with the highest risk of
any re-bleeding in the first month. However, the DSRS procedure provides good
long-term control of bleeding.
What is the potential complication of the DSRS surgery?
Ascites -- This is an accumulation of fluid in the abdomen. This
condition can be treated with medicines called diuretics and by restricting sodium
intake.
What tests are required before the TIPS and DSRS procedures?
Before
these procedures, you will have the following tests to determine the extent
and severity of your portal hypertension condition:
- Evaluation of your medical history
- A physical examination
- Blood tests
- Galactose liver function test
- Angiogram
- Ultrasound
- Endoscopy
Before either the TIPS or DSRS procedure, your doctor might ask you to have pre-operative tests. The tests
might include an
electrocardiogram (also called an EKG), chest X-ray, or additional blood tests.
If your doctor thinks you will need additional blood products (such as
plasma), they will be ordered at this time.
Follow-up medical care for both procedures
- Ten days after your hospital discharge date, you will meet with the
surgeon or hepatologist and nurse coordinator to evaluate your progress. Lab
work will be done at this time.
- Six weeks after the TIPS procedure (and again three months after the
procedure), you will have an ultrasound so your doctor can check that the
shunt is functioning properly. You will have an angiogram only if the
ultrasound indicates that there is a problem. You will also have lab work
done at these times and visit the surgeon or hepatologist and nurse
coordinator.
- Six weeks after the DSRS procedure (and again three months after the
procedure), you will meet with the surgeon and nurse coordinator to evaluate
your progress. Lab work will be done at this time.
- Six months after either the TIPS or DSRS procedure, you will have an
ultrasound to make sure the shunt is working properly. You will also visit
the surgeon or hepatologist and nurse coordinator to evaluate your progress.
Lab work and a galactose liver function test will also be done at
this time.
- Twelve months after either procedure, you will have another ultrasound of
the shunt. You will also have an angiogram so your doctor can check the
pressure within your veins across the shunt. You will meet with the surgeon
or hepatologist and the nurse coordinator. Lab work and a galactose liver
function test will be done at this time.
- If the shunt is working well, every six months after the first year of
follow-up appointments, you will have an ultrasound and lab work, and you will
visit with your doctor and nurse coordinator.
- More frequent follow-up visits might be necessary, depending on your
condition.
What do I need to do to maintain my health after these procedures?
- Attend all follow-up appointments, as scheduled, to ensure that the shunt
is properly functioning.
- Be sure to follow the dietary recommendations provided by your health care
providers.
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